Brain Injury (TBI)
is a leading cause of death and disability in children and adults.
An estimated two million head injury occurs in the United States
each year. The number of treated cases of TBI has
increased over the past 25 years as earlier and more specialized
emergency treatment, especially at the accident scene, has saved
individuals who might otherwise have died before reaching the hospital.
Approximately 50 thousand of these individuals will have persistent
physical, cognitive, behavioral and social deficits that may compromise
their quality of life, as a result of their injury. This increase
in the rate of survival from severe brain injury means that there
will be an increasing number of patients in need of effective treatment
to help them attain a satisfactory long-term life adjustment and
quality of life following their injury. The size of this population
argues for the importance of determining the most effective treatment
and rehabilitation practices.
During the past two decades, understanding
of the pathophysiology of TBI has increased dramatically.
It is now recognized that all neurologic damage does not occur at
the moment of injury, but rather evolves over the ensuing minutes,
hours and days. It is well established that a combination of early
imaging in the emergency room, removal of extra-axial masses, support
of blood pressure, ventilation as well as monitoring of intracranial
pressure (American Association of Neurological Surgeons and the
American Academy of Neurology, 1995) produces improved survival
rates. Equally well established is the role of aggressive follow-on
intensive care treatment. In addition, a growing literature suggests
that adjunctive pharmacological treatment facilitates behavioral
management during the rehabilitation process, and may result in
a better functional outcome. Despite these advances, much remains
to be learned about the underlying damage and pathophysiology of
the deficits associated with TBI, and to link acute
care, rehabilitation and long term patient outcomes.
Because of the subtle and delayed sequelae
associated with TBI, determining the most appropriate
medical, rehabilitative and educational services for children and
young adults with brain injury is especially difficult. Personality
changes that appear to be independent of severity of injury are
common long-term consequences of TBI, and may become
more pronounced over time. Such long-term residual psychiatric sequelae
pose challenges to community re-entry and to quality of life and
are often viewed as more seriously handicapping than the cognitive
and physical aspects of the injury itself.
While there has been substantial improvement
in the outcome from severe head injury, there remains a great deal
of variability in the care of these patients across the country.
Current medical management of TBI has, in some
instances, adopted principles of care and employed pharmaceuticals
and methodologies without rigorous use of evidence-based research
necessary for their objective evaluation. Clinically important variations
may occur because there is no efficacious standard of practice,
linked to long-term outcomes, to guide treatment. Similarly, there
has been little systematic study of the variables that influence
the course and effectiveness of rehabilitation after brain injury.
Comprehensive rehabilitation programs typically address areas of
cognitive processes, behavioral and social interactions, speech,
language and communication, mobility and activities of daily living.
Depending on the particular focus of the program, certain areas
may receive greater emphasis. The precise format and intensity of
the interventions required for a given patient remain highly variable.
Few programs have been subjected to the degree of scientific scrutiny
e.g., case definition, stratification by age and severity, standardized
patient inclusion criteria, standardized and quantitative measurement
of treatment and outcome) needed to draw conclusions about the efficacy
of various treatment methods. As a result, it is difficult to determine
which approaches are the most effective in returning TBI
patients to maximum levels of community or vocational integration.