The move toward evidenced-based medicine has occurred in recent years in response to rising healthcare costs and efforts by third party payors to control escalation of the costs associated with catastrophic injury. While traumatic brain injury (TBI) has placed a significant demand on the healthcare system, medical and rehabilitative advances have reduced the number of fatalities associated with neurotrauma. Individual cognitive outcome following injury has been highly variable (Ponsford et al., 2008). Rehabilitation for Traumatic Brain Injury is a text that addresses recent changes in medicine and the need to focus on evidenced-based research in order to make rehabilitation decisions for the patient who has experienced a TBI.
This book was written following the 2003 conference hosted by the Rehabilitation Research Training Center at the Institute for Rehabilitation and Research (TIRR) in Houston, Texas. The editors joined other TBI rehabilitation experts to discuss empirical findings in specific areas of brain injury research. The results of these presentations and discussions were then edited to form the current text. The volume is comprised of five major sections: (1) Overview and History of Traumatic Brain Injury, (2) Rehabilitation of Specific Cognitive Impairments, (3) Factors Affecting Outcome (e.g., substance abuse, caregiver interventions, and vocational issues), (4) Rehabilitation with Specific Populations (i.e., child, older adults, and multicultural issues), and (5) Medical Topics related to Rehabilitation (i.e., hypotonia, disorders of consciousness, and neuroimaging).
In keeping with the Consensus Conference on Rehabilitation of Persons with Traumatic Brain Injury (1998), hosted by the National Institutes of Health (NIH), the current text highlights the fact that many of recent studies are limited. Overall, the evidence supports the use of cognitive and behavioral strategies; yet, the researcher is encouraged to use more innovative and better designed methods to illustrate the level of importance that early rehabilitative efforts may have in our current medical system. In general, the book does have a consistent thread related to evidence-based rehabilitation; however, each contributor to this volume presents their research and demonstrates their expertise in a varying manner and style. While this makes it easier to pick individual chapters that are most meaningful to the evidence-based practitioner, it may also make it more difficult for readers to follow a consistent theme with regard to narrative style as they read through the chapters of the book.
The first chapter, by Boake & Diller, provides a concise history of brain injury rehabilitation. It begins with a review of Walter Poppelreuter and Kurt Goldstein's (1942) research in Frankfurt and Cologne during the time period of World War I. The chronology then follows Oliver Zangwill's (1946) seminal studies of aphasia, Joseph Wepman's (1951) criteria for spontaneous recovery, and finishes with recent research by Yehuda Ben-Yishay (1996) on frontal lobe function and domain-specific training. There is also a brief review of current rehabilitation trends, which includes standards and accrediting bodies (e.g., Committee for Accreditation of Rehabilitation Facilities) that have affected how many hospital programs have measured rehabilitation success and sustainable efforts for recovery, and recent efforts by the American Congress of Rehabilitation Medicine task force (Cicerone et al., 2000) that reviewed standards of practice, guidelines and options available to the rehabilitation specialist.
A common theme in many chapters, including one with a primary focus on rehabilitation effectiveness, was that virtually no randomized clinical trials demonstrated the effectiveness of acute inpatient rehabilitation. This is, in part, due to the many complex interrelated factors that are resistant to statistical measurement. However, functional gains were demonstrated with the Disability Rating Scale (DRS) and Functional Independence Measure (FIM). A difficult factor in many of research studies was the possibility that patients may spontaneously recover given time. One recommendation was to prospectively create randomized trials to examine timing and intensity of various interventions and outcomes.
In addressing rehabilitation of specific cognitive domains, Rehabilitation for Traumatic Brain Injury focuses on patients with (1) impaired awareness, (2) memory impairments, (3) executive function difficulties, (4) social and communication deficits, and (5) emotional/motivational disorders. In one of the later chapters in the book, Struchen provides an excellent description of the volume's format and how it was conceptualized. In brief, authors utilized a modified classification from the American Academy of Neurology's (2004) approach for classification of scientific evidence. This involved Class I studies (prospective, randomized, controlled clinical trial with masked outcome assessment in a representative population), Class II studies (prospective matched group studies in a representative population), Class III studies (all other controlled trials and clinical series without concurrent controls where outcome is independent of treatment or single cases where appropriate single-subject designs are used), and Class IV studies (case series or reports). A recommendation for future editions may be the delineation of this classification from the outset in an early chapter.
While chapters covering specific cognitive domains vary in their coverage of published research, few studies met the criteria for the American Academy of Neurology's Class I research. Many were flawed in their initial design, with a small number of participants, poor study design, or being case reports based on observational reports. They highlight the need to forgo past methodological limitations and design more effective experimental studies.
A highlight of this book was the chapter on External Aids for Management of Memory Impairment by Sohlberg, whose research has addressed executive skill and social interventions. The references provided include those for external aids to facilitate functional improvement. Specific tools such as memory aids, neuropager, electronic aids, and CellMinder were discussed, along with instructional features based on behavioral theory, such as chaining, pre-exposure stimuli, cumulative review, feedback, shaping, modeling, spaced retrieval, faded prompts.
A useful section of the text addressed factors affecting rehabilitation outcome. In a chapter about substance abuse, it was concluded that “there is far more information on the problem and its scope than there is on treatment approaches to ameliorate use-related disorders”, a message repeated throughout the text. Chapters on vocational rehabilitation and interventions for caregivers were helpful in considering factors besides direct treatment effects of acute rehabilitation. Finally, medical topics are addressed, including spastic hypertonia, rehabilitation of patients with disorders of consciousness, and neuroimaging.
The Editors intended to create a resource text for researchers and practitioners in the field of brain injury rehabilitation. It certainly meets the desired goal for the individual planning to conduct research using rehabilitation paradigms, and it serves as a guide for an individual who may be planning to develop a prospective research based cognitive rehabilitation program; it addresses crucial areas related to study design and sample selection. On the other hand, it may fall short with respect to educating the clinician with regard to specific strategies that may prove to be beneficial in an applied clinical setting. Perhaps the clinician could refer to individual chapters about their area of interest. For example, only two chapters specifically address pediatric rehabilitation in depth. Ylvisaker writes about children in rehabilitation but this is limited to cognitive, behavioral, communication and academic issues. Of note, Ylvisaker references family training and support, citing the work of others on family adjustment and outcome after TBI. It would have been helpful to explain this in light of an earlier chapter addressing interventions for caregivers. Additionally, recent multi-site research on children with learning difficulties after cancer treatment (Butler & Copeland, 2002) focuses on attention and memory remediation. This might be a meaningful paradigm for children diagnosed with TBI.
Overall, this volume is written in a straightforward manner and covers a wide array of topics related to evidence-based medicine and TBI rehabilitation. It is an excellent resource for the clinician and researcher who might be interested in setting up a cognitive rehabilitation program. The chapters represent a collection of scholarly research and reviews; however, poor integration across chapters and varying format make it more of a challenge for the reader. This text will be of particular interest to health professionals working to rehabilitate adults with neurological and psychiatric conditions.