The National Institutes of Health (NIH) has issued a consensus development conference statement on the rehabilitation of persons with traumatic brain injury. The conference that culminated in the consensus statement was convened by the NIH to evaluate the scientific data concerning rehabilitation practices for persons with traumatic brain injury. After listening to presentations and audience discussion at the conference, an independent panel chaired by Kristijan T. Ragnarsson, M.D., Mt. Sinai Medical Center, New York City, weighed the scientific evidence and presented a statement. Particular emphasis was placed on rehabilitation of cognitive, behavioral and psychosocial difficulties associated with mild, moderate and severe traumatic brain injury.
The consensus statement can be found on the NIH Web site at http://odp.od.nih.gov/consensus/. The document can also be obtained from the NIH Consensus Program Information Center, P.O. Box 2577, Kensington, MD 20891; telephone: 888-644-2667.
The consensus statement addresses the following key questions: (1) What is the epidemiology of traumatic brain injury in the United States, and what are its implications for rehabilitation? (2) What are the consequences of traumatic brain injury in terms of pathophysiology, impairments, functional limitations, disabilities, societal limitations and economic impact? (3) What is known about mechanisms underlying functional recovery following traumatic brain injury, and what are implications for rehabilitation? (4) What are the common therapeutic interventions for the cognitive and behavior sequelae of traumatic brain injury, what is their scientific basis, and how effective are they? (5) What are the common models of comprehensive, coordinated, multidisciplinary rehabilitation for persons with traumatic brain injury, what is their scientific basis, and what is known about their short-term and long-term outcomes? (6) Based on the answers to the previous questions, what can be recommended regarding rehabilitation practice for persons with traumatic brain injury? (7) What research is needed to guide the rehabilitation of persons with traumatic brain injury?
Traumatic brain injury is identified in the report as brain injury from externally inflicted trauma that may result in significant impairment of a person's physical, cognitive and psychosocial functioning. The report states that traumatic brain injury is a heterogeneous disorder of major public health significance. An estimated 1.5 to 2 million persons incur traumatic brain injuries annually. The causes include vehicular incidents, falls, acts of violence and sports accidents. Because of more effective emergency treatment in recent years, the number of persons who survive a traumatic brain injury has increased greatly. Each year, as many as 90,000 persons have a brain injury resulting in long-term and substantial loss of functioning. Traumatic brain injury is the leading cause of long-term disabililty among children and young adults.
Traumatic brain injuries are divided into three categories: mild, moderate and severe. The report notes that mild traumatic brain injury is significantly underdiagnosed, and early intervention is often neglected. The panelists believe that the surveillance systems of the Centers for Disease Control and Prevention for traumatic brain injuries should be expanded to include “emergency department encounters” as well as hospital discharges and death records. Knowing the incidence, prevalence, etiology and natural history can help determine the types of rehabilitation services that are needed for persons with traumatic brain injury.
The following list of recommendations regarding rehabilitation practices for persons with traumatic brain injury has been excerpted from the report:
Rehabilitation programs for persons with moderate or severe traumatic brain injury should be interdisciplinary and comprehensive.
Rehabilitation services should be matched to the needs, strengths and capacities of each person with traumatic brain injury.
Rehabilitation should include cognitive and behavioral assessment and intervention.
Patients and their families should have a central role in the planning and design of the individualized rehabilitation programs and research endeavors.
Persons with traumatic brain injury should have access to rehabilitative services through the entire course of recovery, which could last for many years after the injury.
Substance abuse evaluation and treatment should be a component of rehabilitation programs.
Medications used for behavioral management have significant side effects in persons with traumatic brain injury, may impede the rehabilitation progress and should therefore be reserved only for compelling circumstances.
Medications used for cognitive enhancement can be effective, but the benefits should be carefully evaluated and documented in each individual.
Community-based, nonmedical services should be components of the extended care and rehabilitation programs available to persons with traumatic brain injury. These services include but are not necessarily limited to clubhouses for socialization, day programs and social skill development, supported living programs and independent living centers, and formal education programs at all levels.
Families of persons with traumatic brain injury should themselves receive support. This can include in-home assistance and ongoing counseling.
Rehabilitation efforts should include modification of the person's home, social and work environments to enable fuller participation in all venues.
Special programs are needed to identify and treat persons with mild traumatic brain injury.
Specialized, interdisciplinary and comprehensive treatment programs are necessary to address particular medical, rehabilitation, social, family and educational needs of young children with traumatic brain injury.
Specialized, interdisciplinary and comprehensive treatment programs are necessary to address particular medical, rehabilitation, family and social needs of persons older than age 65 with traumatic brain injury.
Educational programs are needed to increase the degree to which community care providers are aware of the problems experienced by persons with traumatic brain injury.
The report also includes a list of recommendations for future research that is needed to help guide the rehabilitation of persons with traumatic brain injury. These recommendations include the following:
Gender differences in survival rates, patterns of severity and long-term manifestations of traumatic brain injury need to be studied.
The duration, natural history and life course manifestations of mild, moderate and severe traumatic brain injury should be studied.
The relationship between the pathophysiology of traumatic brain injury and the effectiveness of different interventions should be studied.
Basic and common classification systems of traumatic brain injury are needed.
Uniform standards and minimal data sets to describe injury type, severity and significant interacting variables, which could provide a total injury profile across a continuum of recovery should be developed.
The long-term consequences of traumatic brain injury of varying severity, including the consequences of aging on persons with traumatic brain injury, should be studied.
The epidemiology of mild traumatic brain injury should be studied.
The consequences and effects of rehabilitation after traumatic brain injury should be studied.
The effectiveness of community-based rehabilitation for persons with traumatic brain injury should be studied.
Severity risk-adjustment models for studies of persons with traumatic brain injury should be established.