Effects of Timing and Intensity of Neurorehabilitation on Functional Outcome After Traumatic Brain Injury
March Konigs, PhD et al: Emma Children's Hospital, Academic Medical Centre, Amsterdam
[Archives of Physical Medicine and Rehabilitation 2018;99:1149-59]
Worldwide an estimated 54 to 60 million individuals sustain a traumatic brain injury (TBI) each year. Severe forms of TBI are associated with acute and persisting detrimental effects on functioning in a wide variety of domains (mobility, neurocognitive functioning, social capabilities, employment and quality of life).
The belief is that multidisciplinary neurorehabilitation programs have great potential to improve functional recovery through experience-dependent neuro reorganisation (neuro plasticity) and the development of compensatory mechanisms.
I am a member of the American Congress of Rehabilitation Medicine and through my membership I have access to the Archives: this article published by Dutch researchers struck a chord because it attempts to review the available published evidence and aggregate it all together into one paper: let's face it anything that saves us having to read 58 individual research papers has to be a good thing right??!!
Having said all that I have to admit that I am not quite sure how far beyond the headline this actually takes us. What one typically finds is a huge amount of variability in the way in which individual trials are undertaken and the protocols which are applied to those trials: it's one of the reasons why we always need to be careful of the headline… different trials undertaken with different protocols produce different results…
Five studies were assessed as to the effectiveness of intensive neuro rehabilitation programmes representing a sample of 211 patients. Three out of the five studies showed a significant positive overall effect of intensive neurorehabilitation but some of the studies did not adopt a randomising method for group allocation. Only one of the included studies blinded patients to group allocation. It isn't helpful: to my naïve mind we need clear protocols to govern the way in which these studies are undertaken as that will assist in driving consistency and an ability to compare / contrast results to achieve the best possible outcomes for the patients.
The headline stands the test: current analysis does indeed support the positive effects of early and intensive neuro rehabilitation but there are so many things that we don't know: how exactly and to what degree does the timing and intensity influence recovery? What does optimal look like? In particular more research is needed to determine the gain of early and intensive neuro rehabilitation in younger patients with [seemingly] greater potential for neural plasticity?
For the time being the message that I take is that as a rough rule of thumb "intensive" neurorehabilitation encompasses at least 20 therapy hours per week. Let's bear that in mind when offering / agreeing to fund rehab for injured claimants… the more that functional recovery can be enhanced the better the result for everyone.
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