There is insufficient evidence to support an evidence-based recommendation related to rehabilitation for pTBI.

In the absence of direct scientific evidence, EXPERT CONSENSUS concluded that:

• Rehabilitation should be initiated for patients with neurologic deficits after pTBI if the rehabilitation treatment does not interfere with necessary medical interventions. (100% consensus)
• We cannot recommend any specific type, duration, or timing of initiation of rehabilitation services in pTBI. (100% consensus)

No evidence or expert opinion supported distinct recommendations based on patient gender, wounding mechanism, or military vs. civilian context.

Penetrating traumatic brain injury often results in significant mortality and morbidity, the latter related to disability amongst survivors. While many surviving patients are offered rehabilitation services, little is known about the benefits and/or harms associated with initiation of these services at various time points after injury.

Multidisciplinary rehabilitation services play an important role in the continuum of care after pTBI. Rehabilitation services are often multidisciplinary, including physical, occupational and speech therapy. These services help to provide not only coping strategies for patients with functional deficits, but also may play a role in functional recovery by enlisting and augmenting neuroplasticity for improvement and recovery over the long term.

The prior penetrating brain injury guidelines (2001) did not review and include the benefits or harm of rehabilitation, or when rehabilitation should be initiated.

We identified no studies that compared rehabilitation versus no rehabilitation in the same patient population (e.g., with a randomized trial) or a similar population (e.g., a cohort study that matched patients based on such factors as mechanism of injury and severity of injury) to determine the benefits and harms of rehabilitation versus no rehabilitation. Thus no study qualified based on inclusion and exclusion criteria. However, indirect evidence of benefits of rehabilitation are demonstrated in the studies described below, though they did not include comparator groups who did not undergo rehabilitation.

Studies not included:

Zafonte and colleagues1 demonstrated improvement with rehabilitation across all domains of civilian victims of gunshot wounds to the head, between admission and discharge, with a mean stay of 38.5 days in 33 of 442 patients: 86% were male with a mean age of 28 years, disability rating scale (DRS) improved tfrom 13.7 to 6.2, functional improvement measure (FIM) on cognitive domain improved from 16.4 to 24.2, FIM-motor from 41.1. to 71.6, total FIM from 57.4 to 95.8, and the Los Ranchos cognitive functioning scale (LCFS) from 4.9 to 6.6. The authors state that rehabilitation is justified if patients "are proven to have favorable outcomes." However, 51.8% of patients had severe injuries and 41.5% mild and it may be that the severely injured succumbed and those with mild injuries underwent rehabilitation. A study by Hotz et al2 replicated the short-term benefits demonstrated with rehabilitation. Zafonte et al also reported continued functional improvements at 1 year in pTBI patients able to undergo rehabilitation.3

Two further studies from army blast injuries, where rehabilitation was implied but not specified, reported improved Glasgow Outcome Scale (GOS) scores from 6 to 24 months post-injury.4,5

These studies do not provide evidence that rehabilitation compared to no rehabilitation provides distinct benefits or harms in pTBI patients. However, they do support that some patients admitted to a rehabilitation program or facility following pTBI improve in function. There is no evidence to say that these patients would or would not have similarly improved without rehabilitation.

There are no research articles that address the specific question of benefits/harms or type and timing of rehabilitation in the setting of pTBI. Several studies report outcomes and discharge disposition for patients, including discharge to rehab, however these studies are not designed to answer the question of benefits or harms of rehabilitation initiation. While many patients discharged to rehab demonstrated improved outcomes over time, it is impossible to determine whether or not these same patients would have also improved and to what degree they may have improved without rehabilitation services. It is strongly believed, however, that the initiation of rehabilitation services is beneficial for functional recovery after pTBI. There is no evidence to suggest harm from initiation of rehabilitation services during the acute treatment phase or the recovery phase.

The National Academies of Science, Engineering and Medicine, published a monograph titled "Traumatic Brain Injury: Roadmap for Accelerating Progress" in which the topic of rehabilitation was addressed in TBI as a whole (not specific to pTBI).6 This document provides a useful resource.

As an extension of the above, rehabilitation is assumed to augment the functional recovery of patients who sustain a pTBI. In addition to building strength, improving balance, and promoting adaptive strategies, rehabilitation may stimulate plasticity and other repair processes. Although rehabilitation is a standard of care, quality of rehabilitation is known to vary and access to it can be problematic for a variety of reasons. The expert consensus states that acute rehabilitation be started as soon as possible, once the patient is medically stable, though evidence does not currently inform what type of rehabilitation or a component thereof is likely to provide the most benefit.

Most patients who survive a pTBI will require rehabilitation. Those who survive to initiate rehabilitation are predicted to have good functional outcomes. Future investigations including randomized and non-randomized studies of rehabilitation strategies should be performed although there may be need for multi-center collaboration to achieve needed patient enrollment. Different rehabilitation modalities also require study. It would of course be unethical to withhold rehabilitation in relevant studies given indirect evidence from blunt TBI. Additional studies focusing on timing of rehabilitation service initiation, as well as comparative outcome studies for patients who did and did not receive rehabilitation services due to barriers, would be beneficial to assist in answering this question. In the absence of these studies, decisions on timing of rehabilitation service initiation should fall to local standards of practice.