Ethical and evidence-based practice in brain injury rehabilitation

The ultimate goal of evidence-based medicine (EBM) is to develop a scientific basis for choosing interventions that will benefit individuals with defined characteristics under specified conditions. By referencing practice recommendations to the strength of the scientific evidence gleaned from systematic reviews, EBM avoids the influence of professional biases. The randomised controlled trial (RCT) has come to be considered the gold standard for EBM methodology. Strengths as well as risks and weaknesses of RCT-focused EBM are reviewed. EBM is also linked to the medical model in which the target of the intervention is a disorder within the individual patient. Some interventions in brain injury rehabilitation may be more appropriately studied within a social model of disability in which the target of intervention is the individual's environment or social system. While the pursuit of a scientific basis for practice is clearly an ethical mandate, defining ethical practice in the absence of strong evidence and in the presence of competing methodologies is elusive. Balancing these considerations, the ethical practice of brain injury rehabilitation requires an awareness not only of the scientific evidence for an intervention but also of current best practices recommended by professional traditions and consensus, the practice situation, and the individual's current and evolving situation, needs and preferences.