Evidence-based and Ethical Practice in Rehabilitation for TBI and Polytrauma

1. Evidence-based and Ethical Practice in Rehabilitation for TBI and Polytrauma James F. Malec, PhD, ABPP-Cn,Rp Research Director Rehabilitation Hospital of Indiana Professor Emeritus, Mayo Clinic

2. Evidence-based Practice Ethical Practice

3. Strengths of Evidence-based practice • Scientific validation of procedures • Quality of scientific support is explicit • Class I: Randomized controlled trials • Class II: Nonrandomized controls • Class II: Uncontrolled case series or reports • The ideal (rarely achieved): • Replicated validation of what intervention is best delivered when to whom and by whom

4. Risks and Weaknesses of Evidence-based Practice • Limits practice (and reimbursement) to those procedures with Class I evidence • Experimental controls limit generalizability of findings • Efficacy vs. effectiveness • Inattention to individual differences

5. Risks and Weaknesses of Evidence-based practice • Inattention to individual preferences • Dismissal of the value of placebo and nonspecific effects • RCT is not the appropriate methodology for evaluating some interventions • Medical Model vs. Social Model

6. Medical Model vs. Social Model • Medical Model: • Intervention directed at the individual who is ill or injured • Social Model: • Intervention directed at the social system in which the “disabled” or “ill” person operates

7. The Evidence • Early medical intervention and monitoring for TBI • Few if any specific studies of polytrauma in theatre of war • Early rehabilitation • Inpatient • Outpatient

8. The Evidence • Cognitive rehabilitation • Attention • Postacute • Practice with strategies • Memory • Mnemonics • External aids • Executive cognitive abilities

9. The Evidence • Emotional and behavioral interventions • Prevalent depression • Vs. limited awareness of impairment • Abulia vs. disinhibition • Negative impact on outcome • Treatment efficacy?

10. The Evidence • Family intervention • Significant minority with family stress at time of injury • Negative impact on outcome • Treatment efficacy? • Efficacy of supportive interventions?

11. The Evidence • Substance abuse evaluation • Significant minority with abuse/addiction • Negative impact on outcome • Treatment efficacy?

12. The Evidence • Vocational intervention • Apparently effective • Appropriate for RCT methodology? • Value of nonspecific effects

13. A Brief HistoryOf Community Based Employment (CBE) after Moderate-Severe TBI (90%+ of mild cases return to work)

14. Reviews 1985 Corthell et al 1987 Ben-Yishay et al 1993 Wehman et al Studies 1998 Gollaher et al 2002 TBIMS 2003 Kreutzer et al % Working 1 Yr Post < 30% 10-20% 30-40% 31% 27% 34% Without Specific Intervention

15. Study 1984 Prigatano et al 1987 Ben-Yishay et al 1991 Cope et al 1993 Wehman et al 1994 Prigatano et al 1999 Braverman et al 2000 Malec et al % Working 1 Yr Post 50% 77% 61% 71% 87% 96% 81% With Specific Intervention

16. Summary • Most optimistic estimates of CBE after moderate to severe TBI without specific intervention = 30-40% employed • Lowest reports with specific intervention = 30-40% unemployed

17. Vocational Independence Scale • Competitive: Community-based work (at least 15 hours per week) without external supports • Transitional: Community-based work (at least 15 hours per week) with temporary supports, such as, job coach, reduced hours OR enrollment in an educational or training program • Supported: Community-based work with permanent supports or less than 15 hours per week OR volunteer work • Sheltered: Work in a sheltered workshop • Unemployed

18. Vocational Outcome: VCC #1

19. Vocational Outcome: VCC #2

20. The Evidence • Follow-up • Telephone follow-up and referral improves outcome • How much? How long? • Value of support network? • Nonspecific effects

21. Ethics and Evidence-based Practice • Ethics a set of rules vs. a level of awareness?

22. Ethical Awareness in Practice • Awareness of current scientific knowledge and best practices • Awareness of current situation • Awareness of individual needs and preferences • Ongoing monitoring and feedback: • changing situation, needs, preferences • Avoiding making things worse (above all do no harm)

23. References • Brain Trauma Foundation. AANS/ACNS Joint Section on Neurotrauma and Critical Care. Guidelines for the management of severe traumatic brain injury. J Neurotrauma 2007; 24 Suppl 1. • Gordon WA et al. Traumatic brain injury rehabilitation: State of the science. Am J Phys Med Rehabil 2006;85:343–382. • Cicerone KD et al. Evidence-based cognitive rehabilitation: recommendations for clinical practice. Arch Phys Med Rehabil 2000;81: 1596-1615. • Cicerone KD et al. Evidence-based cognitive rehabilitation: Updated review of the literature from 1998 through 2002. Arch Phys Med Rehabil 2005:86;1681-92. • Malec JF. Vocational rehabilitation. In High WM et al (Eds.) Rehabilitation for traumatic brain injury. New York: Oxford 2005

24. jim.malec@rhin.com

25. Gordon WA et al. Traumatic brain injury rehabilitation: State of the science. Am J Phys Med Rehabil 2006;85:343–382.