Participation after multidisciplinary rehabilitation for moderate to severe traumatic brain injury in adults

The article by Brasure et al represents a systematic review of the literature on effectiveness of multidisciplinary rehabilitation for traumatic brain injury using rigorous methodology and focusing on participation as an outcome. The review assumes that rehabilitation "seeks to restore an individual's functioning and participation to preinjury levels" and that participation is a preferentially valued outcome. Each of these assumptions can be challenged on clinical and/or methodologic grounds. For example, holistic neuropsychologic rehabilitation seeks to promote changes in a patient's social identity as much as their social participation. Participation may not be directly related to changes in patients' activity limitations or well-being, and will not be the appropriate outcome for all studies of treatment effectiveness. The emphasis on methodologic rigor needs to be balanced by the search for relevance and reliance on the best available evidence to guide clinical practice.