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1. Citation: Turner-Stokes, L., Disler, P. B., Nair, A., & Wade, D. T. (2005). Multi-disciplinary rehabilitation for acquired brain injury in adults of working age. Cochrane Database of Systematic Reviews 2005, 3, CD004170.
Keywords: brain injury, acquired brain injury, rehabilitation, cognitive therapy, vocational rehabilitation
Abstract: Background: Evidence from systematic reviews demonstrates that multi-disciplinary rehabilitation is effective in the stroke population, where older adults predominate. However, the evidence base for the effectiveness of rehabilitation following acquired brain injury (ABI) in younger adults is not yet established, perhaps because there are different methodological challenges.

Objectives: To assess the effects of multi-disciplinary rehabilitation following ABI in adults, 16 to 65 years. To explore approaches that are effective in different settings and the outcomes that are affected.

Search strategy:
We used a wide range of sources including: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966-2004), EMBASE (1988-2004), CINAHL (1983-2004), PsycLIT (1967-2004), AMED, the National Research Register (2004), and ISI Science Citation Index (1981-2004).

Selection criteria: Randomised controlled trials (RCTs) comparing multi-disciplinary rehabilitation with either routinely available local services or lower levels of intervention; or trials comparing intervention in different settings or at different levels of intensity. Quasi-randomised and quasi-experimental designs were also included, providing they met pre-defined methodological criteria.

Data collection and analysis: Two authors selected trials and rated their methodological quality independently. A third reviewer arbitrated when disagreements could not be resolved by discussion. We performed a "best evidence" synthesis by attributing levels of evidence, based on methodological quality. We sub-divided trials in terms of severity of ABI and the setting and type of rehabilitation offered.

Main results: We identified ten trials of good methodological quality and four of lower quality. Within the subgroup of predominantly mild brain injury, "strong evidence" suggested that most patients make a good recovery with provision of appropriate information, without additional specific intervention. For moderate to severe injury, there is "strong evidence" of benefit from formal intervention. For patients with moderate to severe ABI already in rehabilitation, there is strong evidence that more intensive programmes are associated with earlier functional gains, and "moderate evidence" that continued outpatient therapy can help to sustain gains made in early post-acute rehabilitation. There is "limited evidence" that specialist in-patient rehabilitation and specialist multi-disciplinary community rehabilitation may provide additional functional gains, but the studies serve to highlight the particular practical and ethical restraints on randomisation of severely affected individuals for whom there are no realistic alternatives to specialist intervention.

Authors' conclusions: Problems following ABI vary; different services are required to suit the needs of patients with different problems. Patients presenting acutely to hospital with moderate to severe brain injury should be routinely followed up to assess their need for rehabilitation. Intensive intervention appears to lead to earlier gains. The balance between intensity and cost-effectiveness has yet to be determined. Patients discharged from in-patient rehabilitation should have access to out-patient or community-based services appropriate to their needs. Those with milder brain injury benefit from follow-up, and appropriate information and advice. Not all questions in rehabilitation can be addressed by traditional research methodologies. There are important questions still to be answered, and future research should employ the most appropriate methodology.
Plain Language Summary: Rehabilitation for adults of working age who have a brain injury
Background: Studies show that multi-disciplinary (MD) rehabilitation is beneficial for patients with brain damage from stroke. Some MD programmes are targeted to working-age adults who have bra in injury following after trauma or other causes. These patients tend to be younger than most stroke patients and may have different treatment action, medicine, therapy goals, such as returning to work or parenting. Brain-injured people can have a variety of difficulties, including problems with physical body, bodily, real functions, communication, thought processes, behaviour or emotions. The seriousness of problems can vary change, shift from mild gentle, not severe, slight, small to severe. strong, serious, harmful, dangerous, very bad MD rehabilitation addresses one or more of these areas instead of focusing on a single aspect such as physical body, bodily, real (motor) function.

Review go over, check question: The authors of this Cochrane review go over, check looked for studies of MD rehabilitation in adults, 16 to 65 years of age, with acquired brain injury (ABI) from any cause.

Study characteristics: Studies eligible for inclusion in this review go over, check were controlled trials, in which one group of people received treatment action, medicine, therapy (such as MD rehabilitation) and was compared with a similar like group that received a different treatment. action, medicine, therapy We found 19 relevant studies, which involved a total of 3480 people.

Search date: We searched the medical literature worldwide on 14 September 2015.

Review go over, check methods: We used the Van Tulder system to rate the strength of the evidence as it distinguished better between trials of different quality than the standard GRADE system on criteria that are important in the context of rehabilitation.

Key results:
For mild gentle, not severe, slight, small brain injury, information information, to learn more and advice were usually mo re appropriate take, take over, a good fit, proper, right than intensive rehabilitation. As a whole, studies suggest that patients with moderate medium, mild, controllable to severe strong, serious, harmful, dangerous, very bad brain injury who received more intensive rehabilitation showed earlier improvement,and that earlier rehabilitation was better than delayed treatment. action, medicine, therapy Strong evidence supports the provision of cognitive rehabilitation in a therapeutic healing, improving, getting better ’milieu’, that is, an environment all the things around you in your daily life, at home and at work, world around you, your home in which patients receive get, admit, welcome predominantly group-based rehabilitation along side a peer group of others who are facing similar like challenges. Trial-based literature provided little evidence related to other aspects of MD rehabilitation, so the review go over, check authors recommend advise, suggest, urge, says that additional extra, added, more research should be done. Rehabilitation for brain injury is such an individualised and long-term for a long time, over a long period of time process that research studies do not necessarily facilitate make easier, help general conclusions.

Quality of the evidence: Overall the included studies were of good quality; 12 of 19 studies were judged to be of high quality according to the van Tulder scoring system. The other studies were at risk chance of bias because of elements of their design, for example, in one study, treatment action, medicine, therapy depended on the availability of a bed in the rehabilitation unit. Bed availability is a haphazard way of allocating treatment action, medicine, therapy to patients, and this makes results of the study prone to bias.
Link to Full Text:http://www.cochrane.org/CD004170/INJ_rehabilitation-adults-working-age-who-have-brain-injury
http://www.ncbi.nlm.nih.gov/pubmed/16034923
Record Updated:2016-08-02
 

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