Funded by NICHD



Traumatic 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.