NIH Consensus Development Conference on Rehabilitation of Persons with Traumatic Brain Injury
Introduction
Traumatic brain injury (TBI) is a major cause of mortality and morbidity. In the United States, it is estimated that 1.5 to 2 million people sustain TBI of varying severity each year, mostly due to vehicular crashes, falls, violence, and different sports activities. It has been estimated that TBI results in 75,000 deaths and over 300,000 hospitalizations annually. Additionally, more than one million persons, who are not hospitalized, may experience temporary or permanent impairment as a result of TBI. While the annual cost of acute care and rehabilitation of persons with new TBI is estimated to be $9 to $10 billion, the lifetime costs for those injured in a single year has been estimated to be approximately four times higher. TBI is particularly common in persons of young age, who consequently may face lifelong impairment and disability. TBI may significantly affect the productivity and quality of life of the injured individuals as well as their families.
Although TBI may result in physical impairment and disability, its more frequent sequelae are deficits in cognition, behavior, and emotional functioning. TBI varies widely in its severity, largely depending on its specific neuropathology and the resulting impairment and disability. While neurophysiological consequences of severe TBI are usually fairly obvious, the symptoms of mild TBI are often subtle and the long term disability resulting from mild TBI is largely unknown.
During the last 25 years, considerable progress has been made in research on TBI and related neurological conditions. There is better understanding of the total management of acute TBI. Instruments have been developed to measure the severity of TBI, both during its acute and subsequent phases, for example, the Glascow Coma Scale, the Glascow Outcomes Scale, Disability Rating Scale, and the Functional Independence Measure. By applying these instruments early and during long-term follow-up of persons with TBI, information has been gathered about functional outcomes experienced by persons with TBI. Specific and comprehensive rehabilitation interventions have been developed and applied, even though the efficacy of many of these interventions has not been adequately studied for various reasons.
In 1996, Congress passed the Traumatic Brain Injury Act to amend the Public Health Service (PHS) Act to provide for the conduct of expanded studies and the establishment of an innovative program with respect to traumatic brain injury (TBI). As part of this Act, the Secretary of Health and Human Services, through the Director of the National Center for Medical Rehabilitation Research (NCMRR) within the National Institute of Child Health and Human Development (NICHD), was instructed to conduct a national consensus conference on managing TBI and related rehabilitation concerns.
The Planning Committee met on April 28, 1997. Seven questions for the Consensus Panel were developed and discussed in detail:
- What is the epidemiology of traumatic brain injury in the United States, and what are its implications for rehabilitation?
- What are the consequences of traumatic brain injury in terms of pathophysiology, impairments, functional limitations, disabilities, societal limitations, and economic impact?
- What is known about the mechanisms underlying functional recovery following traumatic brain injury, and what are the implications of these mechanisms for rehabilitation?
- What are the common therapeutic interventions for the cognitive and behavioral sequelae of traumatic brain injury, what is their scientific basis, and how effective are they?
- What models are in common use for comprehensive coordinated multidisciplinary rehabilitation for persons with traumatic brain injury, what is their scientific basis, and what is known about their short-term and long-term outcomes?
- Based on the answers to these questions, what can be recommended regarding rehabilitation practices for persons with traumatic brain injuries?
- What research is needed to guide the rehabilitation of persons with traumatic brain injuries?
Recognizing the importance of clearly defining the terms "TBI" and "rehabilitation," it was agreed that the Consensus Panel would not address resuscitation or emergency and acute care of persons with TBI. It was further agreed that with respect to common therapeutic interventions for TBI, the Panel should focus on the cognitive and behavioral sequelae of TBI rather than medical/physical consequences.
I am deeply grateful to all the members of the Panel, the staff members who have assisted us so well, the authors of the papers provided in the appendices, and all the speakers for the Conference. It is our wish that the consensus conclusions will be helpful when clinical policy is developed on how best to help persons with TBI during their rehabilitation.
Kristjan T. Ragnarsson, M.D.
Chair, Consensus Development Panel on
Rehabilitation of Persons With Traumatic Brain Injury
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