Canadian Clinical Practice Guideline for the Rehabilitation of Adults With Moderate to Severe Traumatic Brain Injury
Bayley, M., Gargaro, J., et al. (2023).
Toronto, ON (Canada): Ontario Neurotrauma Foundation, Retrieved September 13, 2023 from https://kite-uhn.com/brain-injury/en.
This guideline provides recommendations on the assessment and rehabilitation of adults, 18 to 65 years old, with moderate-to-severe traumatic brain injury (TBI). This summary highlights recommendations related to the assessment and treatment of adults with TBI within the scope of speech-language pathology and audiology.
Ontario Neurotrauma Foundation (Canada); Institut National D'Excellence en Santé et en Services Sociaux (Canada)
This guideline is periodically updated by section, rather than as a whole document. At the time of writing, we consulted the most current version for each section. To check for content published since the time of our writing, please view the authors' website. Additional information (tools/resources, committees/stakeholders, methods, patient versions, and handout materials) can be found online.
<div>The following recommendations were made regarding transitions of care for people with TBI:</div>
<div>
<ul>
<li>Individuals with TBI, their family/care providers, and their rehabilitation team should establish a formalized discharge plan for transitions to ensure a continuum of care (Level C Evidence).</li>
<li>Transitions from inpatient rehabilitation may include a graduated transition (e.g., home visits, weekend/weekday passes with family, ADL evaluations within the home; Level C Evidence).</li>
<li>As soon as appropriate, individuals with TBI should transition to the community with support services (e.g., physical and environmental safety), referrals, and/or scheduled services and appointments in place and clearly communicate to the individual and their family/care providers (Level C Evidence).</li>
<li>Outpatient rehabilitation plans should involve the healthcare team and family/care provider and should prioritize the individual with TBI’s treatment goals whenever possible (Level C Evidence).</li>
<li>Community-based, age-appropriate peer support programs should be available (Level B Evidence, Priority Recommendation), and additional community-based services with written information should be provided (Level C Evidence).</li>
<li>Access to specialized outpatient, community-based rehabilitation, or telephone/virtual follow-up with TBI professionals should be timely (Level B Evidence, Priority and Functional Recommendation) or available at intervals as needed, particularly in individuals with prolonged recovery or new needs (Level C Evidence).</li>
</ul>
</div>
<div>The following is recommended regarding telepractice interventions:</div>
<ul>
<li><span style="color: #333333;">Telepractice should be considered for the provision of services, in addition to in-person visits, to individuals with traumatic brain injury to provide timely and equitable care (Level B Evidence, New Recommendation). </span></li>
<li><span style="color: #333333;">The individual's abilities, goals, preferences, caregiver support, access to equipment, familiarity with technology, and capacity to participate in telepractice should be considered to determine suitability for participation. Ideal remote cognitive rehabilitation participants will be able to follow directions, demonstrate self-monitoring and self-awareness skills, and have caregiver support. Clinicians should frequently monitor, evaluate, and adapt telepractice services for each patient as needed (Level C Evidence, New Recommendation). </span></li>
<li><span style="color: #333333;">Intervention examples include metacognitive strategy training and communication partner training (Level B Evidence, New Recommendation). </span></li>
<li><span style="color: #333333;">While the provision of remote group intervention is feasible and may be considered for some interventions, they are not recommended to address executive function goals (Level C Evidence, New Recommendation). </span></li>
<li><span style="color: #333333;">The clinician should prepare for remote sessions by setting up their environment for privacy and confidentiality, selecting user-friendly equipment, positioning cameras and lighting for optimal views, and establishing expectations with the patient and caregiver regarding their roles and the handling of technological difficulties (Level C Evidence).</span></li>
</ul>
<div>Individuals with TBI who are conscious should be assessed for impairments in the areas of attention, visuospatial function, executive function, language, social communication, social cognition, learning, memory, awareness, hearing, vision, fatigue, sleep-wake disturbance, mental health, and medication (Level C Evidence, Priority Recommendation).</div>
<div>Individuals with TBI who have a disorder of consciousness should undergo regular medical and neurological assessment and monitoring (Level C Evidence), and they should be periodically assessed through the first year post-injury (Level C Evidence, Priority Recommendation). Individuals who remain in a coma or a minimally conscious state post-TBI should be considered for specialized nursing and rehabilitation care or be candidates for care at a specialized tertiary center (Level C Evidence).</div>
<div>Individuals with TBI should be screened and formally assessed, as needed, for vestibular dysfunction, and if present, should receive vestibular retraining with a professional specializing in vestibular function (Level B Evidence).</div>
<div>Treatment for TBI should be personally relevant and meaningful to the individual while considering their current functional levels (Level C Evidence, Priority Recommendation). Life skills training protocols (e.g., communication, activities of daily living, energy management, self-regulation skills, self-advocacy) should be developed based on the individual’s needs and impairment profile (Level B Evidence, Priority Recommendation). Rehabilitation programs may target social adaptation and sense of well-being through physical exercise, leisure activities, and participation in social support groups (Level C Evidence, Priority Recommendation). When appropriate, family and/or care providers should be directly integrated into the rehabilitation process (Level B Evidence, New Recommendation). Sensory stimulation involving familiar voices, favorite music, or tactile stimulation offered one modality at a time should be considered (Level B Evidence, New Recommendation).</div>
<div>The dysphagia plan for individuals with traumatic brain injury should consider positioning, feeding strategies, medical status, pharmacological profile, cognitive impairments, behavior, comfort, and nutritional status (Level C Evidence). Those requiring enteral feeding should be converted from nasogastric feeding to gastrostomy feeding as soon as the patient’s condition allows (Level B Evidence, Priority Recommendation), and when possible, individuals should be encouraged to self-feed (Level C Evidence). Feeding assistance or supervision should be provided by professionals trained in low-risk feeding strategies (Level C Evidence).</div>
<div>For individuals with TBI, group-based interventions should be considered for social skills, emotional self-regulation, executive function, problem solving, communication, attention, and memory should be considered (Level A Evidence).</div>
<div>Every individual with moderate to severe TBI who experiences impairment or functional change should receive timely and specialized services as soon as the individual is medically stable (Level B Evidence, Priority Recommendation). Those with spinal cord injury or severe musculoskeletal injuries should receive rehabilitation concurrently with or immediately following spinal cord/musculoskeletal treatments (Level C Evidence). A minimum of 3 hours of therapeutic interventions, or more if appropriate, should be provided as tolerated by the individual with TBI (Level B Evidence, Priority Recommendation). Caregivers and the care team should establish a target length of inpatient rehabilitation stay and review this plan with consideration of the patient’s progress to improve planning, continuity of care, and discharge preparations (Level C Evidence, Priority Recommendation).</div>
<div>Vocational rehabilitation should be offered to support the individual's return to work or school. Assessment for vocational supports may include comprehensive pre-injury history, current capacities, current social status, vocational/educational needs, liaison with employers or educational providers, evaluation of the work/school environment, and verbal and written advice about the individual’s return (Level C Evidence, Priority Recommendation). Vocational rehabilitation should include:</div>
<ul>
<li><span style="color: #333333;">strategies for cognition, communication, physical needs, and behavior, </span></li>
<li><span style="color: #333333;">education for the employer/educator, and </span></li>
<li><span style="color: #333333;">on-site training specific to the need of the person with TBI (Level C Evidence).</span></li>
</ul>
<div>Any individual with TBI who experiences post-traumatic amnesia (PTA) should remain in a secure, supervised environment with low stimulation, should be observed for visitor impact (e.g., agitation or excessive fatigue), should receive consistent care from the same healthcare providers, should receive frequent reassurance and orientation cues, and should be provided familiar information or preferred music as tolerated until they emerge from PTA (Level C Evidence, Priority Recommendation).</div>
<div>A comprehensive swallowing assessment should be completed in a timely fashion by an appropriately trained and certified professional (i.e., speech-language pathologist) when one or more of the following risk factors for aspiration occur post-injury:</div>
<ul>
<li>presence of a tracheostomy;</li>
<li>poor cognitive functioning;</li>
<li>hypoactive gag reflex;</li>
<li>reduced pharyngeal sensation;</li>
<li>brainstem involvement;</li>
<li>difficulty swallowing oral secretions;</li>
<li>coughing/throat clearing or wet/gurgly voice quality after swallowing water;</li>
<li>choking more than once while drinking 50 ml of water;</li>
<li>weak voice and cough;</li>
<li>wet-hoarse voice quality;</li>
<li>recurrent lower respiratory infections;</li>
<li>unexplained low-grade fever or leukocytosis; [or]</li>
<li>immunocompromised state (Level B Evidence, Priority Recommendation).</li>
</ul>
<div>Individuals with TBI who are cognitively and physically able to tolerate instrumental dysphagia assessment should be undergo videofluoroscopic modified barium swallow (VMBS) or modified barium swallow (MBS) swallow studies when aspiration is suspected, when the effectiveness of compensatory strategies and techniques are being considered, or when bedside assessment demonstrates risks, lack sufficiently robust clinical evaluation, and/or shows indication of pharyngeal stage problems in the individuals (Level C Evidence). Nutrition and hydration status should also be assessed as soon as the patient’s condition allows evaluation (Level C Evidence, Priority Recommendation).</div>
<div>Healthcare professionals should be trained in behavior and affective disorders and evidence-based interventions specific to TBI in order to apply consistent neurobehavioral strategies for individuals with TBI (Level B Evidence, Priority Recommendation).</div>
<div>Adults with moderate to severe TBI and their caregivers should be provided timely and progressive TBI information adapted to age and culture in both written and verbal formats. Such educational content should include:</div>
<ul>
<li>common physical, cognitive, and emotional consequences and expected symptoms and possible long-term problems of TBI;</li>
<li>advice on high-risk situations, safety, interactions between prescription drugs and alcohol, and self-care measures;</li>
<li>rehabilitation and community services and resources; and</li>
<li>educating others who do not know about the injury on TBI-related problems (Level C Evidence, Priority Recommendation).</li>
</ul>
<div>Individuals with TBI and their caregivers should receive regular communication regarding the rationale for providing interventions that are challenging and/or require significant effort to decrease frustration or misunderstanding of the intervention (Level B Evidence). Training and education regarding compensation strategies and environmental adaptations to optimize independence should be provided (Level C Evidence). Healthcare professionals and visitors should be educated on the patient’s level of hypersensitivity, fatigue, and levels of awareness and cognitive endurance (Level C Evidence).</div>
<div>Adults with moderate to severe TBI should be offered social skills training to improve interpersonal and pragmatic communication (Level B Evidence). Interventions may include role playing, perspective taking, Theory of Mind, and social behavior; however, computerized social cognitive treatments are not recommended (Level A Evidence, New Recommendation).</div>
<div>Assessment of cognitive-communication in individuals with TBI should include a case history that includes the following:</div>
<ul>
<li>personal factors (e.g., cultural background, pre-injury fluency and literacy, and educational/occupational history),</li>
<li>preinjury medical conditions (e.g., substance use/abuse, neurological disorders, hearing loss),</li>
<li>injury related factors (e.g., medications, seizures, acquired language changes, oral motor dysfunction, vestibular function), and</li>
<li>post-injury factors (e.g., medical conditions, new onset mental health disorders, technology literacy; Level C Evidence, Priority Recommendation).</li>
</ul>
<div>For adults with moderate to severe TBI who have cognitive-communication deficits, a reliable verbal or non-verbal "yes/no" response should be established as soon as possible through consistent training and environmental enrichments (Level B Evidence, Priority Recommendation). Individuals with severe communication impairments should undergo assessment for and be trained on the use of augmentative and alternative communication (AAC) by a trained clinician. AAC should be adjusted to meet the individual's needs as they evolve (Level C Evidence).</div>
<div>For adults with moderate to severe TBI, assessment, rehabilitation, and education should be conducted by a coordinated interdisciplinary team of clinicians with specialized experience in TBI to address areas of need such as cognitive function and physical function. Specialists on the team may include a speech-language pathologist, audiologist, occupational therapist, physical therapist, social worker, neuropsychologist, nurse, physician, nutritionist, and other disciplines as needed, especially for individuals with multiple injuries or diagnoses (e.g., amputee care, spinal cord injury; Level C Evidence, Priority Recommendation). Speech-language pathologists should assess cognitive impairment, communication, swallowing, oral motor function, speech, and hearing (Level C Evidence, New Recommendation). Case coordination should be provided across the continuum of care and should be managed by an individual with TBI experience (Level B Evidence, Priority Recommendation). Interprofessional team conferences should occur on a regular basis at a minimum of every two weeks while the individual is in the inpatient setting (Level C Evidence). Additional team members should include caregivers and community partners who should assist in the development of patient and family goals of care, medical and therapy updates, rehabilitation programs, follow-up recommendations to support carryover, and provide consultation regarding community resources, action plans, discharge, and reassessment (Level C Evidence).</div>
<div>Adults with moderate to severe TBI, particularly those with dysphagia, should receive oral and dental care with regular assessment of oral and dental care across rehabilitation stages and settings post-injury (Level B Evidence, Priority Recommendation). Education regarding proper oral care and the possible impacts of cognitive impairment on safe swallowing should be provided to the individual with TBI, healthcare professionals, and care providers (Level C Evidence).</div>
<div>For adults with TBI who have a cognitive-communication disorder, cognitive rehabilitation should focus on activities that are meaningful for the individual and their family, be applicable to their life, and incorporate generalization strategies (Level C Evidence, Priority Recommendation). Interventions should target functional skills (Level B Evidence, Priority Recommendation) and should be provided in the person's own structured, distraction-free environment (Level B Evidence, Priority Recommendation) practiced in situations where they live, work, study or socialize (Level A Evidence, Priority Recommendation). Direct or indirect services may include:</div>
<ul>
<li>communication partner training (Level A Evidence),</li>
<li>communication strategy and metacognitive awareness training (Level A Evidence),</li>
<li>assistance with reintegration and environmental modifications (Level C Evidence),</li>
<li>communication coping treatment (Level C Evidence),</li>
<li>support to improve confidence, self-esteem, and identity (Level C Evidence),</li>
<li>restorative treatments (Level A Evidence),</li>
<li>compensatory strategy training including instructional, metacognitive, and external strategies for learning and memory (Level A Evidence, Priority Recommendation),</li>
<li>reasoning skill and self-awareness strategies for executive functioning (Level A Evidence, Priority Recommendation),</li>
<li>rhythm/music training and virtual reality for executive functioning (Level A Evidence, New Recommendation),</li>
<li>individual care provider training and education about TBI (Level A Evidence),</li>
<li>functional adaptations and environmental modifications (Level A Evidence),</li>
<li>metacognitive strategy and dual-task training (Level A Evidence, Priority Recommendation),</li>
<li>advanced reading and writing (Level B Evidence) and</li>
<li>higher-level cognitive strategies as tolerated (Level B Evidence, Priority Recommendation).</li>
</ul>
<div>Interventions that are not recommended include:</div>
<ul>
<li>computer-based tasks, random auditory alerting tone training, and transcranial magnetic or direct current stimulation for attention (Level B Evidence),</li>
<li>computerized cognitive training alone for learning and memory (Level B Evidence).</li>
</ul>
<div>Assessment and rehabilitation should be initiated as soon as the condition of the individual with TBI allows. Any care plans should be goal-oriented and should include the input of the individual and their family or caregiver (Level B Evidence, Fundamental and Priority Recommendation). Individuals with TBI should be able to demonstrate the ability to consent to intervention (Level C Evidence). Throughout the course of rehabilitation, individuals with TBI should be encouraged and provided supports to safely and independently engage in activities (Level C Evidence, New Recommendation).</div>
<div>Adults with tracheostomy and/or ventilator-dependent status following TBI should be assessed by an appropriately-trained and certified professional to determine appropriateness for Passy Muir Valve placement or tracheostomy capping in preparation for swallowing assessment (Level C Evidence, Priority Recommendation).</div>
