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Brain injury rehabilitation in adults
10 Service delivery
10.1 INPATIENT CARE
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There is little direct evidence to support the rehabilitation of brain injured patients within a specialist unit
compared with a non-specialist/general unit. Ethical considerations surrounding the differential provision
of care to different groups limit the availability of high quality randomised data.
A specialist service has been defined as a group of (therapeutic) interventions delivered by one or more people
or organisation(s), which may incorporate one or more programmes, methods, techniques or approaches.
Such services are:
y not generic primary, intermediate or secondary health or social services (although much of the care
received by people with these conditions are provided by such generic services), and
y generally provided by more than one professional grouping. 167
One Cochrane systematic review considered multidisciplinary rehabilitation for ABI in adults aged 16-65
years. 18 The review included all causes of ABI including stroke and compared specialist inpatient rehabilitation
with rehabilitation carried out by local services. Two studies specifically considered specialist inpatient
rehabilitation in patients with either TBI or stroke. Both of these studies were small and of low methodological
quality and provided limited evidence that specialist inpatient rehabilitation improved functional outcome
over local non-specialist services. The review cited the Uk National Clinical Guidelines for Stroke which
suggests the key features of a successful rehabilitation service comprise a specialist multidisciplinary team
with relevant expertise which is generally found in a specific geographical base or location.
A systematic review of multidisciplinary rehabilitation services identified twelve reviews covering five
populations - stroke, brain injury, rheumatoid arthritis, hip fracture and older adults. 16 In addition to the
above Cochrane review, this reported a further review which included 2,183 people with mixed diagnoses
(mostly stroke) which showed that specialised rehabilitation resulted in increased likelihood of discharge
home from hospital, greater functional outcomes and higher rates of survival.
The Evidence Based Review of Rehabilitation of Moderate to Severe Acquired Brain Injuries, (ERABI), 51 a
modular systematic review including randomised and non-randomised studies concluded that ABI patients
benefit from a dedicated inpatient rehabilitation service. These services vary from institution to institution
but generally include some type of intensive therapy programme for physical, social, behavioural and
cognitive difficulties. The review also showed that early rehabilitation is associated with a shorter length of
stay, higher cognitive levels on discharge, better FIM scores and increased chance of discharge to home.
Patients receiving increased intensity of therapy had better outcomes in most aspects of FIM and FAM and
experienced shorter lengths of stay.
One single-blinded RCT (n=68) in patients with moderate to severe TBI compared different intensities of
treatment (two versus four hours per day for up to six months). 168 This demonstrated that after the second
week most patients could tolerate more than two hours of therapy per day. While no significant difference
was found between the two groups beyond three months, a higher number of patients in the high intensity
group achieved a maximum FIM score at three months and Glasgow Outcome Scale score (GOS) at two
months although these early gains did not impact on overall length of stay. This study suggests that intensive
rehabilitation may speed up overall recovery.
Intensity of rehabilitation is a relative term defined differently by different studies. Some studies of intensity
compare interventions carried out for longer duration than controls, while others define it in terms of the
volume or frequency of delivery of rehabilitation. While there is evidence suggesting an association between
both increased intensity and earlier intervention with positive outcomes, it is not possible to quantify a
threshold for recommendation.
B for optimal outcomes, higher intensity rehabilitation featuring early intervention should be
delivered by specialist multidisciplinary teams.
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