Report No. 1 on the Rehabilitation for Adult Traumatic Brain Injury
Four published reports and one as yet unpublished concerning the reach experience of rehabilitation are worthy of note in our review below.

1. D.N.Cope, Brain Injury 1995, 9, 649-670
This review of largely American data selects, analyses and assesses the most important studies to1994 in terms of overall clinical benefit, and to some extent the cost-benefit of TBI programmes. At that time these were mainly residential but some were outpatient or were carried out in special day centres. None were home-based. Twenty one studies were reviewed involving some 1600 cases of moderate and severe traumatic brain injury. Cope's conclusion was unequivocal: "A very strong case can be made for the assertion - TBI rehabilitation works. It works in ways that make a worthwhile difference to TBI victims and to society". Overall Cope reported significant improvements in quality of life, independent living (that is a reduced need for post rehabilitation care) and in the probability of a return to work. We now turn to a number of more detailed individual studies.

2. P. Eames & colleagues, Brain Injury 1955, 10, 631-650
This is a British report from the well known Grafton Manor Unit and concerns 64 severely brain injured adults followed up from 19 to 101 months after discharge. Whereas nearly 90% needed significant amounts of personal care pre-rehabilitation, only half did so both at discharge from rehabilitation and at follow up, indicating that about 40% both showed a considerable reduction in care need after rehabilitation (to a zero or minimal level) and maintained that improvement over the follow up period. Nearly one third returned to work, but only one third of those did so at the same level or better.

3. Wood & colleagues, Brain Injury 1999, 13, 69 - 88
This is another British report and again involves residential rehabilitation, but this time is from the Brain Injury Rehabilitation Trust. It presents discharge and follow up data on 76 cases of severe traumatic brain injury, with an average follow up time of 33 months. Compared with the situation immediately before rehabilitation there was a reduction of care need of nearly 13 hours per day at follow up for those who entered rehabilitation early (up to 2 years post injury) and of 6.6 hours per day for those who entered up to 5 years post, indicating the importance of early rehabilitation. So far as work was concerned the results were somewhat less striking. Twenty one percent were in employment at follow up of whom only one quarter were in full time employment.

4. Klonoff & colleagues, Brain Injury 2001, 15, 413 - 428
An American report of a day-treatment programme (participants live at home and attend a centre daily). Of the 164 brain injured persons who were reported on, 70% had suffered a traumatic brain injury with the remainder having experienced cerebro-vascular accidents or other injury/disease. More than half were at the severe end of the continuum of severity (on the usual Glasgow Coma Scale measure). Follow up was from 3 months to 11 years for separate sub-groups of the total. Irrespective of the length of follow up nearly half were in full time paid work with another fifth in part-time work or in full time education. No separate data were provided on independent living/care needs but it is a reasonable conclusion that if you are in work, even part-time, or in education, your care needs will be minimal. Unfortunately no separate data were provided for the relationship between severity or injury and return to work, but there is an implication (hardly surprising) that the more severe the injury, the less likely there is to be a return to work.

5. Pace & colleagues, Brain Injury 1999, 13, 535 - 546
An important American report of the home and community based rehabilitation of 77 brain injured children and adults (the majority were under 20) carried out one-to-one by a para-professional rehabilitation technician (with the support of a team of professionals). An important part was played for each client by a key family member. This approach is very close to the reach model (see below and described in presentations in Britain over the years). Outcomes were impressive: about 80% of the individual treatment goals were achieved and were maintained at the same level at six to twelve months follow up. Both families and funding agencies were satisfied, both yielding average ratings of 4.5 for satisfaction (out of a maximum possible score of 5). Unfortunately, no data were provided on the severity of the brain injuries in this group (the majority were traumatic, rather than brain disease) or on the relationship between severity and outcome. Nor are there separate outcome data for adults and children. (And the term "outcome" is not unpacked into care needs and return to work/education). Nevertheless, these results are very encouraging as the rehabilitation time was relatively brief (an average of 170 hours - about 17 weeks) per client and rehabilitation costs averaged about £15,000, making for significant longer term care savings.

6. reach
reach's approach to rehabilitation will be well known to most recipients of this report, but to recapitulate briefly: it is home-based, is matched to the individual and delivered one-to-one, provides a multi-tier quality control, families are involved to whatever extent they are capable, the rehabilitation plan is based on an initial prediction of outcome in the areas of quality of life, independent living and return to work/education, and aims at the best possible outcome in each of these areas at the lowest possible cost.

The results of the rehabilitation of the 16 most recent reach clients (all but two are adults) are as follows: All had a severe/very severe traumatic brain injury causing widespread functional, cognitive, behavioural and emotional problems, which had not abated or had even worsened at the point at which they were assessed - from 10 months to 11 years after injury. At that time they required an average of 16 hours of care per day; none had returned to work. At the conclusion of rehabilitation (average length of time = 9 months), the average care requirement was 4.7 hours per day and 81% had returned to work (full or part time) or was in a position to do so.

Overall, it can be concluded in general that Copes dictum: TBI rehabilitation works, is well supported by the published data and by reach's experience (publication in preparation). This is particularly the case both for quality of life (much improved) and for the need for care (much reduced) but the results for return to work, particularly for the most severely brain injured, while encouraging, indicate (particularly for residentially treated samples) that much further progress is possible and that vocational rehabilitation requires an enhanced degree of focus.

The next report will take up the issues of when and where rehabilitation should be carried out and it's cost-effectiveness (overall and as related to the when and where issues).

Philip Feldman and Heather Batey 18th April, 2002.