Conclusions

Rehabilitation for persons with mild traumatic brain injury (TBI) and persistent post-concussion symptoms:

• Specialised brain injury rehabilitation that employs problem-solving therapy or cognitive behavioural therapy (CBT) results in less severe post-concussion symptoms and depressive symptoms, improved psychological function, increased activity and participation and quality of life, when compared to usual care (low certainty of evidence, ⊕⊕◯◯). A simple cost-effectiveness analysis indicates a cost of about 500 000 SEK per quality-adjusted life year (QALY) for the intervention, but this cost might be overestimated since it does not incorporate possible cost savings resulting from the rehabilitation.
• Specialised interdisciplinary brain injury rehabilitation results in reduced post-concussion symptoms, when compared to usual care (low certainty of evidence, ⊕⊕◯◯).

Rehabilitation for persons with moderate to severe TBI:

• As few high-quality studies were identified, it was not possible to estimate the effects of vocational rehabilitation, rehabilitation with case management/coordinator, rehabilitation in supported living, specialised inpatient rehabilitation or specialised outpatient rehabilitation (very low certainty of evidence, ⊕◯◯◯).

Experiences and perspectives of the rehabilitation process from persons with TBI:

• A synthesis of qualitative studies showed that the persons with TBI were struggling on their own with adapting in their daily lives and that family members were important in that process. They experienced limited access to rehabilitation services, and perceived the interventions they receive as neither individualised nor coordinated. Furthermore, they experienced professional and respectful treatment, as well as individualised information, as beneficial for their rehabilitation process.

Current state of research in the field:

• There is a general need for high-quality studies with control groups in this research field. Standardization of study design, treatment intensity, as well as outcome instruments and measures is needed to allow the effects of different forms of rehabilitation to be compared. It would be preferable if future studies assess the effects and costs of interventions beyond one year. Furthermore, there is a need for studies in settings directly relevant to the Swedish health care system that investigate intervention efficacity as well as individuals’ experiences of receiving rehabilitation.

Aim

The aim of the project was to assess rehabilitation interventions for adults with traumatic brain injury from medical, social, ethical and health economic perspectives.

Background

Traumatic brain injuries (TBIs) are caused by external force or sudden movement of the head. The most common causes are falls and traffic accidents. The injuries are classified as mild, moderate or severe, based on the duration of unconsciousness and the extent of posttraumatic amnesia. TBI is the most common cause of neurological disability and has often a major impact on life for the affected persons and their family members. According to Swedish hospital data, approximately 10 000 cases are treated in inpatient care and 20 000 in outpatient care every year. Approximately 50% of TBI patients are 65 years or older.

Most persons with mild TBI (including concussions) experience full recovery within a few weeks, but up to 20% experience persistent symptoms including fatigue, headache, hypersensitivity to visual and auditory stimuli, dizziness and memory problems. Access to rehabilitation services for this group varies in Sweden, from specialised care to limited care or no interventions at all.

Persons with moderate to severe TBI typically receive individual rehabilitation from a specialised inpatient brain injury team, but rehabilitation can also take place within geriatric care. After discharge from hospital, rehabilitation is given in outpatient care according to local routines.

Method

Systematic literature reviews were conducted in accordance with PRISMA guidelines and SBU’s standardised methods. All steps in the literature assessment were conducted by two independent reviewers, and any disagreement was resolved by discussion. Quantitative data were combined in meta-analyses when study characteristics and outcome measures were comparable. The findings from the qualitative studies were synthesised through an inductive content analysis. The certainty of evidence of quantitative results was assessed according to grading of recommendations assessment, development and evaluation (GRADE), and qualitative results were assessed with Confidence in Evidence from Reviews of Qualitative research (CERQual).

Results

In total, 19 RCTs, 12 NRSIs, 10 qualitative and 3 health economic studies were included in the report (see flow charts).

Ethical and societal aspects

Persons with traumatic brain injury may have impaired capacity to make informed decisions and to make their own voice heard. This means that their autonomy is reduced, and they may be dependent on the help from family members or health care staff. Unstructured care pathways involving many different care givers in combination with the individuals’ complex rehabilitation needs and vulnerable situation, amplifies the importance of adequate support, information and coordination.

It is necessary for the health care system to provide various forms of rehabilitation interventions in order to meet patients’ individual needs. More research is needed, however, in order to conclude on which interventions that are the most effective, and in order to make health economic assessments preceding priority decisions.

It is important to acknowledge aspects related to equity and justice regarding the distribution of rehabilitation interventions, where the patient’s geographical residence, age and ability to work may impact on the access to rehabilitation. Presence or absence of family members may also have influence on the patient’s access to support and services.

Discussion

It should be noted that very low certainty of evidence does not imply that an intervention lacks effect, but rather that its effect has not been sufficiently researched. This assessment has identified several scientific knowledge gaps where there is a substantial need for further research. As there was an extensive heterogeneity across the included studies regarding design, treatment intensity, outcomes and instruments, it is desirable for the field to strive for improved consistency in design and reporting.

It is also important to acknowledge that the assessment did not target rehabilitation interventions that focus on treating single symptoms. Therefore, there are several rehabilitation forms that are not included in the report.

The full report in Swedish

/sv/publikationer/SBU-utvarderar/rehabilitering-for-vuxna-med-traumatisk-hjarnskada/

Flow charts of included studies

Figure 4

Flow chart of the literature review for the three research questions relating to specialised brain injury rehabilitation compared to less specialised interventions. A common literature search was made for the three research questions. Two of the included (more...)

Figure 4.16

Flow chart of the literature review regarding Coordinator or Case management. NRSI = Non-randomised study of intervention; RCT = Randomised controlled trial.

Figure 4.17

Flow chart of the literature review regarding rehabilitation in supported living. NRSI = Non-randomised study of intervention; RCT = Randomised controlled trial.

Figure 4.18

Flow chart of the literature review regarding vocational rehabilitation. NRSI = Non-randomised study of intervention; RCT = Randomised controlled trial.

Figure 5.1

Flow chart of the Health economic literature review.

Figure 6.1

Flow chart of the literature review on the intervention Experiences and perceptions of rehabilitation.

Project group

Characteristic of included studies with reference list

Download PDF (595K)

Search strategies

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Excluded studies

Download PDF (290K)

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