Rehabilitación multidisciplinaria para la lesión cerebral adquirida en adultos en edad laboral

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 aged 16 to 65 years. To explore approaches that are effective in different settings and the outcomes that are affected.

SEARCH STRATEGY:

We searched CENTRAL (The Cochrane Library 2008, Issue 2), MEDLINE (Ovid SP), EMBASE (Ovid SP), ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED), ISI Web of Science: Conference Proceedings Citation Index-Science (CPCI-S), and Internet-based trials registers: ClinicalTrials.gov, Current Controlled Trials, and RehabTrials.org. We also checked reference lists of relevant papers and contacted study authors in an effort to identify published, unpublished, and ongoing trials. Searches were last updated in April 2008.

SELECTION CRITERIA:

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

DATA COLLECTION AND ANALYSIS:

Two authors independently selected trials and rated their methodological quality. A third review author 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 subdivided trials in terms of severity of brain injury, the setting, and type of rehabilitation offered.

MAIN RESULTS:

We identified 11 trials of good methodological quality and five of lower quality. Within the subgroup of predominantly mild brain injury, 'strong evidence' suggested that most patients made a good recovery with provision of appropriate information, without additional specific intervention. For moderate to severe injury, there was 'strong evidence' of benefit from formal intervention. For patients with moderate to severe ABI already in rehabilitation, there was strong evidence that more intensive programmes are associated with earlier functional gains, and 'moderate evidence' that continued outpatient therapy could help to sustain gains made in early post-acute rehabilitation. There was '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. Consequently, different interventions and combinations of interventions 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 needs 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 randomised controlled trials or other experimental approaches. Some questions include which treatments work best for which patients over the long term, and which models of service represent value for money in the context of life-long care. In future, such questions will need to be set alongside practice-based evidence gathered from large systematic, longitudinal cohort studies conducted in the context of routine clinical practice.