Traumatic Brain Injury Clinical Guidelines

Introduction

Momentum for evidence-based healthcare is rapidly gaining momentum as clinicians and administrators express concerns about quality consistency and cost of healthcare interventions. The use of clinical guidelines based on standardized best practices has been shown to support Improving the quality and consistency of healthcare is considered one of the main ways to implement evidence-based medicine. Clinical practice guidelines are defined by Field and Lohr [1] as systematically formulated statements to assist practitioners and patients in making decisions about Appropriate medical care for specific situations. [1][2]

According to Woolf et al. [3], clinical guidelines have become one of the foundations for improving healthcare and healthcare management. The approach to guideline development has advanced in terms of process and necessary procedures, and the context for guideline development has changed With the emergence of guideline clearinghouses and large guideline production organizations such as the National Institute for Health and Clinical Excellence (NICE). [3]

The short video below shows how they are used in practice.

[4]

Purpose

Clinical guidelines provide advice on how health care professionals should care for people with specific diseases. They can cover any aspect of the disease and may include advice on providing information and advice, prevention, diagnosis, treatment and long-term management, and Designed to support the decision-making process in patient care. The content of the guidelines is based on a systematic review of the research literature and clinical evidence – the main sources of evidence-based care. [5]

The purpose of clinical guidelines is to improve the quality of care by translating new research findings into practice. Evidence suggests that the following characteristics facilitate their use: Contains specific recommendations Sufficient supporting evidence Clearly structured and attractive In developing recommendations, the implicit norms of the target users should be considered. Guidelines should be developed by a credible central organization in a structured and coordinated programme. Facilitating their implementation guidelines can be used as Templates for local agreement clinical pathways and interprofessional agreements. [6]

• Describe appropriate care based on the best available scientific evidence and broad consensus
• Reduce inappropriate variation in practice
• Provide a more reasonable basis for referrals
• Provides a focus for continuing professional education
• To promote efficient use of resources
• As a focus of quality control, including auditing
• Highlight deficiencies in the existing literature and suggest appropriate future research. [5]

Limitations and Controversy

Clinical guidelines may have limitations, and there may be controversy surrounding some of the recommendations in some guidelines. Not every patient or situation fits the guidelines. Guidelines do not always cover all possible scenarios and each patient’s situation needs to be considered to consider when deciding on treatment. Recommendations should be considered statements to inform clinicians, patients and any other users, rather than strict rules.

Research in the field of acquired brain injury and the resulting evidence-based recommendations have made it difficult to develop best practice and clinical guidelines. Challenges in management according to clinical guidelines in the Guidelines for Rehabilitation after Brain Injury Traumatic brain injuries include:

• Significant heterogeneity in patient groups, interventions and settings, and outcomes associated with each recovery phase
• Since many traumatic brain injury patients lack the mental capacity to give full informed consent, minority group ethical considerations confound the application of randomized controlled trial designs
• Ethical issues of randomizing patients to ‘no treatment’ or even ‘standard’ care, as evidence mounts of the effectiveness of multidisciplinary rehabilitation in other settings, notably stroke
• Funding issues for long-term projects, and the length of time (often months or years) over which rehabilitation can have an impact is often longer than any funded research.

Because these limitations have a significant impact on study design and quality, the guidelines also draw on a wealth of expert opinion and existing consensus-based documents.

Level of Evidence Type of Evidence Recommendation Grade Ia Meta-analysis of randomized controlled trials (RCTs) AIb At least one RCTA IIa At least one well-designed controlled study without randomization BIIb At least one well-designed quasi-experimental design BIII At least one non-experimental Research Descriptive research (e.g. comparative correlations or case studies) BIV expert committee reporting opinion and/or experience of authority C

Table 1 Evidence categories and recommendations commonly used in developing clinical guidelines

Degree of recommendation A At least one meta-analytic systematic review or clinical trial classified as level 1 and directly applicable to the target population of the guideline; or substantial scientific evidence consisting of studies classified as 1 with high agreement between them Volume BA Scientific evidence consisting of studies classified as 2 is directly applicable to the target population of the guideline and shows a high degree of agreement between them; or scientific evidence inferred from studies classified as 1 or 1 CA consists of studies classified as 2 amount of evidence Directly applicable to the target population of the guideline and demonstrates a high degree of agreement; or scientific evidence extrapolated from category 2 studies level 3 or 4 scientific evidence or extrapolated from category 2 studies clinical good Practice recommended practices based on clinical experience and expert group consensus

table. 2 Recommended by the Scottish Interscholastic Guide Network

Clinical guidelines are not always an exhaustive form of evidence-based practice. It is recommended to use other sources such as the Cochrane Collaboration or evidence databases such as PEDro to find clinically valuable assessment and treatment methods and organizing principles, especially in such Heterogeneous populations, such as traumatic brain injury survivors. Therefore, it is most effective to combine the knowledge of established guidelines with the clinical findings of patients with traumatic brain injury and the clinical reasoning judgment of treating therapist clinicians Management of patients with traumatic brain injury.

Traumatic Brain Injury Clinical Guidelines

While the evidence base for traumatic brain injury management and rehabilitation is increasing, large gaps remain and more research is needed to improve service delivery and more importantly patient outcomes. Numerous clinical guidelines related to traumatic brain injury Injury treatment focuses on medical management, such as avoiding secondary injury. Overall, most guidelines for each stage of management recommend that all people with a TBI should receive dedicated TBI care.

Guidelines

Head Injury: Assessment and Early Management (2014)

Type: NICE Guideline

Publication Date: 2014

This guidance contains recommendations for the assessment and early management of head injuries in children, adolescents, and adults for brain-injured healthcare professionals and their families. “It facilitates effective clinical assessment so people get the right care Understand the severity of their head injury, including direct referral to specialist care if needed. “The guidance includes advice on:

• Pre-hospital assessment consultation and on-site real-time management
• Assessment in the emergency department
• Investigation of clinically important brain and cervical spine injuries
• Information and support for families and carers
• Transfer from hospital to neuroscience unit
• Admission and observation
• Discharge and follow-up

The guideline demonstrates best practices for patient-centered care and key priorities for implementation in the field of transport to hospital assessments in emergency departments to perform CT head scans to investigate cervical spine discharge injuries and follow-up criteria.

Guidelines for the management of severe traumatic brain injury (2016)

Type: Trauma Brain Injury Foundation International Brain Injury Guidelines from the Joint Section of the American Association of Neurosurgeons (AANS) Congress of Neurosurgeons (CNS) AANS and CNS Neurotrauma and Critical Care. [7]

Publication Date: 2016

The guidelines contain a set of evidence-based recommendations for the acute medical and clinical care of adults with severe TBI to prevent complications and improve patient outcomes. It provides recommendations for treatment, such as hypothermic decompressive craniectomy using anesthesia or Sedatives can also prevent complications such as infections, seizures, and deep vein thrombosis. The guideline informs the development of local algorithms and care pathways

Concussion – Management of Mild Traumatic Brain Injury (2016)

Type: Clinical Guidelines from the Department of Veterans Affairs and Department of Defense

Publication Date: 2016

This guidance document supports key decision points in the management of concussion/mild traumatic brain injury (mTBI) and provides comprehensive evidence-based recommendations, incorporating current information and practice, for clinicians dealing with adults with TBI and concussion. this The guidelines aim to improve patient outcomes, including symptom and functional adherence, treatment recovery, well-being, and quality of life. These recommendations are designed to minimize preventable complications and morbidity.

The guidance includes recommendations for diagnostic evaluation and treatment of symptoms, including headaches, dizziness, balance problems, cognitive symptoms, fatigue, visual and auditory symptoms, sleep disturbances, and pain.

Rehabilitation After Acquired Brain Injury (2003)

Type: Guidelines developed by the British Society for Rehabilitation Medicine (BSRM) and supported by the Clinical Validity and Evaluation Unit of the Royal College of Physicians (RCP). [8]

Publication Date: 2003

The guidelines were developed by multidisciplinary and multi-agency experts to address the issues of BSRM RCP charities working with people with acquired brain injuries and people with ABI. It provides a robust framework for the management of adults with ABI and provides the standard of care from the post-acute stage Long-term care aimed at reducing morbidity contributes to functional recovery and community reintegration. The guidelines provide a set of recommendations for the quality of life of people with ABI and their relatives.

Through the “Head Injury: Assessment and Early Management” guideline, the “Rehabilitation after Acquired Brain Injury” guideline provides a comprehensive framework for the management of ABI in long-term care from prehospital to clinical care and service delivery levels.

The guide provides advice on:

• Principles and organisation of services
• Approaches to rehabilitation
• Carers and families
• Early discharge and transition to rehabilitation services
• Inpatient clinical care – prevention of secondary complications of severe brain injury
• Rehabilitation Settings and Transition Phases
• Rehabilitation interventions
• Continuing care and support
• The need for further research
• Algorithm for early discharge and referral to rehabilitation

Particularly relevant to physiotherapy services:

G1 Every patient with an acquired brain injury should have access to specialized neurorehabilitation services:

• Covers all phases from acute management to mid-term rehabilitation to long-term support
• As long as needed – this could be for life.

G11 Patients with acute ABI following the following should:

• Move as quickly as possible to a rehabilitation program of appropriate intensity to meet their needs
• Receive as much treatment as they need and find tolerable
• Gain as many opportunities as possible to practice skills outside of formal therapy sessions

Rehabilitation

G12 After the acute phase, ongoing rehabilitation in the community should support a balance of activities according to the individual patient situation. This should move gradually from formal treatment to guided and supported return to selected activities over months or years.

G13 Recognize the need for lifelong engagement to meet the changing clinical social and psychological needs of patients and caregivers.

G19 There should be a single interdisciplinary patient record system where all members of the team document their interventions.

G23 A rehabilitation plan should be developed in collaboration with the family carer or paramedics to ensure that the plan is integrated into daily activities.

Optimising Respiratory Function

G43 The patient’s respiratory function should be optimized through early mobilization positional recommendations for oxygen therapy and appropriate manual techniques, based on the advice of an expert interdisciplinary team.

G45 Tracheostomy patients should be reviewed regularly and, if appropriate, weaning plans should be instituted as soon as possible to facilitate early extubation.

G46 Tracheostomy care and weaning should be performed according to published guidelines.

G47 A designated interdisciplinary tracheostomy team, including nurse physiotherapists and speech and language therapists, should be responsible for setting and reviewing weaning parameters for good tracheostomy procedures and maintenance care.

Positioning and Handling

G57 All team members who handle patients should be taught safe and appropriate methods of handling patients.

G58 The mobility/handling procedure for each patient with reduced mobility should be:

• Established within 48 hours of admission through the collaboration of physiotherapists and nursing staff
• applied consistently by all staff
• Review and revise as patient needs change.

G59 Patients unable to protect pressure areas should:

• Clinical assessment of pressure ulcer risk
• Immediately obtain proper pressure relief equipment (mattress, etc.)
• Regular inspection of at-risk skin areas to ensure adequate protection
• Get expert advice from Special Seats, Team Organizational Vitality, and more.

Spasticity management and contracture prevention

G60 Patients with spasticity should be evaluated and treated by an interdisciplinary team experienced in spasticity management.

G61 Patients with significant spasticity and/or contractures should have a coordinated plan of interdisciplinary management including:

• Eliminate simple causative or aggravating factors, such as pain and infection
• Use of specific treatment modalities, such as series plaster casts or removable splints (if applicable)
• Antispasmodics, including botulinum toxin, are used as appropriate.

Early Sitting and Standing

G63 Every brain-injured patient who remains comatose or is unable to sit up by himself should have a graded program to increase tolerance to sitting and standing.

G64 Patients should be stood and seated by adequately skilled staff using appropriate support equipment.

Motor Function and Control

G100 Physiotherapists with neurological expertise should coordinate treatment to improve motor function in all patients with brain injury.

G101 Any current physical therapy approach should be implemented within a neurological framework to improve patient function, but associated orthopedic or musculoskeletal injuries should also be considered.

G102 The plan should include a written plan, with illustrations where appropriate, to guide the rest of the team in applying the motor skills to other daily activities.

Supportive Seating and Standing

G103 Patients who are unable to maintain their balance in a sitting position should:

• Timely delivery of suitable wheelchairs and suitable support seat packs
• Periodic reviews to ensure the seating system continues to fit as needs change.

G104 Patients with complex postural needs should be referred to an interdisciplinary team of specialists with specialized seating expertise.

G105 Patients who are unable to stand unaided should be provided with appropriate standing aids, as appropriate, and should continue to be available to the community if they are still needed on transfer.

Aids and Orthoses

G106 Patients with reduced mobility should consider the use of appropriate walking or standing aids for stability (C), which may include ankle-foot orthoses.

G107 Orthotics, if provided, shall be fitted separately.

Improving Motor Control

G108 When planning a program to improve motor control, the following should be considered to improve motor control and general health:

• Treadmill training with partial body weight support as an adjunct to usual therapy
• Strength training to improve motor control of targeted muscle groups
• Gait Reeducation to Improve Walking Ability
• Exercise training promotes cardiorespiratory fitness.

Optimize performance in daily life tasks

G141 All patients with difficulties with activities of daily living

• Should be evaluated by an occupational therapist with expertise in brain injuries
• There should be an individual treatment plan designed to maximize self-sustaining productivity and independence for leisure.

G142 All tasks of daily living should be performed in the most realistic and appropriate setting, with opportunities to practice skills outside of therapy sessions.

G143 Social services should recognize that providing “care” for some people with acquired brain injury may mean supervision and practice of community life skills rather than actual physical care.

G144 Families and caregivers should be involved in establishing the most appropriate ADL routine, taking into account their lifestyles and choices.

SIGN Guidelines for Adult Brain Injury Rehabilitation (2013)

Type: Guide for the Scottish Inter-School Guide Network (SIGN) [9]

Publication Date: March 2013

Guidelines for healthcare professionals across sectors (primary, secondary, tertiary or independent healthcare or voluntary sectors) in the management of brain-injured patients, covering in detail long-term rehabilitation after brain injury in adults (16 years and older) post-acute stage. The guidelines provide evidence for cognitive-communication-emotional-behavioral and physical rehabilitation interventions and patient outcomes, benefits of discharge planning, and applicability of telemedicine in relation to optimal models and care settings. this The information presented is relevant to people with brain injuries and their families.

Physical rehabilitation and management recommendations include:

• Repetition of task-oriented activities is recommended to improve functional abilities, such as sitting to standing or fine motor control. Recommended grade B
• In cases of progressively worsening contractures and deformities, plaster splinting and passive stretching may be considered. Recommended grade C
• Botulinum neurotoxin therapy (BoNT) may be considered for reducing tension and deformity in patients with focal spasticity. Recommended grade B
• A comprehensive assessment of bladder and bowel function should be performed within a few days of admission. The patient’s physical cognitive and emotional functioning should be considered, and a multidisciplinary team should be involved in developing an individualized treatment plan. [null append Good practice recommendation]

Service delivery recommendations include:

• For best results, intensive rehabilitation featuring early intervention should be provided by a professional multidisciplinary team. Recommended grade B
• Community-based rehabilitation services for brain-injured patients should include a broad range of disciplines working within a coordinated interdisciplinary model/framework, with direct access to common services through patient pathways. Other good practice recommendations

Clinical practice guidelines for the rehabilitation of adults with moderate to severe traumatic brain injury

Type: Guidelines from the Quebec National Institute for Excellence in Health and Social Services (INESSS) and the Ontario Neurotrauma Foundation (ONF) [10]

Publication Date: September 2018

The guidelines, developed as a collaborative effort between researchers, clinicians, and policymakers in Ontario and Quebec, focus on community-based rehabilitation and end-user needs, “including prioritization of recommendations for implementing tools Metrics to measure the impact of absorption systems and the background rationale and evidence supporting this recommendation”.

Clinical practice guidelines contain recommendations related to components of an optimal TBI rehabilitation system and components of assessment and rehabilitation for sequelae of brain injury, such as:

• Intensity / Frequency of Interventions
• Rehabilitation Mechanisms
• Duration of interventions and mechanisms to facilitate continuity of care
• Facilitating reintegration and participation
• Brain Injury Education and Awareness
• Capacity and Consent
• Family
• Comprehensive assessment of the patient with traumatic brain injury
• Medical and Nursing Management
• Motor Function and Control
  • M1. Motor function and control assessment
  • M2. motor function and control rehabilitation
  • M3. Assessment of Spasticity
  • M4. Management of Spasticity
  • M5. Assessment for Assistive Technology
  • M6. Prescription of Assistive Technology
• Sensory Impairment
• Cognitive Dysfunction and Communication
• Fatigue and Sleep Disturbance
• Pain and Headache
• Disorders of Consciousness
• Dysphagia and Nutrition
• Psychosocial / Adaptation Issues
• Neurobehavior and Mental health
• Substance Misuse

Long-term impairment of consciousness: National clinical guidelines (2015)

Type: Royal College of Physicians (RCP) guideline [11]

Publication Date: October 2015

National clinical guidelines help to develop clinical and ethical standards for the treatment and care of people with impaired consciousness and chronically impaired consciousness. This guideline, developed by a panel of experts, provides additional healthcare information for clinicians Professional service providers and commissioners what constitutes a tool in the practical and legal decision-making process. It helps decide where patients should be cared for and how life-sustaining treatments are used appropriately, and provides principles for end-of-life management.

It contains the following sections:

• Defining Criteria and Terminology
• Assessment, Diagnosis, and Monitoring
• Acute to Longer-Term Management
• Ethical and Medico-Legal Issues
• End-of-Life Issues
• Service Organisation and Commissioning

The guidelines promote the important role that families play in the care of PDoC patients and emphasize their need for information, training and support. “Further Systematic Longitudinal Data Collection” and Development of National Registers and Disease Case Datasets Consciousness and chronic disturbances of consciousness are supported.

Downloadable chapters include:

• Chronic impairment of consciousness – complete national clinical guidelines
• Annex 1a Assessing Response in MCS Patients
• Annex 1b Literature on rehabilitation outcomes
• Annex 2a Full Formal Clinical Assessment
• Annex 2b Minimum Requirements for Assessors of Patients with Chronic Impairment of Consciousness
• Annex 2c Optimized Response Conditions
• Annex 2d Comparison of WHIM CRS-R and SMART tools
• Annex 2e Characteristics for families and caregivers to look for
• Annex 2f Assessment and Diagnostic Record for VS or MCS
• Annex 3a Clinical Management
• Annex 4a Best Interests Checklist for PDOC Patients
• Annex 4b The role of family and friends in medical decision-making
• Annex 4c Template for Advance Decision to Refuse Treatment (ADRT)
• Information for Families About Medical Decisions

Suggestions for early aggressive management of patients with impaired consciousness include:

A goal-oriented multidisciplinary care plan should include a 24-hour care plan that includes:

• Airway management, including tracheostomy care Secretion management Ventilatory support as needed
• Enteral nutrition and hydration with each gastrostomy (or jejunostomy, if gastric stasis or esophageal reflux is problematic) – provides adequate nutritional support to meet dietary needs, including in hypercatabolic states increase calorie intake
• Manage oral reflexes (e.g. bite reflex, teeth grinding, etc.)
• Appropriate bowel management program
• Appropriate precautions to avoid pressure ulcers, including risk assessment, special mattresses, etc.
• Positioning/stretching to control tension and avoid contractures maintain skin integrity
• Supportive seat offers a range of positions and allows assessment in a seated position
• Early discharge planning, including a formal meeting with the family (and/or other representatives) and the healthcare commissioner to discuss place of care and start working on appropriate funding arrangements (usually through an application for NHS Continuity of Care).

Interim care in the slow flow pathway should include providing:

• An appropriate maintenance treatment plan to manage their physical disability
• An appropriate environment that provides controlled stimulation and encourages interaction
• Continuously monitor their level of response.

Long-Term Care

Long-term care should be provided in an appropriate setting that ensures:

• Management of physical disabilities, including maintenance therapy for tone/posture management (including spasticity management and prevention of contractures/pressure ulcers, etc.), medical monitoring, etc.
• enteral feed and tracheostomy management
• Ongoing assessment of appropriate stimuli and behavioral responses
• support for families.

If the nursing home does not have its own treatment team, arrangements should be made to provide the maintenance treatment program through visits from the local community rehabilitation team or other on-site procurement arrangements.

Clinically Adjunct Nutrition and Hydration and Adults Lacking Consenting Capacity (2018)

Type: Guidelines from the Royal College of Physicians (RCP) and General Medical Council (GMC) of the British Medical Association [12]

Publication Date: October 2018

The Long-term Impairment of Consciousness guidelines are closely related to the clinically assisted nutrition and hydration guidelines published by the Royal College of Physicians (RCP) and the British Medical Association (BMA) and General Medical Council (GMC) in 2018. This guide covers decisions Start Restart Continue or stop CANH for adults who lack self-determination capacity in England and Wales. It includes information relevant to previously healthy patients with sudden brain injury as well as patients with complex comorbidities and neurodegenerative diseases complication.

Key topics covered in the guide include:

• The Legal Context for decision-making
• Who are the decision makers and who must be consulted?
• Conscientious Objections
• Clinical Assessments
• Best Interests Assessments
• Second opinions
• Managing Disagreement and Uncertainty
• Record-Keeping
• Governance and Audit

Splints for the prevention and correction of contractures in adults with neurological deficits

Type: Practice guide from the Royal College of and Occupational Therapists (RCOT) and the Association of Chartered Physiotherapists in Neurology (ACPIN) [13]

Publication Date: 2015 

This guideline provides evidence for clinical practice and the decision-making process when splinting adults with neurologic disorders, especially TBI stroke and MS. It describes the roles and responsibilities of health professionals in the prevention and correction of contractures In patients at risk of deformities. This guideline carefully weighs the benefits and risks of the splinting procedure in patients with upper motor neuron syndrome. It demonstrates the cautionary factor and when splinting should not be recommended.

The guidelines advise “not to consider splinting in isolation, but rather as part of a comprehensive goal-directed rehabilitation or management program” and demonstrate systemic key steps to consider when splinting adults with contractures. it supports clinical Reasoning for patient selection recommends an action plan agreed upon prior to splinting with the MDT and the patient and/or relatives, as well as outcome measures used to assess the process. It doesn’t give any practical tips on making casts or splints. Online resources include Nerve splint CPD session.

Spasms in Adults: Treatment with Botox

Type: Royal College of Physicians Guidelines British Association of Rehabilitation Medicine Chartered Physiotherapy Society Neurology Chartered Institute of Physiotherapists and Royal College of Occupational Therapists [14]

Publication Date: March 2018

This guideline provides recommendations for the use of botulinum toxin (BoNT) to treat spasticity in adults with neurological disorders. It recommends botulinum toxin therapy as part of a comprehensive goal-directed rehabilitation and management program. Guide Highlights Mainly upper and lower extremity treatments, but some other uses of Botox are mentioned, such as neck or jaw muscles. It lists common areas of intervention when using BoNT:

• Pain Relief
• Reduction of involuntary movements (ie, associated response spasms)
• Prevention of contractures and deformity
• Passive function (easier to take care of the affected limb)
• Active function (use of affected limb)
• Mobility

Before demonstrating the role of botulinum toxin in this process, the guideline presents evidence for self-management of posture management, stretching tasks, practice of strength training, electrical stimulation, and various pharmacological treatments in spasticity management.

The guideline provides recommendations for prescribing depot dosing, as well as muscle selection techniques for therapeutic evaluation and post-injection management when using BoNT to treat neurologic patients. It also provides advice on service organization.

Standards for rehabilitation services mapped to the national long-term condition services framework

Type: British Society for Rehabilitation Medicine (BSRM) Standard of Service [15]

Publication Date: 2009

Specialty neurorehabilitation services: Serving patients with complex rehabilitation needs

Type: British Society for Rehabilitation Medicine (BSRM) Standard of Service [16]

Publication Date: 2009

These two documents define a clear set of guidelines and objectives, mapped to the NSF-LTC, for planning and delivering rehabilitation services in the UK. These documents define specialist rehabilitation and individual patient needs.

These documents provide recommendations for neurorehabilitation services; organization (including staffing and funding flows to improve patient outcomes) and functioning of clinical pathways and networks (e.g. Trauma Stroke Neuroscience).