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marianna13
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litarch

+{"file": "erta2_NBK32897/app1.nxml", "text": "\nQuestion 1\n\n\n1.  Does the application of early, interdisciplinary rehabilitation improve outcomes for people with traumatic brain injury?\n\nRationale:\nThe use of interdisciplinary rehabilitation varies in when it is applied.  The purpose of this question is to find out if there is evidence that the application of this intervention during treatment in the acute care hospital improves outcomes.\nThe use of interdisciplinary rehabilitation varies in when it is applied.  \nThe purpose of this question is to find out if there is evidence that the application of this intervention during treatment in the acute care hospital improves outcomes.\nDefinitions:\nEarly applies to the phase of treatment after discharge from the emergency department and prior to discharge from the acute care hospital.Interdisciplinary rehabilitation is an intervention that utilizes a variety of methods, usually including but not limited to physical therapy, occupational therapy, and speech therapy.\nEarly applies to the phase of treatment after discharge from the emergency department and prior to discharge from the acute care hospital.\nInterdisciplinary rehabilitation is an intervention that utilizes a variety of methods, usually including but not limited to physical therapy, occupational therapy, and speech therapy.\nPatient population:\nPeople who sustained traumatic brain injury between the ages of 18 and 65 years whose injury severity warranted admission to a hospital emergency department and subsequent transfer to acute care.\nPeople who sustained traumatic brain injury between the ages of 18 and 65 years whose injury severity warranted admission to a hospital emergency department and subsequent transfer to acute care.\nPatient characteristics:\nAge, severity of injury, pre-morbid data, mechanism of injury (kind of trauma and intracranial diagnosis), and functional status measure. Measures of injury severity include Glasgow Coma Scale Score and multiple injuries.\nAge, severity of injury, pre-morbid data, mechanism of injury (kind of trauma and intracranial diagnosis), and functional status measure. Measures of injury severity include Glasgow Coma Scale Score and multiple injuries.\nStudies must include or measure:\nAgeGlasgow Coma Scale ScoreSeverity of injuryMultiple injuriesPre-morbid dataMechanism of injury (kind of trauma)Intracranial diagnosisFunctional status measure\nAge\nGlasgow Coma Scale Score\nSeverity of injury\nMultiple injuries\nPre-morbid data\nMechanism of injury (kind of trauma)\nIntracranial diagnosis\nFunctional status measure\nOutcome measures:\nPresence or absence of complications (i.e., skin problems, pneumonia)Length of stay in hospital.Immediate care costs and long-term financial burden.Health status at discharge from the acute care hospital (ADLs, locomotion, and short-term functional status measure such as Disability Rating Scale).Long-term measure of impairment (loss or abnormality of psychological, physiological, or anatomical structure or function).Long-term measure of disability (restriction or lack [resulting from an impairment] of ability to perform an activity in the manner or within the range considered normal for a human being).\nPresence or absence of complications (i.e., skin problems, pneumonia)\nLength of stay in hospital.\nImmediate care costs and long-term financial burden.\nHealth status at discharge from the acute care hospital (ADLs, locomotion, and short-term functional status measure such as Disability Rating Scale).\nLong-term measure of impairment (loss or abnormality of psychological, physiological, or anatomical structure or function).\nLong-term measure of disability (restriction or lack [resulting from an impairment] of ability to perform an activity in the manner or within the range considered normal for a human being).\n\nQuestion 2\n\n\n2.  Does the intensity of inpatient rehabilitation affect outcomes for people with traumatic brain injury?\n\nRationale:\nThe application of inpatient rehabilitation varies in intensity.  The purpose of this question is to find out if there is evidence that a particular level of intensity of inpatient rehabilitation optimizes outcomes.\nThe application of inpatient rehabilitation varies in intensity.  \nThe purpose of this question is to find out if there is evidence that a particular level of intensity of inpatient rehabilitation optimizes outcomes.\nDefinitions:\nInpatient rehabilitation applies to the phase of treatment after discharge from the acute care hospital into an inpatient rehabilitation facility.\nInpatient rehabilitation applies to the phase of treatment after discharge from the acute care hospital into an inpatient rehabilitation facility.\nIntensity--Levels of the intervention vary in intensity based on:\n1Whether the intervention was directed and managed by a physiatrist.2Number, kinds, and frequency of methods applied.\nWhether the intervention was directed and managed by a physiatrist.\nNumber, kinds, and frequency of methods applied.\nPatient population:\nPeople who sustained traumatic brain injury between the ages of 18 and 65 years whose injury severity warranted admission to a hospital emergency department, transfer to acute care, and subsequent transfer to inpatient rehabilitation.\nPeople who sustained traumatic brain injury between the ages of 18 and 65 years whose injury severity warranted admission to a hospital emergency department, transfer to acute care, and subsequent transfer to inpatient rehabilitation.\nPatient characteristics:\nAge, severity of injury, pre-morbid data, mechanism of injury (kind of trauma and intracranial diagnosis) and functional status measure.  Measures of injury severity include Glasgow Coma Scale Score and multiple injuries.\nAge, severity of injury, pre-morbid data, mechanism of injury (kind of trauma and intracranial diagnosis) and functional status measure.  Measures of injury severity include Glasgow Coma Scale Score and multiple injuries.\nStudies must include or measure:\nAgeGlasgow Coma Scale ScoreSeverity of injuryMultiple injuriesPre-morbid dataMechanism of injury (kind of trauma)Intracranial diagnosisFunctional status measure\nAge\nGlasgow Coma Scale Score\nSeverity of injury\nMultiple injuries\nPre-morbid data\nMechanism of injury (kind of trauma)\nIntracranial diagnosis\nFunctional status measure\nOutcome measures:\nLength of stay in rehabilitation facility.Immediate care costs and long-term financial burden.Health status at discharge from inpatient rehabilitation (ADLs, locomotion, and short-term functional status measure such as Disability Rating Scale).Long-term measure of impairment (loss or abnormality of psychological, physiological, or anatomical structure or function).Long-term measure of disability (restriction or lack [resulting from an impairment] of ability to perform an activity in the manner or within the range considered normal for a human being).Independence, relationships, family life, satisfaction.\nLength of stay in rehabilitation facility.\nImmediate care costs and long-term financial burden.\nHealth status at discharge from inpatient rehabilitation (ADLs, locomotion, and short-term functional status measure such as Disability Rating Scale).\nLong-term measure of impairment (loss or abnormality of psychological, physiological, or anatomical structure or function).\nLong-term measure of disability (restriction or lack [resulting from an impairment] of ability to perform an activity in the manner or within the range considered normal for a human being).\nIndependence, relationships, family life, satisfaction.\n\nQuestion 3\n\n\n3.  Does the application of compensatory cognitive rehabilitation enhance outcomes for people who sustain traumatic brain injury?\n\nRationale:\nThe efficacy of cognitive rehabilitation is being questioned.  In addition, the application of the intervention may be based on patient resources; the availability may be based on regional differences.  The purpose of this question is to find out if there is evidence that compensatory cognitive rehabilitation is an effective intervention.\nThe efficacy of cognitive rehabilitation is being questioned.  In addition, the application of the intervention may be based on patient resources; the availability may be based on regional differences.  \nThe purpose of this question is to find out if there is evidence that compensatory cognitive rehabilitation is an effective intervention.\nDefinitions:\nCognitive rehabilitation -- Treatment to increase or improve the capacity to process and use incoming information so as to allow increased functioning in everyday life. Focus is correcting deficits in memory, concentration and attention, perception, learning, planning, sequencing, and judgment. The broad definition includes both methods to restore cognitive function and compensatory techniques, such as use of memory aids.\nCognitive rehabilitation -- Treatment to increase or improve the capacity to process and use incoming information so as to allow increased functioning in everyday life. \nFocus is correcting deficits in memory, concentration and attention, perception, learning, planning, sequencing, and judgment. The broad definition includes both methods to restore cognitive function and compensatory techniques, such as use of memory aids.\nPatient population:\nPeople who sustained traumatic brain injury between the ages of 18 and 65 years whose functional status level allows for employment and/or community integration, but who require an intervention to facilitate success.\nPeople who sustained traumatic brain injury between the ages of 18 and 65 years whose functional status level allows for employment and/or community integration, but who require an intervention to facilitate success.\nPatient characteristics:\nAge, severity of injury, pre-morbid data, mechanism of injury (kind of trauma and intracranial diagnosis), application and methods of inpatient rehabilitation, and chronicity at time of entry to out-patient program.\nAge, severity of injury, pre-morbid data, mechanism of injury (kind of trauma and intracranial diagnosis), application and methods of inpatient rehabilitation, and chronicity at time of entry to out-patient program.\nOutcome measures:\nADLs.Return to work/school, maintenance of job/school, long-term financial burden.Long-term measure of disability (restriction or lack [resulting from an impairment] of ability to perform an activity in the manner or within the range considered normal for a human being).Long-term measure of impairment (loss or abnormality of psychological, physiological, or anatomical structure or function).Independence, relationships, family life, satisfaction.\nADLs.\nReturn to work/school, maintenance of job/school, long-term financial burden.\nLong-term measure of disability (restriction or lack [resulting from an impairment] of ability to perform an activity in the manner or within the range considered normal for a human being).\nLong-term measure of impairment (loss or abnormality of psychological, physiological, or anatomical structure or function).\nIndependence, relationships, family life, satisfaction.\n\nQuestion 4\n\n\n4.  Does the application of supported employment enhance outcomes for people with traumatic brain injury?\n\nRationale:\nFor people who have sustained traumatic brain injury, the ability to maintain employment may be compromised by cognitive deficits and behaviors not normally accepted in the workplace.  The purpose of this question is to find out if there is evidence that the intervention of supported employment operates to facilitate job maintenance and success.\nFor people who have sustained traumatic brain injury, the ability to maintain employment may be compromised by cognitive deficits and behaviors not normally accepted in the workplace.  \nThe purpose of this question is to find out if there is evidence that the intervention of supported employment operates to facilitate job maintenance and success.\nDefinitions:\nSupported employment -- An intervention in which the occupational tasks and environment are modified specific to the needs of the patient, where training is modified according to the patient's deficits, and where responsibility for attendance and performance at a job are shared by a professional.\nSupported employment -- An intervention in which the occupational tasks and environment are modified specific to the needs of the patient, where training is modified according to the patient's deficits, and where responsibility for attendance and performance at a job are shared by a professional.\nPatient population:\nPeople who sustained traumatic brain injury between the ages of 18 and 65 years whose functional status level allows for employment, but who require an intervention to facilitate success.\nPeople who sustained traumatic brain injury between the ages of 18 and 65 years whose functional status level allows for employment, but who require an intervention to facilitate success.\nPatient characteristics:\nAge, severity of injury, pre-morbid data, mechanism of injury (kind of trauma and intracranial diagnosis), application and methods of inpatient rehabilitation, and chronicity at time of entry to supported employment program.\nAge, severity of injury, pre-morbid data, mechanism of injury (kind of trauma and intracranial diagnosis), application and methods of inpatient rehabilitation, and chronicity at time of entry to supported employment program.\nOutcome measures:\nJob maintenance.Job success.Efficiency.Types of work held relative to that of pre-injury.Income level relative to that of pre-injury.Immediate care costs and long-term financial burden.Independence, relationships, family life, satisfaction.\nJob maintenance.\nJob success.\nEfficiency.\nTypes of work held relative to that of pre-injury.\nIncome level relative to that of pre-injury.\nImmediate care costs and long-term financial burden.\nIndependence, relationships, family life, satisfaction.\n\nQuestion 5\n\n\n5.  Does the provision of long-term care coordination enhance the general functional status of people with traumatic brain injury?  What is the cost-effectiveness of the provision of this intervention?\n\nRationale:\nAs people with traumatic brain injury move through their recovery process, they may be particularly vulnerable during periods of transition.  Case management by a certified individual may not always be available or optimal; a family member may provide the service.  This question asks if there are benefits to continuity of care, and if so, what the costs are relative to those benefits.\nAs people with traumatic brain injury move through their recovery process, they may be particularly vulnerable during periods of transition.  \nCase management by a certified individual may not always be available or optimal; a family member may provide the service.  \nThis question asks if there are benefits to continuity of care, and if so, what the costs are relative to those benefits.\nDefinitions:\nCare coordination -- Service provided by someone other than the patient throughout phases of recovery that: \n\n1considers alternative interventions and venues relevant to the patient's needs,2considers available resources and/or identifies and secures new resources to fund the interventions, 3provides information to patient and family about alternatives, 4facilitates selection and implementation of the intervention that best represents the needs and desires of the patient and family, and 5monitors and communicates about the progress of the patient and family while the patient is participating in the intervention.A care coordinator may be a private contractor, representative of an agency, family member or friend, medical professional, or rehabilitation professional.\nCare coordination -- Service provided by someone other than the patient throughout phases of recovery that: \n\n1considers alternative interventions and venues relevant to the patient's needs,2considers available resources and/or identifies and secures new resources to fund the interventions, 3provides information to patient and family about alternatives, 4facilitates selection and implementation of the intervention that best represents the needs and desires of the patient and family, and 5monitors and communicates about the progress of the patient and family while the patient is participating in the intervention.\nconsiders alternative interventions and venues relevant to the patient's needs,\nconsiders available resources and/or identifies and secures new resources to fund the interventions, \nprovides information to patient and family about alternatives, \nfacilitates selection and implementation of the intervention that best represents the needs and desires of the patient and family, and \nmonitors and communicates about the progress of the patient and family while the patient is participating in the intervention.\nA care coordinator may be a private contractor, representative of an agency, family member or friend, medical professional, or rehabilitation professional.\nPatient population:\nPeople with traumatic brain injury between the ages of 18 and 65 years.\nPeople with traumatic brain injury between the ages of 18 and 65 years.\nPatient characteristics:\nAge, severity of injury, pre-morbid data, mechanism of injury (kind of trauma and intracranial diagnosis, application and methods of inpatient and/or out-patient rehabilitation. Identification of care coordinator.\nAge, severity of injury, pre-morbid data, mechanism of injury (kind of trauma and intracranial diagnosis, application and methods of inpatient and/or out-patient rehabilitation. Identification of care coordinator.\nOutcome measures:\nReturn to work/school, maintenance of job/school, long-term financial burden.Long-term measure of disability (restriction or lack [resulting from an impairment] of ability to perform an activity in the manner or within the range considered normal for a human being).Long-term measure of impairment (loss or abnormality of psychological, physiological, or anatomical structure or function).Independence, relationships, family life, satisfaction.\nReturn to work/school, maintenance of job/school, long-term financial burden.\nLong-term measure of disability (restriction or lack [resulting from an impairment] of ability to perform an activity in the manner or within the range considered normal for a human being).\nLong-term measure of impairment (loss or abnormality of psychological, physiological, or anatomical structure or function).\nIndependence, relationships, family life, satisfaction.", "pairs": [], "interleaved": []}
+{"file": "erta2_NBK32897/ch4.nxml", "text": "General Conclusions\nThe purpose of this document is to provide an exhaustive, evidence-based approach to rehabilitation for traumatic brain injury. In order to make this a feasible undertaking, five specific topics were selected from among the many aspects of TBI rehabilitation. These aspects were closely defined and then subjected to rigorous and explicit evidence-based literature review and analysis.\nIn producing a \"conclusions\" section to this work, two issues need to be addressed. First, the results of the literature investigations into the five topics should be summarized.  Second, their implications should be discussed. Because of the nature of the evidence-based medicine process and the overall weakness of the literature, however, these processes must be undertaken with care.\nAlthough formulated around specific questions, evidence-based medicine is driven by the literature. For instance, the questions that are developed at the outset are almost never directly reflected in any one individual study much less in a body of literature. Therefore, the results of evidence-based medicine efforts will be strongly influenced by the approaches to individual topics taken in the body of relevant literature and by the strength of those studies. Because of these constraints, it is hazardous to separate a synopsis of the conclusions of an evidence-based medicine analysis from the studies that specifically drive those conclusions. Unless there is a large body of Class I literature, separating summary statements from the strength of their supporting evidence vastly increases the risk of their misinterpretation. For that reason, the summary statements contained in this section with respect to the five questions are strictly limited to reflections of the statements made in their individual sections. Readers are strongly encouraged to study those sections prior to interpreting these summary statements.\nIn addition, because of the overall weakness of the literature as reflected in this work, clinical interpretation is hazardous. It must be remembered that the absence of evidence is not evidence of absence. Although none of the issues involved in TBI rehabilitation that are addressed in this work are supported by Class I evidence, it must be recognized that there also is not a similarly strong body of evidence standing in disproof. Therefore, because something has not been definitively proven as effective must not be interpreted to mean that it does not have clinical utility, should not be continued, or should not be funded. The proper interpretation would be that, in the presence of a need for treatment and the absence of clearly superior alternatives, choices must be made between therapies without proven superiority over others based on clinical pragmatism.\nFrom a funding viewpoint, it must also be recognized that there is a vast difference between making a choice between alternate therapies based on less than optimal evidence and denying an entire category of therapeutic management based on the absence of strong scientific proof of efficacy. The application of evidence-based medicine techniques to the current body of clinical literature over the past several years has effectively raised the scientific bar much higher than ever before. Although it is expected that the new height of the bar will be recognized by clinical researchers and result in significantly better design and more powerful studies in the future, the application of this new degree of rigor to studies done in even the recent past must be seen as an attempt to improve medicine, not paralyze it.\nSummary of Findings\nQuestion 1: Should interdisciplinary rehabilitation begin during the acute hospitalization for traumatic brain injury?\nOne small, retrospective, observational study from a single rehabilitation facility supports an association between the acute institution of formalized, multidisciplinary, physiatrist-driven TBI rehabilitation and decreased LOS (acute hospital and acute rehabilitation) and some measures of short-term physiologic (non-cognitive) patient outcome. The level of evidence is Class III. This study concerned patients with severe brain injury (GCS 3-8).  There is no evidence from comparative studies for or against early rehabilitation in patients with mild and moderate injury.\nDeriving clinical implications from the single Class III study that directly addresses this question must be done with trepidation. It is generally felt that the application of modalities such as physical therapy as early as possible following TBI is beneficial. In addition, the transition from acute stay at the trauma hospital to a rehabilitation facility for severe TBI patients is almost always driven by issues that are peripheral to the proper timing of rehabilitation efforts (e.g., systemic complications, bed availability, etc.). Since the one study did suggest that the institution of formalized, multidisciplinary, physiatrist-driven TBI rehabilitation efforts early in the posttraumatic period was favorably associated with short-term outcome and logistics, it would seem reasonable, based on the present body of literature, to include a physiatrist in the acute care team in as expedient a fashion as possible.\nQuestion 2: Does the intensity of inpatient interdisciplinary rehabilitation affect long-term outcomes?\nWhen measured as the hours of application of individual or group therapies, there is no indication that the intensity of acute-inpatient TBI rehabilitation is related to outcome. Because of methodological weaknesses, however, previous studies are likely to have missed a significant relationship if one exists (a Type II error). These studies contained insufficient information about severity of injury and baseline function to ensure the comparability of the compared groups. These studies also did not consider the quality of individual treatments, their lack of autonomy in the cognitive realm, and the delivery milieu. One or more of these factors might affect the outcome of care more than the time spent in each modality. Therefore, future research into efficacy of acute inpatient TBI rehabilitation must more adequately measure such factors and include them in their predictive models. Future studies also must employ a wider spectrum of outcome measures including measurement of outcomes for a longer period after discharge. Such an analysis would be an ideal application of a universal uniform data set.\nWith regard to the clinical aspect, the evidence does not support equating different systems of TBI rehabilitation delivery based on equivalent times of patient exposure to various therapeutic modalities. For example, this analysis would not support the assumption that patient benefit would be equal if an equal time spectrum of rehabilitation therapies were delivered at a rehabilitation center as compared with a skilled nursing facility. More detailed analysis of factors involved in predicting response to rehabilitation modalities must be considered in approaching such questions.\nAdditionally, mandating a minimum number of hours of applied therapy for all TBI patients is not supported by the present state of scientific knowledge. The issues of how much intervention optimizes recovery in a given type of patient remains inadequately studied. It is certainly reasonable to avoid situations in which patients do not receive potentially beneficial treatment. Based on the above studies, however, defining a minimum rehabilitation program in terms of time of applied therapy is not likely to optimize either therapist time or patient recovery. It is probable that a specific basic program will have to be related to individual patient groups. Developing such algorithms requires future research.\nMany people who suffer TBI do not enter acute inpatient rehabilitation. Only one study of the effectiveness of inpatient rehabilitation included a comparison group of patients who did not undergo inpatient rehabilitation. Future studies should compare acute, inpatient rehabilitation with commonly used alternatives to inpatient rehabilitation, such as care in a well-staffed, skilled nursing facility or in less intense variations of acute rehabilitation. Very little is known about the outcomes of TBI in these settings.\nQuestion 3: Does the application of compensatory cognitive rehabilitation enhance outcomes for people who sustain TBI?\nOne small randomized controlled trial (Class I) and one observational study (Class III) provide evidence of the direct effects of compensatory cognitive devices (notebooks, wristwatch alarms, programmed reminder devices) on the reduction of everyday memory failures for people with TBI. A second randomized controlled trial provides evidence that compensatory cognitive rehabilitation reduces anxiety and improves self-concept and interpersonal relationships for people with TBI. The level of evidence is Class II[a].\nTwo small randomized controlled trials (Class I) provide limited evidence that practice and computer-aided cognitive rehabilitation improve performance on laboratory-based measures of immediate recall. No studies evaluated the link between such cognitive tests and health outcomes, and the associations between performance on cognitive tests and employment in the literature were inconsistent.\nCurrent practice in cognitive rehabilitation lacks a firm basis in experimental clinical studies. It is unlikely that the studies we reviewed, designed to address effectiveness, accurately describe the totality of techniques, stimulation, and human effort and ingenuity that constitute cognitive rehabilitation programs, particularly if the programs are multi- or transdisciplinary. Therapists observe that their patients improve; what is causing the improvements is not understood. In making decisions about the course of treatment, clinicians are compelled to follow their experiences and observations until strong research designs provide evidence from which guidelines and standards can be derived.\nQuestion 4: Does the application of supported employment enhance outcomes for people with TBI?\nThere is some Class II evidence that supported employment can improve the vocational outcomes of survivors of TBI. Most of the evidence on the effects of supported employment comes from two programs of research, each of which used different experimental designs and different models of supported employment. Both designs used prospective data collection, but one compared the treatment group with an independent control, while the other was a case control study comparing preinjury employment with postinjury employment without and then with supported employment. The findings have not been replicated at other centers, so the results cannot be generalized to the general population of survivors of TBI. Most studies of supported employment in TBI research are of the individual placement model, but some evidence also supports the use of the apprenticeship model.\nThe evidence for improvement of vocational outcomes with supported employment is sufficient to warrant its use in practice while further research continues. However, much remains unknown about the amount of improvement that is actually gained by these programs and which components of the programs contribute most to the improved outcomes. It also may be important to explore other models of supported employment, like the apprenticeship model or some variations of the work enclave model.\nQuestion 5: Does the provision of long-term care coordination enhance the general functional status of people with TBI?\nVery few studies of the effectiveness of case management have been done, and results have been mixed. The clearest demonstration of improvement due to case management is in vocational status, where at least two studies, using different models of case management, showed similar improvements. One of these two programs showed superior results when a single case manager administered all the insurance benefits of each patient; the other showed results in the same direction using a combination of nurse and vocational case manager to select and time the interventions. There were conflicting results on other effects of case management, including disability or functional status, living status, and effects on the family, and some outcomes were mentioned in only one study. The clinical trial, using separate hospital systems randomly assigned to a case management condition, showed that there were no functional status changes among case management participants, despite an extended period of rehabilitation and followup. But, when two forms of case management were compared, both the single and multiple case manager/insurance models showed significant functional improvements.\nAlthough the present evidence is mixed, it seems warranted to continue the use of several case management models to select and time interventions in cases of TBI, and it also may be of benefit to survivors to have the advocacy by the case manager in finding and obtaining treatments. There is a certain face validity to the basic idea of case management, which is simply a matter of careful planning of the choice, sequence, and timing of interventions, and some variation of it is really a standard component of most clinical practice. Also, there probably is some value to the person with TBI of an advocate able to obtain benefits that otherwise would be missed by an unaided survivor.  The extent of the benefit of case management, however, remains undemonstrated, and more studies using control groups would be very beneficial in clarifying the actual improvement in outcomes due to case management. It also is unclear whether some models of case management are better than others and for what kinds of clients they might be best suited. These questions contribute to the agenda for future research.\nDue to the methods through which the above five topics have been approached in the literature and the relative absence of powerful studies in these areas, the conclusions reached by this evidence-based approach and the clinical implications drawn therefrom are extremely limited. As a direct result, the utility of this document in driving profound alterations in TBI rehabilitation based on the scientific literature is very restricted. Because this report is the product of an exhaustive review of the literature in these five areas, however, we are in an ideal position to be able to summarize the shortcomings of the studies in these fields and to make generalizable recommendations regarding how future efforts could be improved. Since the five topics addressed in this work run the temporal gamut from acute care through long-term survival, this document also serves as an ideal conduit for suggesting the means for optimizing continuity and consistency of research efforts across the spectrum of recovery from TBI. Because the ability to suggest improvements in research efforts in a knowledgeable fashion is probably the most valuable result of this work, special attention was directed to this area. For further information, readers are directed to the analyses of research shortcomings and sets of recommendations presented in the Aspen Consensus Conference proceedings (Chesnut, Alexander, Antoinette, et al., forthcoming).", "pairs": [], "interleaved": []}
+{"file": "erta2_NBK32897/app5.nxml", "text": "Research Team\nPrincipal Investigator\nRandall M. Chesnut, M.D.\nAssociate Professor of Neurological Surgery\nDirector, Neurotrauma and Neurosurgical Critical Care\nOregon Health Sciences University\nTask Order Manager\nNancy Carney, Ph.D.\nDivision of Medical Informatics and Outcomes Research\nOregon Health Sciences University\nN. Clay Mann, Ph.D.\nAssistant Professor of Emergency Medicine\nOregon Health Sciences University\nHugo Maynard, Ph.D.\nProfessor of Psychology\nPortland State University\nPortland, OR    \nPatricia Patterson, Ph.D.\nAssistant Professor of Nursing and Medical Informatics \nand Outcomes Research\nOregon Health Sciences University\nPetronella Davies, M.S.\nReference Librarian\nOregon Health Sciences University\nCynthia Davis-O'Reilly\nDivision of Medical Informatics and Outcomes Research\nOregon Health Sciences University\nMark C. Hornbrook, Ph.D.\nProgram Director\nHealth Services, Social and Economics Studies\nKaiser Permanente Center for Health Research\nSusan Mahon, M.P.H.\nResearch Associate\nDivision of Medical Informatics and Outcomes Research\nOregon Health Sciences University\nMartie Sucec\nSenior Technical Writer\nKaiser Permanente Center for Health Research\nJames Wallace\nOperations Director, Outcomes Research\nDivision of Medical Informatics and Outcomes Research\nOregon Health Sciences University\nMelanie Zimmer-Gembeck, Ph.D.\nSenior Data Analyst\nOffice of Planning and Development\nMultnomah County Health Department\nMark Helfand, M.D., M.P.H.\nDirector, Evidence-Based Practice Center \nAssociate Professor of Internal Medicine and Medical Informatics and Outcomes Research\nOregon Health Sciences University\nKathryn Pyle Krages, A.M.L.S., M.A.\nAdministrator, Evidence-Based Practice Center \nDivision of Medical Informatics and Outcomes Research\nOregon Health Sciences University\nNational Expert Panel\nBryna Helfter, M.A., C.T.R.S.\nDirector, Technical Assistance Center\nTraumatic Brain Injury State Demonstration Grant Program of Maryland\nJames Kelly, M.D.\nDirector, Brain Injury Program\nRehabilitation Institute of Chicago\nJeffrey Kreutzer, Ph.D.\nDirector of Rehabilitation Psychology and Neuropsychology\nMedical College of Virginia\nNathan Zasler, M.D.\nExecutive Medical Director, National NeuroRehabilitation Consortium, Inc.\nMedical Director, Concussion Care Centre of Virginia\nLocal Expert Panel\nRobert Brown \nSurvivor\nBrain Injury Support Group of Portland\nCarol Christofero-Snider\nSpouse of Survivor\nBrain Injury Support Group of Portland\nDanielle Erb, M.D.\nRehabilitation Medicine Associates\nMolly Hoeflich, M.D.\nPhysiatrist\nDaniel Irwin\nVocational Rehabilitation Division\nOregon Department of Human Services    \nDonald Lange, Ph.D.\nNeuropsychologist\nHugo Maynard, Ph.D.\nProfessor of Psychology\nPortland State University\nAimee Mooney, M.S.\nRehabilitation Program Coordinator\nLegacy Rehabilitation Services Community Re-entry Service   \nMeg Munger, R.N., M.S.\nRehabilitation Program Coordinator\nKaiser Permanente\nReviewers\nBrian Andrews, M.D., F.A.C.S.\nSan Francisco, CA\nRepresenting the American Association of Neurological Surgeons\nHarriet Udin Aronow, Ph.D.\nAssociate Director of Research\nCasa Colina Hospital for Rehabilitative Medicine\nLos Angeles, CA\nDawn Bunting, M.S.N., R.N.\nPlantsville, CT\nRepresenting the Association of Rehabilitation Nurses\nConsensus Development Conference Panel for Rehabilitation of Persons with Traumatic Brain Injury\nc/o Judith M. Whalen\nAssociate Director for Science Policy, Analysis and Communication\nNational Institute of Child Health and Human Development\nBethesda, MD\nPatricia Goodall\nVA Department of Rehabilitative Services\nRichmond, VA\nRepresenting the Association for Persons in Supported Employment\nRichard J. Greenwood, M.D., F.R.C.P.\nRegional Neurological Rehabilitation Unit\nHomerton Hospital\nLondon, England\nCandace F. Gustafson, R.N.\nBurlington, MA\nRepresenting the Development Conference Panel for Rehabilitation of Persons with Traumatic Brain Injury\nAllen Heinemann, Ph.D.\nRehabilitation Institute of Chicago\nChicago, IL\nJess F. Kraus, Ph.D.\nSouthern California Injury Prevention Research Center\nUCLA School of Public Health\nLos Angeles, CA\nRepresenting the Brain Injury Association\nMark Melgard, M.D.\nWorkers Compensation Division\nDepartment of Consumer & Business Services\nState of Oregon\nSalem, OR  \nAnthony Morgan, M.D., F.A.C.S.\nChief of Trauma Services\nSaint Francis Hospital and Medical Center\nHartford, CT\nThomas Novack, Ph.D.\nSpain Rehabilitation Center\nBirmingham, AL\nKristjan T. Ragnarsson, M.D.\nDepartment of Rehabilitation Medicine\nMount Sinai Medical Center\nNew York, NY\nRepresenting the Consensus Development Conference Panel for Rehabilitation of Persons with Traumatic Brain Injury\nCheryl Ramandan-Jradi\nMercer Island, WA\nRepresenting the American Occupational Therapy Association\nRonald Ruff, Ph.D.\nSan Francisco Neuropsychology Associates\nSan Francisco, CA\nBarbara Scheffel, R.N.\nScheffel Associates, Inc.\nBedminster, NJ\nRepresenting the Case Management Association of America\nMaureen Schmitter-Edgecombe, Ph.D.\nDepartment of Psychology\nWashington State University\nPullman, WA\nMarymargaret Sharp-Pucci, Ed.D., M.P.H.\nTechnology Evaluation Center\nBlue Cross Blue Shield Association\nChicago, IL\nMcKay Moore Sohlberg, Ph.D.\nDepartment of Communications Disorders & Sciences\nUniversity of Oregon\nEugene, OR\nLinda Toms Barker\nBerkeley Planning Associates\nOakland, CA\nCharles Turkelson, Ph.D.\nECRI\nPlymouth Meeting, PA\nDennis A. Turner, M.D.\nDivision of Neurosurgery\nDuke University Medical Center\nDurham, NC\nProfessor Barbara Wilson\nMedical Research Council \nApplied Psychology Unit\nAddenbrooke's Hospital\nCambridge, England\nMark Ylvisaker, Ph.D.\nDepartment of Communications Disorders\nCollege of Saint Rose\nSchenectady, NY\nNathan Zasler, M.D.\nExecutive Medical Director, NationalNeuroRehabilitation Consortium, Inc.\nMedical Director, Concussion Care Centre of Virginia\nGlen Allen, VA", "pairs": [], "interleaved": []}
+{"file": "erta2_NBK32897/sec1.nxml", "text": "ADL: Activities of daily living\nAHCPR: Agency for Health Care Policy and Research\nAIS: Abbreviated injury score\nANCOVA: Analysis of covariance\nBVRT: Benton Visual Retention Test\nCACR: Computer-aided cognitive rehabilitation\nCCR: Compensatory cognitive rehabiliation\nCFT: ComplexTest\nCIQ: Community Integration Questionnaire\nCT: Computerized tomography\nD/C: Discharge\nDRS: Disability rating scale\nEMF: Everyday memory failure\nEPC: Evidence-based Practice Center\nFAM: Functional Adaptability Measure\nFIM: Functional Independence Measure\nGCS: Glasgow Coma Scale\nGOS: Glasgow Outcomes Scale\nHCFA: Health Care Financing Administration\nICP: Intracranial pressure\nILP: Independent living programs\nISS: Injury severity scale\nKAS: Katz Adjustment Scale\nLOS: Length of stay\nMANOVA: Multivariable analysis of variance\nMAR: Monthly activity ratio\nMER: Monthly employment ratio\nMMPI: Minnesota Multiphasic Personality Inventory\nOHSU: Oregon Health Sciences University\nOT: Occupational therapy\nPAI: Portland Adaptability Inventory\nPASAT: Paced Auditory Serial Addition Task\nPT: Physical therapy\nPTA: Post-traumatic amnesia\nRBMT: Rivermead Behavioral Memory Test\nRCR: Restorative cognitive rehabilitation\nRCT: Randomized, controlled trial\nRKE: Rabideau Kitchen Evaluation\nRLA: Ranch Los Amigo\nRLAS: Ruff Language Assessment Scale\nRT: Reaction time\nSRT: Selective Reminding Test\nST: Speech therapy\nTBI: Traumatic brain injury\nTCDB: Traumatic Coma Data Bank\nTEP: Transitional employment program\nTLT: Trail Learning Test\nVerPa: Verbal Paired Associated Task\nVisPa: Visual Paired Associates Task\nWAIS: Wechser Adult Intelligence Scale\nWMS: Wechser Memory Scale\nWRP: Work reentry program", "pairs": [], "interleaved": []}
+{"file": "erta2_NBK32897/app3.nxml", "text": "\n\n", "pairs": [], "interleaved": []}
+{"file": "erta2_NBK32897/fmsec--1-A1281.nxml", "text": "The authors thank the members of the Brain Injury Support Group of Portland for their\n            support and the use of their library. They also thank the Portland State University\n            Capstone students who volunteered their time to help with the project: Heather Brooks,\n            Samantha Cohen, Justin Davis, Cynthia Davis-O'Reilly, Julie Geil, Cheryl Matsumura, and\n            Jeana Schoonover.\nThe American Academy of Family Practice provided the model, its Clinical Policy Review\n            Form, on which the authors based their review form for this report.", "pairs": [], "interleaved": []}
+{"file": "erta2_NBK32897/app2.nxml", "text": "\n1. \t MEDLINE search string\n\nMEDLINE  Initial Strategy  (Identical for all questions) - 1993 to November 1997\n\n1Explode Head Injuries/Rehab2Explode Head/Injury3rh.fs.42 and 35Head injur $.tw6Brain injur $.tw75 or 687 and 391 or 4 or 8\nExplode Head Injuries/Rehab\nExplode Head/Injury\nrh.fs.\n2 and 3\nHead injur $.tw\nBrain injur $.tw\n5 or 6\n7 and 3\n1 or 4 or 8\nMEDLINE Questions 1 and 2 Strategy\n\n10Limit 9 to human11Exp hospitals/12Accute.tw.13Exp intensive care units14Early.tw.15Length of stay/16Exp emergency medical services/17Emergency medicine/18Exp hospitalization/19Interdisciplinary rehabil$.tw.20Speech therapy/21Physiatry.tw.22Exp physical therapy/23Physical therapy department, hospital/24Occupational therapy/25Occupational therapy department, hospital/26Exp rehabilitation/27Exp rehabilitation centers/28Rehabilitation.tw.2919 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 2830Exp head injuries/3129 and 303210 or 313311 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 283432 and 3335Exp clinical trials3632 and 3537From 36 keep 1-438From 34 keep 1-5, 8-12, 14, 18, 20-22, 25, 27-28\nLimit 9 to human\nExp hospitals/\nAccute.tw.\nExp intensive care units\nEarly.tw.\nLength of stay/\nExp emergency medical services/\nEmergency medicine/\nExp hospitalization/\nInterdisciplinary rehabil$.tw.\nSpeech therapy/\nPhysiatry.tw.\nExp physical therapy/\nPhysical therapy department, hospital/\nOccupational therapy/\nOccupational therapy department, hospital/\nExp rehabilitation/\nExp rehabilitation centers/\nRehabilitation.tw.\n19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28\nExp head injuries/\n29 and 30\n10 or 31\n11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28\n32 and 33\nExp clinical trials\n32 and 35\nFrom 36 keep 1-4\nFrom 34 keep 1-5, 8-12, 14, 18, 20-22, 25, 27-28\nMEDLINE Question 3 Strategy\n\n10Limit 9 to human11Exp cognition/12Exp cognition disorders/13Cognit$.tw14Exp memory/15Exp memory disorders/16Attention/17exp perception/18exp learning19exp learning disorders/20judgment/2111 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 192210 and 2123from 22 keep 2-3, 8, 11, 14-15, 17-18, 20-21, 23\nLimit 9 to human\nExp cognition/\nExp cognition disorders/\nCognit$.tw\nExp memory/\nExp memory disorders/\nAttention/\nexp perception/\nexp learning\nexp learning disorders/\njudgment/\n11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19\n10 and 21\nfrom 22 keep 2-3, 8, 11, 14-15, 17-18, 20-21, 23\nMEDLINE Question 4 Strategy\n\n10Limit 9 to human11Exp employment/12Work capacity evaluation/13Exp work/14absenteeism/15Employment.tw.16Employed.tw.17Vocational education/18Exp rehabilitation, vocational/\nsheltered workshops/11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 1910 and 20from 21 keep 1-10, 12-13, 15-16, 18-26, 28-38, 40exp brain injuries/20 and 2324 not 21limit 25 to humanfrom 26 keep 7-9, 19, 22, 29\nLimit 9 to human\nExp employment/\nWork capacity evaluation/\nExp work/\nabsenteeism/\nEmployment.tw.\nEmployed.tw.\nVocational education/\nExp rehabilitation, vocational/\nsheltered workshops/\n11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19\n10 and 20\nfrom 21 keep 1-10, 12-13, 15-16, 18-26, 28-38, 40\nexp brain injuries/\n20 and 23\n24 not 21\nlimit 25 to human\nfrom 26 keep 7-9, 19, 22, 29\nMedline Question 5 Strategy\n\n10case management/11exp home nursing/12forecasting/13follow-up studies/14long term.tw.15longterm.tw.16social work/\n\n10 or 11 or 12 or 13 or 14 or 15 or 16exp *brain injuries/9 or 1817 and 19limit 20 to human10 or 11 or 1622 and 21from 23  keep 1-2, 4-821 not 23from 25 keep 5-8, 11-13, 15, 20, 23, 32, 35-36, 38\ncase management/\nexp home nursing/\nforecasting/\nfollow-up studies/\nlong term.tw.\nlongterm.tw.\nsocial work/\n\n10 or 11 or 12 or 13 or 14 or 15 or 16exp *brain injuries/9 or 1817 and 19limit 20 to human10 or 11 or 1622 and 21from 23  keep 1-2, 4-821 not 23from 25 keep 5-8, 11-13, 15, 20, 23, 32, 35-36, 38\n10 or 11 or 12 or 13 or 14 or 15 or 16\nexp *brain injuries/\n9 or 18\n17 and 19\nlimit 20 to human\n10 or 11 or 16\n22 and 21\nfrom 23  keep 1-2, 4-8\n21 not 23\nfrom 25 keep 5-8, 11-13, 15, 20, 23, 32, 35-36, 38\n\n2.\tHealthSTAR search strings\n\nHealthSTAR  strategy  (identical for all questions) \t1993 to November 1997\n\n1Explode Head Injuries/Rehab2Explode Head/Injury3rh.fs.42 and 35Head injur$.tw6Brain injur $.tw75 or 687 and 3\nExplode Head Injuries/Rehab\nExplode Head/Injury\nrh.fs.\n2 and 3\nHead injur$.tw\nBrain injur $.tw\n5 or 6\n7 and 3\n\n1 or 4 or 8\n1 or 4 or 8\n\n3.\tCINAHL search strings\n\nCINAHL general search strategy  (all questions)\t\t1982 to October 1997\n\namerican journal of occupational therapy.jnarchives of physical medicine and rehabilitatclinical rehabilitation.jn.disability & rehabilitation.jn.international journal of rehabilitation resjournal of rehabilitation research & develophysical therapy.jn.quality of life research.jn.rehabiliation nursing.jn.rehabiliation.jn.9 or 10scandinavian journal of rehabiliation mediscandinavian journal of rehabiliation medi1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10exp brain injuries/brain injur$.tw.15 or 16exp rehabiliation/rh.fs.18 or 1917 and 3021 not 14from 22 keep 1-7, 9-10, 12-13, 15-20, 22-24, 26from 22 keep 6, 12-13, 15-16, 20-22, 24, 29-30, 3323 or 24brain injury.jn.22 not 2625 not 2627 not 28from 29 keep 6-7, 14, 17, 20, 22, 25, 32-33, 35-3628 or 3022 not 31\namerican journal of occupational therapy.jn\narchives of physical medicine and rehabilitat\nclinical rehabilitation.jn.\ndisability & rehabilitation.jn.\ninternational journal of rehabilitation res\njournal of rehabilitation research & develo\nphysical therapy.jn.\nquality of life research.jn.\nrehabiliation nursing.jn.\nrehabiliation.jn.\n9 or 10\nscandinavian journal of rehabiliation medi\nscandinavian journal of rehabiliation medi\n1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10\nexp brain injuries/\nbrain injur$.tw.\n15 or 16\nexp rehabiliation/\nrh.fs.\n18 or 19\n17 and 30\n21 not 14\nfrom 22 keep 1-7, 9-10, 12-13, 15-20, 22-24, 26\nfrom 22 keep 6, 12-13, 15-16, 20-22, 24, 29-30, 33\n23 or 24\nbrain injury.jn.\n22 not 26\n25 not 26\n27 not 28\nfrom 29 keep 6-7, 14, 17, 20, 22, 25, 32-33, 35-36\n28 or 30\n22 not 31\n\n4.\tPyschInfo search string\n\nPsycInfo search strategy  (all questions)\t\t1982 to October 1997\n\nexp brain damage/exp head injuries/2 not 1brain.tw.3 and 41 or 5exp cognitive rehabilitationexp rehabilitationexp rehabilitation centers/exp vocational rehabilitation/exp employment status/exp case management/clinical trials.tw.7 or 8 or 9 or 10 or 11 or 12 or 136 and 14\nexp brain damage/\nexp head injuries/\n2 not 1\nbrain.tw.\n3 and 4\n1 or 5\nexp cognitive rehabilitation\nexp rehabilitation\nexp rehabilitation centers/\nexp vocational rehabilitation/\nexp employment status/\nexp case management/\nclinical trials.tw.\n7 or 8 or 9 or 10 or 11 or 12 or 13\n6 and 14\n\n5.\tCurrent Contents search string\n\nCurrent Contents search strategy ( all questions) \tWeek 01, 1998 to Week 21, 1998\n\nhead injur$.ab,ti,kw,kp.Brain injur$.ab,ti.kw,kp.1 or 2\nhead injur$.ab,ti,kw,kp.\nBrain injur$.ab,ti.kw,kp.\n1 or 2", "pairs": [], "interleaved": []}
+{"file": "erta2_NBK32897/app4.nxml", "text": "Abstraction Instrument, items 1-17\u2028\nAbstraction Instrument, items 18-28\u2028\nAbstraction Instrument, items 29-37\u2028\nAbstraction Instrument, Question #1: Does the Application of Early,\nInterdisciplinary Rehabilitation Improve Outcomes for Persons With Traumatic Brain\nInjury? (items 1-7)\u2028\nAbstraction Instrument, Question 1, items 8-12\u2028\nAbstraction Instrument, \nQuestion #2: Does the Intensity of In-Patient Rehabilitation Affect Outcomes for\nPersons With Traumatic Brain Injury? (items 1-5)\u2028\nAbstraction Instrument, Question 2, items 6-11\u2028\nAbstraction Instrument, Question #3:  Does the Application of Compensatory\nCognitive Rehabilition Enhance Outcomes for Persons Who Sustain Traumatic Brain Injury\n(items 1-8)\u2028\nAbstraction Instrument, Question 3, items 9-13\u2028\nAbstraction Instrument, Question #4: Does the Application of supported Employment\nEnhance Outcomes for Persons With Traumatic Brain Injury? (items 1-8)\u2028\nAbstraction Instrument, Question 4,  items 9-11\u2028\nAbstraction Instrument, Question #5: Does the Provision of Long-Term Care\nCoordination Enhance the General Functional Status of Persons With Traumatic Brain\nInjury?  What is the Cost-Effectiveness of the Provision of this Intervention? (items 1-9\u2028\nAbstraction Instrument, Question 5 item 10\u2028", "pairs": [], "interleaved": []}
+{"file": "erta2_NBK32897/fmsec--3-A1286.nxml", "text": "Background\nAdvances in medical technology and improvements in regional trauma services have\n                increased the number of survivors of traumatic brain injury (TBI), producing the\n                social consequences and medical challenges of a growing pool of people with\n                disabilities. Wider awareness of the scope of the problem and its consequences for\n                society has led to rapid growth in the rehabilitation industry. Because of this\n                growth and particularly because clinical rehabilitation strategies vary widely, many\n                groups are interested in the effectiveness of rehabilitation for TBI.\nTo address this need to identify and assess evidence on TBI rehabilitation, the\n                Agency for Health Care Policy and Research awarded a contract to Oregon Health\n                Sciences University for a review of published reports and compilation of an evidence\n                report. This summary highlights information presented in the full report. \nImpact of Traumatic Brain Injury\nInjury is the leading cause of mortality among Americans under 45 years of age; TBI\n                is responsible for the majority of these deaths. An estimated 56,000 lives are lost\n                in the United States each year to TBI. Motor vehicle accidents, followed by gunshot\n                injuries and falls, are the leading causes of injuries resulting in death from TBI.\n                Males are 3.4 times as likely as females to die of TBI. About 50 percent of people\n                who sustain TBI are intoxicated at the time of injury.\nIn a recent analysis based on hospital discharge data and vital statistics, the\n                annual incidence of TBI in the United States was estimated to be 102.8 per 100,000.\n                In males, the incidence peaks between the ages of 15 and 24 (248.3 per 100,000) and\n                again above 75 years of age (243.4 per 100,000). The incidence in females peaks in\n                the same age groups, but the absolute rates are lower (101.6 and 154.9,\n                respectively). These rates underestimate the true incidence of head trauma because\n                patients with milder symptoms at the time of injury usually are not hospitalized. \nAbout three-quarters of traumatic brain injuries that require hospitalization are\n                nonfatal. Each year, about 80,000 survivors of TBI will incur some disability or\n                require increased medical care. Direct medical costs for TBI treatment have been\n                estimated at $48.3 billion per year, including the costs of hospitalization for\n                acute care and various rehabilitation services. In the years 1988 to 1992, reports\n                of average length of stay (LOS) for the initial admission for inpatient\n                rehabilitation range from 40 to 165 days. In one multicenter study (the Model\n                Systems study), the average rehabilitation LOS was 61 days, and the average charge\n                was $64,648 exclusive of physician fees. Total charges averaged $154,256. In more\n                recent studies performed in the early 1990s, rehabilitation LOS and charges were\n                lower, ranging from 19 days and $24,000 for patients with milder injuries to 27 days\n                and $38,000 for those with severe injuries. In the Medicare population in 1994, mean\n                charges for patients admitted for brain injury (excluding stroke) were $42,056.\nTo focus attention on important questions, the life of an adult survivor of TBI was\n                characterized by the developers of the report in terms of five phases. The first\n                phase is pre-injury. Medical treatment is divided into two phases: the acute (or\n                immediate) treatment phase and the intensive treatment phase, lasting days to weeks.\n                The rehabilitation phase may last months to years. The survivor phase implies the\n                remaining life of the person with TBI and involves continual development and\n                adjustment. This division into phases clarifies the three challenges to assessing\n                the efficacy of rehabilitation discussed above. For each phase, patient populations,\n                interventions, and outcome measures were identified, and the literature was reviewed\n                to answer key questions identified by technical experts.\nKey Questions About Traumatic Brain Injury\nThe following three questions about the status of brain injury research underlie\n                uncertainty about the effectiveness of rehabilitation services.\n\n1How should fundamental concepts such as recovery, functional status, and\n                            disability be defined? Because brain function is highly complex, TBI has\n                            an extremely wide range of potential outcomes, including cognitive\n                            deficits, motor disabilities, emotional and social dysfunction,\n                            personality changes, and changes in appearance. As a result, therapeutic\n                            aims and perspectives vary widely among studies, as do definitions of\n                            outcomes, making valid comparisons across studies difficult.2How should the type and severity of the injury itself be measured?\n                            Variations in methods to assess the severity of injury in patients\n                            entering rehabilitation make it difficult to estimate the effectiveness\n                            of different rehabilitation methods.3Which therapies are effective, and what is the best way to match patients\n                            with treatment approaches likely to be effective for them?\n\nHow should fundamental concepts such as recovery, functional status, and\n                            disability be defined? Because brain function is highly complex, TBI has\n                            an extremely wide range of potential outcomes, including cognitive\n                            deficits, motor disabilities, emotional and social dysfunction,\n                            personality changes, and changes in appearance. As a result, therapeutic\n                            aims and perspectives vary widely among studies, as do definitions of\n                            outcomes, making valid comparisons across studies difficult.\nHow should the type and severity of the injury itself be measured?\n                            Variations in methods to assess the severity of injury in patients\n                            entering rehabilitation make it difficult to estimate the effectiveness\n                            of different rehabilitation methods.\nWhich therapies are effective, and what is the best way to match patients\n                            with treatment approaches likely to be effective for them?\nToday, a person's path to rehabilitation after sustaining brain injury may be\n                determined by the mechanism of injury, the resources of the community, the person's\n                employment or financial status, the consent of the family, and/or the accuracy of\n                the emergency department diagnosis. While a few metropolitan areas have organized\n                referral systems that connect patients with resources and rehabilitation programs,\n                systematic methods for evaluating the needs of people who have sustained brain\n                injury and referring them to appropriate programs are unusual. Without knowing the\n                efficacy of rehabilitation methods in their specific applications, systematic\n                referral that produces the desired result is not possible.\nReporting the Evidence\nTwo panels of experts worked with the research team to identify key questions in the\n                rehabilitation and survivor phases for adults with TBI. The first panel was composed\n                of two physiatrists, a survivor of TBI, the wife of a survivor of TBI, a State\n                vocational rehabilitation counselor, a neuropsychologist, a psychologist, a clinical\n                coordinator of an outpatient TBI rehabilitation program, and a rehabilitation\n                clinical nurse specialist, all from the Portland, OR, area. The second panel was\n                composed of nationally recognized experts in rehabilitation.\nThe panels formulated five questions pertaining to the phases of recovery described\n                above. These questions addressed the effectiveness of (1) early rehabilitation in\n                the acute care setting (timing), (2) intensity of rehabilitation, (3) cognitive\n                rehabilitation, (4) supported employment, and (5) care coordination (case\n                management). For each of these questions, members of the research team worked with\n                panelists to write a brief rationale for the question, define key terms, and specify\n                the relevant patient populations, interventions, and outcome measures to be examined\n                in the literature review. The questions were: \nShould interdisciplinary rehabilitation begin during the acute\n                            hospitalization for traumatic brain injury?Does the intensity of inpatient interdisciplinary rehabilitation affect\n                            long-term outcomes?Does the application of cognitive rehabilitation enhance outcomes for\n                            people who sustain TBI?Does the application of supported employment enhance outcomes for people\n                            with TBI?Does the provision of long-term care coordination enhance the general\n                            functional status of people with TBI?\nShould interdisciplinary rehabilitation begin during the acute\n                            hospitalization for traumatic brain injury?\nDoes the intensity of inpatient interdisciplinary rehabilitation affect\n                            long-term outcomes?\nDoes the application of cognitive rehabilitation enhance outcomes for\n                            people who sustain TBI?\nDoes the application of supported employment enhance outcomes for people\n                            with TBI?\nDoes the provision of long-term care coordination enhance the general\n                            functional status of people with TBI?\nMethodology\nA MEDLINE search (1976 to 1997), supplemented by searches of HealthSTAR (1995 to\n                1997), CINAHL (1982 to 1997), and PsycINFO (1984 to 1997), produced a total of 3,098\n                references to be considered for inclusion; of these, 569 applied to questions 1 and\n                2, 600 applied to question 3, 392 applied to question 4, and 975 applied to question\n                5.\nAbstracts of each article retrieved by these searches were reviewed independently by\n                two members of the research team, who applied predefined, broad eligibility\n                criteria. When the two reviewers disagreed, a third reviewer read the abstract and\n                cast the deciding vote on whether it should be included. In the event a reference\n                did not have an abstract, and the title for the reference was not sufficient for\n                determination of status, the article was retrieved and reviewed to determine its\n                eligibility. The two reviewers examined each abstract and indicated whether it met\n                the inclusion criteria and, if not, the reason for exclusion. If the abstract was\n                eligible, or if it did not contain sufficient information to determine eligibility,\n                the full text of the article was retrieved for review in the next phase of the\n                selection process. \nEighty-seven articles pertaining to questions 1 and 2, 114 articles for question 3,\n                93 articles for question 4, and 69 articles for question 5 passed the eligibility\n                screen. Sixty-seven additional articles were recommended for inclusion by experts or\n                by review of reference lists of review articles. In all, 363 articles were retrieved\n                for review and abstraction.\nAdditional criteria for inclusion were defined separately for each of the five\n                questions. The criteria varied because the necessary types of studies varied from\n                question to question. Articles that applied to more than one question were\n                maintained as duplicates (or triplicates, etc.) in each question-specific file, so\n                they could be considered for inclusion based on their relevance to each question. \nData Abstraction\nAn instrument was designed to record data abstracted from each eligible article. The\n                instrument includes items for patient characteristics, interventions,\n                cointerventions, outcomes, study methods, relevance to the specific research\n                questions, and results of the study. The instrument has two components: the first\n                three pages of the instrument apply to all articles specified for inclusion in the\n                study; the remaining pages are individual instruments that apply to one of the five\n                questions. To abstract an article, a reader used the initial abstraction instrument\n                plus one or more of the five question instruments.\nThe first few questions of the initial abstraction instrument allowed the reviewer to\n                determine if the article actually met the eligibility criteria for inclusion in the\n                report. If an article was determined to be ineligible, it was passed to a second\n                reader for confirmation. The remaining articles were subjected to the full\n                abstraction protocol.\nSpecification of Level of Evidence\nA three-level system was used to rate individual studies. Well-designed randomized\n                controlled trials (RCTs) were rated as Class I. Studies rated as Class II were RCTs\n                with design flaws; well-done, prospective, quasiexperimental or longitudinal\n                studies; and case-control studies. Case reports, uncontrolled case series, and\n                expert or consensus opinion were generally rated Class III. A well-done,\n                prospective, multicenter or population-based case series can provide valuable\n                information that, in some ways, is more reliable than data from a randomized trial\n                done in a highly selected sample of patients. However, when used to make inferences\n                about effectiveness, an uncontrolled case series is generally classified as Class\n                III, indicating the lowest level of confidence.\nA \"gray zone\" exists between Class II and definite Class III articles. Much of the\n                research in rehabilitation uses quasiexperimental designs. In these observational\n                study designs, control subjects are sometimes identified from a separate patient\n                population. For instance, one group of researchers compared patients undergoing\n                inpatient rehabilitation to a sample of people with TBI who had been treated in a\n                region of the country where formal inpatient TBI rehabilitation was not available.\n                This was an entirely separate patient group, and all the data except outcome\n                measures came from an independent database.\nThe main difficulty with the quasi-experimental design is lack of control over the\n                constitution of the compared groups. Because there is no randomization and generally\n                no control over the details of the selection process through which the patients\n                received their separate therapies, the groups are likely to differ in the frequency\n                of characteristics that are associated with the outcomes of interest. Even when\n                significant efforts are made to match the experimental and the quasi-control groups,\n                it is likely that significant differences between the groups will remain.\nMuch of the literature relevant to the five questions addressed in this effort falls\n                into the \"gray zone\" between Class II and Class III. For this reason, critical\n                appraisal of key studies played a particularly important role in this review. A\n                number of characteristics of these studies were considered relevant to all\n                rehabilitation questions and were recorded in the data abstraction form. Evaluation\n                of the following factors played a major role in critically appraising these\n                articles: \nProspective collection of data.Complete description of parent study population.Large study population (driven by hypothesis, power, type I error\n                            threshold).Study setting--a single center, many centers, or population based.Description of reasons for referral to service being studied.Description of methods sufficiently complete to permit study\n                            replication.Complete description of rehabilitation technique in question (independent\n                            variable).Complete description of differences between \"control\" and \"experimental\"\n                            groups.Conditions determining whether patients did or did not receive the\n                            rehabilitation technique in question.Information about potential confounders, including types and severity of\n                            injury, age, and others (including, in some cases, economic status,\n                            educational level, lack of family support).Measurement of confounding variables using instruments validated as\n                            accurate, sensitive, and reliable.Payer group.Choice of outcome variables that are meaningful to patients and\n                            caregivers.Use of functional status and other health outcomes rather than surrogate\n                            (intermediate) outcomes.Measurement of outcome variables using instruments validated as accurate,\n                            sensitive, and reliable.Timing of outcome measurements.Assessment of patient characteristics and outcomes by blinded\n                            observer.Use of multivariate statistical analysis: Were interactions sought and\n                            controlled for? Were risk estimates calibrated? Were all relevant\n                            confounders included as candidate variables?\nProspective collection of data.\nComplete description of parent study population.\nLarge study population (driven by hypothesis, power, type I error\n                            threshold).\nStudy setting--a single center, many centers, or population based.\nDescription of reasons for referral to service being studied.\nDescription of methods sufficiently complete to permit study\n                            replication.\nComplete description of rehabilitation technique in question (independent\n                            variable).\nComplete description of differences between \"control\" and \"experimental\"\n                            groups.\nConditions determining whether patients did or did not receive the\n                            rehabilitation technique in question.\nInformation about potential confounders, including types and severity of\n                            injury, age, and others (including, in some cases, economic status,\n                            educational level, lack of family support).\nMeasurement of confounding variables using instruments validated as\n                            accurate, sensitive, and reliable.\nPayer group.\nChoice of outcome variables that are meaningful to patients and\n                            caregivers.\nUse of functional status and other health outcomes rather than surrogate\n                            (intermediate) outcomes.\nMeasurement of outcome variables using instruments validated as accurate,\n                            sensitive, and reliable.\nTiming of outcome measurements.\nAssessment of patient characteristics and outcomes by blinded\n                            observer.\nUse of multivariate statistical analysis: Were interactions sought and\n                            controlled for? Were risk estimates calibrated? Were all relevant\n                            confounders included as candidate variables?\nThe criteria used to classify articles and the features to be considered in\n                critically appraising them were discussed at the subcommittee, committee, national\n                expert panel, and Aspen Neurobehavioral Conference levels with the goal of\n                maintaining consensus at least on the relative stratification of individual\n                articles. \nConstruction of Evidence Tables\nEvidence tables were constructed to summarize the best evidence about effectiveness\n                pertaining to each question. No randomized trials and only a few quasiexperimental\n                studies were available for questions 1 and 2. There were a large number of relevant\n                observational studies of important relationships (for example, the relation of\n                patient characteristics to outcome); studies that concerned individual causal links\n                or relationships in evidence tables were not summarized. For question 3, addressing\n                cognitive rehabilitation, 15 randomized controlled trials and comparative studies\n                that met specified inclusion criteria were placed into evidence tables. All\n                comparative studies located for the last two questions, which addressed supported\n                employment and care coordination, were included in evidence tables.\nCritical Appraisal of Key Articles\nFor each of the five questions, subcommittees were formed consisting of one or two\n                members of the research team and one or two members of the local technical panel.\n                Each subcommittee was chaired by a member of the research team. Key articles\n                relevant to the assigned question were reviewed in depth by all members of the\n                subcommittees. These reviews were discussed among the various members of the\n                subcommittees, and the results were summarized by the chair. This was an effort to\n                ensure that the summary statements on the research questions reflected the expertise\n                and experience of a variety of technical experts with relevant skills and training.\n                These interpretive efforts addressed the methods and results of individual studies,\n                their rating, and their scientific importance.\nAll of the critical articles for the five questions were individually read by the\n                principal investigator. Summaries were presented and discussed with national experts\n                at the Aspen Neurobehavioral Conference in April 1998.\nFindings\nQuestion 1\nOne small, retrospective, observational study from a single rehabilitation\n                    facility supports an association between the acute institution of formalized,\n                    multidisciplinary, physiatrist-driven TBI rehabilitation and decreased length of\n                    stay (acute hospital and acute rehabilitation) and some measures of short-term\n                    physiologic (noncognitive) patient outcomes. The level of evidence is Class III.\n                    This study concerned adult patients with severe brain injury (Glasgow Coma Scale\n                    3-8); there is no evidence from comparative studies for or against early\n                    rehabilitation in patients with mild and moderate injury.\nQuestion 2\nWhen measured as the hours of application of individual or grouped therapies,\n                    there is no indication that the intensity of acute, inpatient TBI rehabilitation\n                    is related to outcome. Because of methodological weaknesses, however, previous\n                    studies are likely to have missed a significant relationship if one exists (a\n                    Type II error). These studies contained insufficient information about severity\n                    of injury and baseline function to ensure the comparability of compared groups.\n                    Also, these studies did not consider the quality of individual treatments, their\n                    lack of autonomy in the cognitive realm, and the delivery milieu. One or more of\n                    these factors may affect the outcome of care more than the time spent in each\n                    modality. Therefore, future research into efficacy of acute inpatient TBI\n                    rehabilitation must more adequately measure such factors and include the factors\n                    in their predictive models. Future studies also must employ a wider spectrum of\n                    outcome measures, including measurement of outcomes across longer periods of\n                    time after discharge. \nFrom a clinical aspect, the evidence does not support equating different TBI\n                    rehabilitation delivery systems based on equivalent times of patient exposure to\n                    various therapeutic modalities. For example, this analysis would not support\n                    predicting that patient benefit would be equal if an equal time spectrum of\n                    rehabilitation therapies were delivered at a rehabilitation center as compared\n                    with a skilled nursing facility. More detailed analysis of factors involved in\n                    predicting response to rehabilitation modalities must be considered in\n                    approaching such questions.\nAdditionally, mandating a minimum number of hours of applied therapy for all TBI\n                    patients is not supported by the present state of scientific knowledge. How much\n                    of which intervention(s) optimizes recovery in a given type of patient has been\n                    inadequately studied. It is certainly reasonable to avoid situations in which\n                    patients do not receive potentially beneficial treatment. Based on the above\n                    studies, however, defining a minimal rehabilitation program in terms of time of\n                    applied therapy is not likely to optimize either the therapists' time or\n                    patients' recovery. It is probable that specific basic programs will have to be\n                    related to individual patient groups. Developing such algorithms requires\n                    further research.\nMany patients who suffer TBI do not enter acute inpatient rehabilitation. Only\n                    one study of the effectiveness of inpatient rehabilitation included a comparison\n                    group of patients who did not undergo inpatient rehabilitation. Future studies\n                    should compare acute, inpatient rehabilitation to commonly used alternatives to\n                    inpatient rehabilitation, such as care in a well-staffed skilled nursing\n                    facility or in less intense variations of acute rehabilitation. Very little is\n                    known about the outcomes of TBI in these settings. \nQuestion 3\nThere is evidence from two small studies (Class I and Class III) that a\n                    personally adapted electronic device, a notebook, and an alarm wristwatch reduce\n                    everyday memory failures for people with TBI. There is evidence from one study\n                    (Class II[a]) that compensatory cognitive rehabilitation (CCR) reduces anxiety\n                    and improves self-concept and relationships for people with TBI. Evidence from\n                    two studies (Class I and Class II[b]) supports the use of computer-aided\n                    cognitive rehabilitation (CACR) to improve immediate recall on\n                    neuropsychological testing, but the clinical importance of this finding has not\n                    been validated. \nQuestion 4\nClass II evidence indicates that supported employment can improve the vocational\n                    outcomes of TBI survivors. Nearly all information about supported employment\n                    comes from two bodies of work, each of which used different experimental designs\n                    and different models of supported employment. The findings have not been\n                    replicated in other settings or by other centers, so the generalizability of\n                    these programs remains untested.\nQuestion 5\nThere have been very few studies on the effectiveness of case management, and the\n                    results of these studies are mixed. The only outcome for which there were\n                    results in the same direction from two or more studies pertained to changes in\n                    vocational status. This was associated with the single case-manager and\n                    insurance approach, as well as with the combined nurse and vocational\n                    case-manager model. There were conflicting results about the effects of case\n                    management on disability or functional status, living status, family impact, and\n                    other aspects, and some findings were mentioned in only one study. The clinical\n                    trial resulted in no functional status changes among case-managed subjects,\n                    despite an extended period of rehabilitation. However, when two forms of case\n                    management were compared, both the single and multiple case-manager/insurance\n                    approaches showed significant functional improvements.\nFuture Research\nThe evidence report identifies the following areas for future research. \n\n1Randomized trials of the timing and intensity of early and acute\n                            rehabilitation would be useful. Because the patient characteristics that\n                            affect outcomes also affect the type and level of rehabilitation\n                            services delivered, it may be unlikely that any observational study can\n                            provide definitive evidence about effectiveness. Moreover, assigning\n                            patients to different levels of intensity or to early versus\n                            conventional initiation of rehabilitation in a prospective trial may be\n                            ethically acceptable, since these different levels represent a range of\n                            current practice rather than a deviation from it.2Population-based studies of all patients with TBI, including those who do\n                            not enter inpatient rehabilitation facilities, are imperative. Important\n                            questions about the effectiveness of rehabilitation and its component\n                            disciplines require the development of regional or national registries,\n                            with standardized data collection and identification and followup of all\n                            patients with head injury.3Research designs for future studies should incorporate health outcomes of\n                            importance to people with TBI and their families. Commonly used measures\n                            should be more strongly linked to health outcomes. Future studies should\n                            address the effect of spontaneous recovery, systematize criteria for\n                            entering cognitive rehabilitation, and differentiate between the effects\n                            of general stimulation and specific techniques.4The greatest overall need for the evaluation of supported employment\n                            programs is a series of trials with adequate controls and unbiased\n                            allocation of clients to the conditions compared. 5Future research should focus on improving the outcome measures used to\n                            examine the results of case management in TBI rehabilitation. In\n                            addition to outcomes of changed patient functionality, there should be\n                            outcomes of changed family functionality. Since much of case management\n                            communication is directed toward helping family members learn what to\n                            expect and where to obtain services, relevant outcomes would include\n                            family use of community and rehabilitation services and indicators of\n                            family assertiveness about care expectations. While case management may\n                            exert only an indirect effect on a patient's functional outcomes such as\n                            level of disability, vocational status, and living status, it is\n                            possible that case management can directly affect family knowledge of\n                            TBI rehabilitation needs and services, level of psychosocial anxiety,\n                            and family competency in coping with TBI.\n\nRandomized trials of the timing and intensity of early and acute\n                            rehabilitation would be useful. Because the patient characteristics that\n                            affect outcomes also affect the type and level of rehabilitation\n                            services delivered, it may be unlikely that any observational study can\n                            provide definitive evidence about effectiveness. Moreover, assigning\n                            patients to different levels of intensity or to early versus\n                            conventional initiation of rehabilitation in a prospective trial may be\n                            ethically acceptable, since these different levels represent a range of\n                            current practice rather than a deviation from it.\nPopulation-based studies of all patients with TBI, including those who do\n                            not enter inpatient rehabilitation facilities, are imperative. Important\n                            questions about the effectiveness of rehabilitation and its component\n                            disciplines require the development of regional or national registries,\n                            with standardized data collection and identification and followup of all\n                            patients with head injury.\nResearch designs for future studies should incorporate health outcomes of\n                            importance to people with TBI and their families. Commonly used measures\n                            should be more strongly linked to health outcomes. Future studies should\n                            address the effect of spontaneous recovery, systematize criteria for\n                            entering cognitive rehabilitation, and differentiate between the effects\n                            of general stimulation and specific techniques.\nThe greatest overall need for the evaluation of supported employment\n                            programs is a series of trials with adequate controls and unbiased\n                            allocation of clients to the conditions compared. \nFuture research should focus on improving the outcome measures used to\n                            examine the results of case management in TBI rehabilitation. In\n                            addition to outcomes of changed patient functionality, there should be\n                            outcomes of changed family functionality. Since much of case management\n                            communication is directed toward helping family members learn what to\n                            expect and where to obtain services, relevant outcomes would include\n                            family use of community and rehabilitation services and indicators of\n                            family assertiveness about care expectations. While case management may\n                            exert only an indirect effect on a patient's functional outcomes such as\n                            level of disability, vocational status, and living status, it is\n                            possible that case management can directly affect family knowledge of\n                            TBI rehabilitation needs and services, level of psychosocial anxiety,\n                            and family competency in coping with TBI.", "pairs": [], "interleaved": []}