From the 1Department of Rehabilitation Medicine, Royal Melbourne Hospital, 2Department of Medicine (Royal Melbourne Hospital), University of Melbourne, Parkville, 3Australian Rehabilitation Research Centre, Royal Melbourne Hospital, and 4School of Allied Health, Human Services and Sports, La Trobe University, Victoria, Australia.
Objective: To determine the effectiveness of multidisciplinary rehabilitation in improving functional and psychological outcomes in person with multiple trauma.
Date sources: A comprehensive literature review was conducted using medical and health science electronic databases up to February 2019.
Data extraction: Two independent reviewers selected studies, extracted data and assessed study quality using the Critical Appraisal Skills Programme (CASP) checklists and Grading of Recommendations, Assessment, Development and Evaluations (GRADE).
Data synthesis: One randomized controlled trial, 1 clinical controlled trial and 4 observational studies (1 with 2 reports) were included. Qualitative analysis was used to synthesize the evidence due to the heterogeneity of included trials. The quality of the studies varied (CASP approach); the majority were of “low quality”. The findings suggest “very low to moderate” evidence (GRADE) for the effectiveness of multidisciplinary rehabilitation in improving functional ability and participation. The majority of studies (n = 6) reported functional improvements after multidisciplinary rehabilitation in the short-term.
Conclusion: The lack of “high-quality” evidence for multidisciplinary rehabilitation in improving outcomes following trauma highlights gaps in the available evidence, signifying the need for more robust studies.
Key words: multiple trauma; multidisciplinary; rehabilitation; disability.
Accepted Aug 21, 2020; Epub ahead of print Sep 17, 2020
J Rehabil Med 2020; 52: jrm00108
Correspondence address: R. Al Hanna, Department of Rehabilitation Medicine, Royal Melbourne Hospital, 34–54 Poplar Road, Parkville, Melbourne, Victoria 3052, Australia. E-mail: Reem.AlHanna@mh.org.au
Trauma is major cause of death and disability worldwide. An increasing number of people survive multiple traumatic injuries due to improvements in emergency, surgical and trauma services. Rehabilitation is therefore necessary to maximize patients’ function and successful societal reintegration. This study assessed the evidence from published clinical studies to determine the effectiveness of multidisciplinary rehabilitation in improving function in persons with multiple traumatic injuries. The findings suggest limited high-quality evidence to support multidisciplinary rehabilitation for improved function and quality of life. Further research with better study design is needed to justify multidisciplinary rehabilitation in the management of survivors of multiple trauma.
Multiple trauma is defined as “the presence of 2 or more injuries to physical regions or organ systems, 1 of which may be life threatening, resulting in physical, cognitive, psychological or psychosocial impairments or disability” (1). Trauma is a major public health issue and a leading cause of mortality, morbidity and long-term disability. The World Health Organization (WHO), estimates trauma contributes to ~10% of mortalities and an annual death rate of >5.8 million people worldwide (2, 3). Trauma is associated with moderate-to-severe disability for >45 million people, mainly in adults
Recent advances in acute trauma care have resulted in a greater survival rate. This may result in long-term psychological distress and/or physical impairment often associated with work disability (12). In Australia, 10% of trauma survivors had severe, and 28% had mild, limitations in core activities (e.g. mobility) and 45% had schooling/employment restrictions (5). This highlights the need for multidisciplinary rehabilitation (MDR) services within existing trauma care systems to minimize the burden of surviving injuries and improve functional outcomes and quality of life (QoL) of persons with multiple trauma (pwMT).
Rehabilitation assists pwMT to return to their home/community, live independently and participate in education, and the workforce (13). MDR is defined as “an inpatient, outpatient, home or community-based coordinated intervention, delivered by 2 or more disciplines in conjunction with medical input (rehabilitation medicine physician) that aims to limit patient symptoms, enhance functional independence and participation” (14). These disciplines may include nursing, physiotherapy, occupational therapy, speech pathology, social work or psychology.
Similar to the UK, Australia does not have a universal guideline for rehabilitation management in pwMT. However, in the UK, the National Institute for Health and Care Excellence (NICE) is developing a guideline for people with complex rehabilitation requirements after traumatic injury (15). Other countries (e.g. USA, Canada and New Zealand) also lack rehabilitation guide-lines, highlighting the absence of an internation-ally agreed framework for the assessment of disability and function and an inconsistency in the rehabilitation management of pwMT (6).
Previous systematic reviews have highlighted the lack of “high-quality” evidence for MDR effectiveness in improving functionality and QoL of pwMT (6), as well as effective collaborative care rehabilitation for traumatic injury survivors (16). The gaps identified included the types of rehabilitation settings, modalities and duration of therapy, lack of effective care pathways and long-term neuropsychological or functional outcomes. These findings were akin to issues identified in interventions for people with complex neurological conditions, spinal cord injury and brain tumours (6, 17–19). To the authors’ knowledge only 1 review evaluated the effectiveness of MDR in pwMT (6). Thus, the purpose of this study is to provide a comprehensive and updated systematic review on this topic.
The objective of this review is to determine the effectiveness of MDR in improving functional and psychological outcomes in pwMT.
A literature search was conducted using Cochrane Central Register of Controlled Trials (CENTRAL), Allied and Complimentary Medicine (AMED), Embase, MEDLINE, Latin American and Caribbean Literature on Health Sciences (LILACS), PUBMED, INFORMIT and CINAHL up to February 2019. A manual search of reference lists of potential articles, govern-mental and nongovernmental healthcare institutions’ websites was also conducted. The grey literature search included: System for Information on Grey Literature in Europe (SIGLE), New York Academy of Medicine Grey Literature Collection, National Quality Measures Clearinghouse and Google Scholar.
The search was constructed in Ovid MEDLINE using a combination of multiple search items for 2 themes: multiple/poly trauma and rehabilitation (multidisciplinary). A combination of MeSH terms and keywords were used and translated to other databases. A full description of the search strategy can be found in Appendix 1 and Appendix 2.
Inclusion and exclusion criteria
Randomized controlled trials (RCTs), clinical controlled trials (CCTs) and observational studies (n > 10) in pwMT were includ-ed if: (i) patients were > 18 years old; and (ii) MDR involved > 1 intervention or discipline. No date, setting or interventions dosage restrictions were applied. Studies were excluded if: (i) focusing on isolated trauma (e.g. burns only), (ii) single discipline intervention/modality (e.g. physical exercise only), (iii) design other than RCT, CCT or observational studies (n < 10) (e.g. case reports), and (iv) non-English language.
All studies identified through the search process and other sources were exported to an EndNote X9 (Clarivate, London, UK) database for removal of duplicates. Titles and abstracts were screened by RA and BA. Selected articles’ full text was then screened independently by RA and BA using in/exclusion criteria. Any disagreements were resolved by consensus with FK.
Data extraction was performed independently by RA and BA using a standard pro forma, which included: design, date, country, sample size, demographics, outcome measures and intervention (type, intensity, domains, setting, delivery mode and duration).
Due to the heterogeneity of the studies, a qualitative analysis was performed by RA and BA for best-evidence synthesis using Critical Appraisal Skills Programme (CASP) appraisal tools. Any disagreements were resolved through consensus (20, 21). The CASP tools for Cohort Studies and RCTs were used to assess the observational studies and clinical trials respectively (20, 21). One item from the CASP RCT and Cohort checklists “Can the results be applied to the local population?” and a second item from CASP Cohort Studies checklist “’Do the results fit with other available evidence?” were not included because the focus of this review was not tied to a specific local population and the purpose was to compare results across studies (20, 21). Risk of bias for each of the items from the checklists were scored as follows: yes (low = 1), no (high = 0), or cannot tell (unclear or unknown = 0). Total scores were used to grade the methodologic quality of each study and categorized as: “poor” (< 5/10), “moderate” (6–8/10) and “high” (9–10/10).
The quality of evidence for each study outcome was independently assessed by RA and EC using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool and graded as “high”, “moderate”, “low” or “very low” (22, 23). Any disagreements were resolved through a consensus-based discussion.
A total of 3,025 titles and abstracts were retrieved (Appendix 2); electronic database searches (n = 2,982) and other sources (n = 43). Forty-one abstracts met the preliminary eligibility criteria; however, 34 were excluded due to inappropriate study design (n = 8), no intervention (n = 18), uni-disciplinary intervention (n = 5) or not multiple trauma (n = 3). A total of 6 studies (1 with 2 reports) were finally included (1, 12, 24–28). A PRISMA flow diagram is presented in Fig. 1.
Fig. 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram showing selection of article review. CCT: clinical controlled trial; RCT: randomized controlled trial.
Characteristics of included studies
The characteristics of the included studies are summarized in Table I (1, 12, 24–28), which included 1 single-blinded RCT, 1 CCT and 4 observational studies (1 with 2 reports). Only 2 studies (1 with 2 reports) mentioned the total duration and intensity of the MDR programme, however, fail to specify modalities (24, 25, 28). Four studies (1 with 2 reports) included the type of allied health disciplines involved in the patients’ care (24–28). No study provided information regarding “optimal dose” or type of modality. One study included follow-up assessment at 3 months and 8 years following discharge including the long-term sustainability of gains and participation related community re-integration (1). In addition, 2 studies evaluated psychological outcomes and QoL (26, 27).
Table I. Characteristics of included studies
Quality assessment of included studies
The mean CASP score (CASPs) was 4.3 (range 2 to 9/10). Only the RCT was rated as “high” quality (CASPs=9/10) (26), the CCT as “moderate” quality (CASPs=6/10) (27) and the four observational stud-ies (1 with 2 reports) were rated as “low” quality (CASPs=2 to 5/10) (1, 12, 24, 25, 28). Detailed CASP scores are shown in Table II.
Table II. Quality assessments of individual studies (CASPa approach)
Quality of evidence
Four observational studies (1 with 2 reports) (1, 12, 24, 25, 28) and the CCT (27) were graded “low”, as a higher risk of bias due to the study design. The 4 observational studies (1 with 2 reports) were further downgraded to “very low”, suggesting high risk of bias, mainly driven by selection bias, lack of effect estimates and study power (1, 12, 24, 25, 28). The CCT was upgraded to “moderate” for demonstrating a large consistent effect and the absence of imprecision (27). The RCT was initially graded “high” as a priori ranking for study design, then downgraded to “very low” for single blinding and imprecision, and finally upgraded to “moderate” quality for demonstrating large consistent affect and dose response (26). The detailed GRADE assessments are shown in Table III.
Table III. Levels of quality of studies (GRADE approacha)
Four studies reported statistically significant functional gains in motor FIM at discharge after an inpatient MDR programme (p-value range = <0.01–0.05) (1, 12, 24, 28), of which 3 studies also showed cognitive FIM improvements (p-value = < 0.01–0.5) (1, 12, 24). In addition, one study showed that both Fast Track and Care and Usual rehabilitation programmes were effective in improving functional status (total FIM score) (p < 0.0001) and QoL (27). However, an earlier improvement was reported in the Fast Track group for functional gains between 3 and 6 months compared with Fast Track between 3 and 9 months, with no differ-ential effects between both groups at 1 year (27). Only 2 studies (1 with 2 reports) mentioned the duration and intensity of MDR provided in an inpatient setting (24, 25, 28). Four studies (1 with 2 reports) included the type of allied health disciplines involved in the patients’ care (24–28), of which one study included the corresponding median number of sessions (70 vs 42.5 sessions for in-reach MDR vs usual care) (26). This study demonstrated a mean FIM improvement in both the intervention and control groups, but found no significant differences in in-reach MDR vs usual care in functional, psychosocial or pain outcomes at time of discharge or follow-up (26).
This review included both experimental and observational studies. The findings demonstrated a small number of methodologically rigorous clinical trials in this population. This is probably due to the clinical complexity, heterogeneity, diverse clinical presentation and disability of pwMT, which affects standardization of intervention characteristics, and the clinical outcomes used (18). This review examined the effectiveness of MDR in improving functional and psychological outcomes in pwMT.
Despite the recognition of the integral role of MDR in pwMT, the findings suggest a number of limitations in existing literature. Consistent with a similar review by Khan et al. conducted in 2012 (6), there is still a paucity of evidence to support the beneficial effect of the MDR in pwMT (1, 12, 24–28).
The included studies showed a marked heterogeneity in terms of characteristics, type and mode of delivery, treatment intensity and length of follow-up (1, 12, 24–28). The findings suggest that there is “very low to moderate” evidence for MDR in producing functional gains at both activity and participation levels (1, 12, 24, 26–28). Two clinical trials compared in-reach (26) and fast track (27) MDR to usual care of pwMT found no significant differences between the groups in functional or psychological outcomes at time of follow-up.
The existing outcome measures do not thoroughly describe the impact of major trauma on function, health and disability (6, 29). The FIM tool is used as an outcome measure in the 6 included studies (1, 12, 24, 26–28), is an indicator of a patient’s level of disability dominated by physical disability and a basic assessment of cognitive and psychosocial disability (30). The FIM has also “floor” and “ceiling” effects, which impedes determining the real impact of MDR in pwMT (30). In this regard, the UK FAM extends the 18-item FIM by adding items for extended activities of daily living, physical, cognitive and psychosocial function, and may potentially be more sensitive in determining functional improvements (31). Other complementary tools may include the Trauma Outcome Profile (Germany) and Trauma QoL Measure (USA) (32–34) and WHO Disability Assessment Schedule II – 12 Item. However, these outcome measures require further validation in pwMT.
Similar to studies of in-reach stroke MDR programme (35), the included RCT (26) did not find benefit for in-reach rehabilitation for pwMT. This was attributed to methodological challenges and, possibly, the lack of resources on the surgical ward (26). Stratification of pwMT based on their initial motor and cognitive impairment, type, nature and pattern of injury should be considered in future research. There is also a need to determine optimal MDR approaches in different settings (acute, sub-acute and community), and effect on long-term outcomes (return to work, community re-integration). Future studies would benefit from greater clarity regarding the types, intensity and duration of therapy.
This review has some limitations. Due to the dominance of male participants in included studies, it was not possible to assess effects of sex (1, 12, 24–27). Limiting the search to English language articles may have introduced a risk of selection bias. The search identified a limited number of robust clinical trials (RCT and CCT); however, there are many challenges conducting such trials due to heterogeneity and diverse clinical presentation in this patient cohort. Furthermore, the “black box of rehabilitation” makes it difficult to determine the effectiveness of active components of MDR (e.g. type, modality, intensity or duration of intervention) (36). Furthermore, 3 included studies (1 with 2 reports) assessed MDR in veterans or war service members (1, 12, 24, 25). These are difficult to extrapolate to civilian trauma survivors, particularly in middle-to-low-income countries where there is a lack of funding and rehabilitation resources. We strengthened this review by placing no date restrictions, including a grey literature search, and by utilizing a comprehensive list of search terms.
There is “very low to moderate” evidence for the effectiveness of MDR in improving function and participation in pwMT. Robust studies are required using responsive appropriate outcome measures, and description of modality, intensity, frequency and duration of rehabilitation interventions; and models of care.
The authors thank Ms Catherine Voutier for her assistance with the search strategy.
The authors have no conflict of interest to declare.
Appendix 1. Key words and search terms for the search strategy
Appendix 2. Search strategies
Appendix 2. Cont.