Rehabilitation following Acquired Brain Injury: National Clinical Guidelines
British Society of Rehabilitation Medicine, Royal College of Physicians, et al. (2003).
London (United Kingdom): Royal College of Physicians; British Society of Rehabilitation Medicine, 81.
This guideline provides recommendations on the longer-term needs of adults (mostly working age) with acquired brain injury of any cause, including trauma, stroke, anoxia, infection and other causes. The recommendations, intended for use by a variety of medical and social service professionals, "focus mainly on rehabilitation and community integration in the post-acute period during the early years following brain injury" (p. 4). Speech-language pathologists and audiologists may find relevant recommendations on management of swallowing, communication/language, cognition and hearing.
British Society of Rehabilitation Medicine, Royal College of Physicians
<div>Patients with dysphagia or at risk for aspiration should be evaluated "by a suitably trained speech and language therapist who should assess further and advise the patient and staff on safe swallow and consistency of diet/fluids" (Grade A Evidence; p. 29). The interdisciplinary team should work collaboratively to ensure appropriate posture and equipment for safe feeding.</div>
<p>Patients with communication problems should be offered treatment and monitored for progress. Treatment should take into consideration:</p>
<ul>
<li>patient's premorbid communication style and any underlying cognitive deficits (Grade C Evidence);</li>
<li>opportunities to practice communication skills in environments functional to the patient and with typical communication partners (Grade C Evidence); and/or</li>
<li>possible needs for augmentative and alternative communication.</li>
</ul>
<div>Speech-language pathologists should be part of the interdisciplinary team involved in assessment, treatment, and decision-making for adults with tracheostomy following acquired brain injury (Grade C Evidence; p. 29).</div>
<div>SLPs should assess adults with tracheostomy secondary to acquired brain injury. This should include assessment regarding potential methods of communication and should consider appropriateness for cuff deflation and use of fenestrated tracheostomy or speaking valve (Grade C Evidence).</div>
<div>Use of compensatory strategies may be used to treatment memory impairments for individuals with persistent cognitive deficits post-ABI (Grade C Evidence).</div>
<p>"Once a patient with [acquired brain injury] ABI is conscious they should be assessed for all common impairments" (Grade C Evidence; p. 25), including the following:</p>
<ul>
<li>bulbar involvement affecting speech and swallowing;</li>
<li>cognition, especially memory, concentration, and orientation; and</li>
<li>language, especially aphasia.</li>
</ul>
<div>A diagnostic instrumental evaluation using videofluoroscopy or fiberoptic endoscopic evaluation of swallowing should be considered following bedside examination when "the risk/benefit ratio of proceeding with trial of food is poor" or "there is doubt about future management options or a need for clarification of diagnosis" (Grade B Evidence; p. 29).</div>
<div>Individuals with acquired brain injury should have their hearing assessed by an audiologist and use of previous assistive aids, such as hearing aids, should be restored as appropriate (Grade C Evidence; pp. 33, 41).</div>
<p>"Patients with persistent cognitive deficits following [acquired brain injury] ABI should be offered cognitive rehabilitation" (Grade B Evidence; p. 43). This may include treatment of:</p>
<ul>
<li>executive functioning, in a structured environment without distractions (Grade A Evidence);</li>
<li>attention and information processing (Grade B Evidence); and </li>
<li>memory impairments, using external memory aids (Grade A Evidence).</li>
</ul>
<p>"Trial-and-error learning should be avoided in patients with memory impairment" (Grade B Evidence; p. 44).</p>
<div>Individuals with severe communication problems, but relatively good cognition and language, "should be assessed for and provided with appropriate alternative or augmentative communication devices" (p. 33).</div>
<div>"To minimize the risk of aspiration, patients with any significant symptoms, signs or disability should be screened for swallowing impairment before given food or drink" (Grade B Evidence; p. 28).</div>
<div>"Conscious patients with communication difficulties should be assessed by a speech and language therapist who should work with staff and relatives to delineate appropriate communication techniques" (p. 32). The speech-language pathologist will be able to assess appropriateness for intensive or regular treatment and monitor progress.</div>
<div>"Patients presenting with persistent visual neglect or field deficits should be offered specific retraining strategies" (p. 41).</div>
