Brain Injury Rehabilitation in Adults
Scottish Intercollegiate Guidelines Network. (2013).
Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network, (130), 1-75.
This guideline provides recommendations for the management of cognitive, communication, and physical rehabilitation of adults with acquired brain injury (ABI), including those with traumatic brain injuries (TBIs). The target audience for this guideline includes speech-language pathologists providing assessment and treatment in post-acute settings.
Scottish Intercollegiate Guidelines Network
Data in this guideline are included in elsewhere in the Evidence Maps. See the Associated Article section for more information.
<div>Post-acute cognitive interventions should utilize a comprehensive/holistic neuropsychological rehabilitation approach for individuals with TBI. This rehabilitation approach should involve a multidisciplinary team and target the improvement of cognitive, behavioral, and emotional deficits in functional everyday activities (Grade D Evidence).</div>
<div>For individuals with memory impairments secondary to TBI, cognitive rehabilitation should include:</div>
<ul>
<li><span style="color: #333333;">training and use of internal and/or external compensatory memory strategies focused on "improving everyday functioning rather than [the] underlying memory impairment" (Grade D Evidence; p. 21),</span></li>
<li><span style="color: #333333;">external compensatory memory treatments targeting functional activities for individuals with severe memory impairments post traumatic brain injury (Grade D Evidence), and </span></li>
<li><span style="color: #333333;">both external memory aids (e.g., planners, personal digital assistants) and internal memory strategies (e.g., visual imagery) for individuals with mild to moderate memory impairments post traumatic brain injury (Grade D Evidence).</span></li>
</ul>
<div>For individuals with moderate-severe memory impairments, learning techniques should be considered to reduce the likelihood of errors being made during the learning of specific information (Grade B Evidence).</div>
<div>"There is insufficient evidence available to support recommendations relating to the rehabilitation of poor insight or self-awareness" for individuals with ABI (p. 21). Complexity and lack of consensus on self-awareness as a construct has produced a variety of different treatment approaches, with very limited evidence for effectiveness.</div>
<div>"For optimal outcomes, higher intensity rehabilitation featuring early intervention should be delivered by specialist multidisciplinary teams" (Grade B Evidence; p. 38).</div>
<p>An instrumental swallowing assessment should be considered for individuals post TBI when bedside assessment</p>
<ul>
<li>identifies pharyngeal swallowing problems;</li>
<li>concludes that risk of aspiration outweigh benefits of oral intake; and/or</li>
<li>does not provide sufficient information regarding the individual's swallowing deficits and further clinical evaluation is needed to determine adequate plan for swallowing treatment (Grade D Evidence).</li>
</ul>
<p>There is "little evidence comparing outcomes following instrumental assessment versus beside assessment in patients post TBI" (p. 30), but instrumental evaluation assists in informed decision making for feeding and/or intervention and the detection of silent aspiration.</p>
<div>For individuals with TBI, training in use of compensatory attention strategies in functional situations is recommended at the post-acute rehabilitation phase (Grade C Evidence).</div>
<div>Cognitive remediation can be conducted in face-to-face or telerehabilitation (e.g., telephone) settings (Good Practice Point).</div>
<div>"There is insufficient evidence to support a recommendation on restorative exercises to improve outcome in dysphagia post TBI" (p. 31). Further research is warranted.</div>
<div>Clinicians should be familiar with and trained in the use of diagnostic tools to assess consciousness in adults with TBI (Good Practice Point).</div>
<div>Individuals with executive functioning deficits post TBI should be trained in the use of metacognitive strategies to improve performance in functional activities (Grade B Evidence).</div>
<div>There was some evidence to support the use of Lee Silverman Voice Treatment to improve speech and voice outcomes in individuals with dysarthria following brain injury. However, there was no other conclusive evidence for any other speech intervention to remediate dysarthria in this population. </div>
<div>Individuals with communication deficits post TBI should be referred to speech and language therapy for evaluation and treatment of communication impairments (Grade D Evidence). At this time, evidence is not available to recommend specific interventions; further high-quality and well-powered research is needed.</div>
<div>"The Coma Recovery Scale - Revised should be used to assess [adults] in states of disordered consciousness" (Grade B Evidence; p. 35).</div>
