Diana Velikonja

Updated clinical practice guidelines for concussion/mild traumatic brain injury and persistent symptoms

Abstract Objective: To introduce a set of revised guidelines for the management of mild traumatic brain injury (mTBI) and persistent symptoms following concussive injuries. Quality of evidence: The Guidelines for Mild Traumatic Brain Injury and Persistent Symptoms were made available in March 2011 based on literature and information up to 2008. A search for new clinical practice guidelines addressing mTBI and a systematic review of the literature evaluating treatment of persistent symptoms was conducted. Healthcare professionals representing a range of disciplines from Canada and abroad attended a consensus conference to revise the original guidelines in light of new evidence. Main message: A modified Delphi process was used to create 96 recommendations addressing the diagnosis and management of mTBI and persistent symptoms, including post-traumatic headache, sleep disturbances, mental health disorders, cognitive difficulties, vestibular and vision dysfunction, fatigue and return to activity/work/school. Numerous resources, tools and treatment algorithms were also included to aid implementation of the recommendations. Conclusion: The revised clinical practice guideline reflects the most current evidence and is recommended for use by clinicians who provide care to people who experience PPCS following mTBI.

Incog Recommendations for Management of Cognition Following Traumatic Brain Injury, Part V: Memory

Introduction:Traumatic brain injury results in complex cognitive sequelae. Impairments in memory are among the most common sequelae resulting in significant functional problems. An international team of researchers and clinicians (known as INCOG) was formed to develop recommendations for the management of impairments in memory. Methods:The experts met to select appropriate recommendations and then reviewed available literature to ensure recommendations were current. Decision algorithms incorporating the recommendations based on inclusion and exclusion criteria of published trials were developed. The team then prioritized recommendations for implementation and developed audit criteria to evaluate adherence to the best practice recommendations. Results:The recommendations for rehabilitation of memory impairments support the integration of internal and external compensatory strategies implemented using appropriate instructional techniques that consider functional relevance and important patient characteristics. Restorative strategies have regained significant popularity, given broader access to computer technology; however, evidence for efficacy of these techniques remains weak and the choice in using these should be guided by special considerations. Conclusion:There is good evidence for the integration of internal and external compensatory memory strategies that are implemented using instructional procedures for rehabilitation for memory impairments. The evidence for the efficacy of restorative strategies currently remains weak.

INCOG recommendations for management of cognition following traumatic brain injury, part III: executive function and self-awareness.

Introduction:Traumatic brain injury (TBI) results in complex cognitive (and other) sequelae. Impairments in executive function and self-awareness are among the most characteristic neuropsychological sequelae and can exert a profound effect on resuming previous life roles. An international group of researchers and clinicians (known as INCOG) convened to develop recommendations for interventions to improve impairments in executive functioning and self-awareness after TBI. Methods:The team reviewed the available literature and ensured the recommendations were current. To promote implementation, the team developed decision algorithms incorporating the recommendations based on inclusion and exclusion criteria of published trials. The team then prioritized the recommendations for implementation and developed audit criteria to evaluate the adherence to the best practice recommendations. Results:Intervention programs incorporating metacognitive strategy instruction for planning, problem-solving, and other cognitive-executive impairments have a solid evidence base. New evidence supports the use of strategies to specifically improve reasoning skills. Substantial support exists for use of direct corrective feedback to improve self-awareness. Conclusions:An increasing number of scientifically well-designed studies are available that demonstrate the effectiveness of a variety of interventions for the remediation of impairments in executive function and self-awareness after TBI.

INCOG Recommendations for management of cognition following traumatic brain injury. Part II: Attention and information processing speed

Introduction:Traumatic brain injury, due to its diffuse nature and high frequency of injury to frontotemporal and midbrain reticular activating systems, may cause disruption in many aspects of attention: arousal, selective attention, speed of information processing, and strategic control of attention, including sustained attention, shifting and dividing of attention, and working memory. An international team of researchers and clinicians (known as INCOG) convened to develop recommendations for the management of attentional problems. Methods:The experts selected recommendations from published guidelines and then reviewed literature to ensure that recommendations were current. Decision algorithms incorporating the recommendations based on inclusion and exclusion criteria of published trials were developed. The team then prioritized recommendations for implementation and developed audit criteria to evaluate adherence to these best practices. Results:The recommendations and discussion highlight that metacognitive strategy training focused on functional everyday activities is appropriate. Appropriate use of dual task training, environmental modifications, and cognitive behavioral therapy is also discussed. There is insufficient evidence to support mindfulness meditation and practice on de-contextualized computer-based tasks for attention. Administration of the medication methylphenidate should be considered to improve information-processing speed. Conclusion:The INCOG recommendations for rehabilitation of attention provide up-to-date guidance for clinicians treating people with traumatic brain injury.

INCOG recommendations for management of cognition following traumatic brain injury, part I: posttraumatic amnesia/delirium.

Introduction:After traumatic brain injury (TBI) and emergence from coma, the majority of people experience posttraumatic amnesia (PTA), characterized by confusion, disorientation, retrograde and anterograde amnesia, poor attention, and sometimes agitation and delusions. An international team of researchers and clinicians developed recommendations for assessment and management of PTA. Methods:The experts met to select recommendations, then reviewed literature to ensure they were current. The team then prioritized recommendations for implementation and developed audit criteria to evaluate the adherence to the best practice recommendations. Results:Evidence in support of assessment and management strategies during PTA is weak. It is recommended that duration of PTA be assessed prospectively using a validated tool. Consideration should also be given to use of a delirium assessment tool. No cognitive or pharmacological treatments are known to reduce PTA duration. Recommendations for environmental manipulations to reduce agitation during PTA are made. Minimizing use of neuroleptic medication is supported by animal research and 1 retrospective study. Conclusions:The duration of PTA is an important predictor of late outcome after TBI and should be monitored prospectively with a standardized tool. Neuroleptic medication should be avoided. There is a significant need for controlled studies evaluating the impact of therapy during PTA.

Subtypes of Emotional and Behavioural Sequelae in Patients With Traumatic Brain Injury

This study examined patterns of emotional and behavioural sequelae in 300 individuals who sustained a traumatic brain injury (TBI). Participants were obtained through the Adult Acquired Brain Injury Program at Chedoke Hospital in Hamilton, Ontario, based on the following inclusionary criteria: (1) single incident of TBI; (2) no history of additional neurological diseases; (3) time postinjury =8.5 years; (4) WAIS-R FSIQ >85 and/or estimated reading skills above grade 5 level; and (5) valid Minnesota Multiphasic Personality Inventory (MMPI) profiles (i.e., F <90, L <66, and K <66). MMPI profiles of these individuals, in randomly split samples of 150 per group, were subjected to a three-step cluster analytic approach. A six-cluster solution was adequately replicated across samples and across clustering techniques. The identified subtypes included profiles indicative of: (1) no concerns or normal functioning; (2) mild somatic and pain concerns; (3) mild internalizing difficulties; (4) marked disinhibition and externalizing behavioural difficulties; (5) marked internalizing difficulties; and (6) marked somatic, internalizing, and externalizing behavioural disturbances. Members of the Externalized subtype were significantly younger in age than those in the other five subtypes, and more likely to be single than those in the Internalized subtype. Individuals in the Internalized subtype tended to be married, have longer times postaccident, and lower WAIS-R Verbal Intelligence Quotients than those comprising the Normal subtype.

Evaluation of the effectiveness of two clinical training procedures to elicit yes/no responses from patients with a severe acquired brain injury: a randomized single-subject design

Primary objective: Thirteen (10 males) participants with severe acquired brain injuries (ABI) were randomly assigned to two treatments, A or B (ABAB, BABA) in a crossover study to determine which treatment approach elicited more consistent and reliable yes/no responses. Research design: Treatment A consisted of an enriched stimulus environment, collaborative multidisciplinary interventions and additional yes/no response training, while Treatment B consisted of the standard hospital environment and interventions. Main outcomes: An ANOVA showed no order effect (AB vs BA; p ¼ 0:60), but a trend (A vs B; p ¼ 0:07) towards statistical significance for increased responsiveness with treatment A. Inter-rater reliability (n ¼ 10) ranged from fair-to-good, intra class correlation (ICC) 0.51; 95% confidence interval (CI) (0.29–0.93). Post-hoc analyses showed statistically significant increased responsiveness for four participants with treatment A (p < 0:001). Conclusion: Evidence is provided that enhanced communication strategies can improve responsiveness in a sub-group of participants with severe acquired brain injuries.

Quality of clinical practice guidelines for persons who have sustained mild traumatic brain injury

Background: Mild TBI is one of the most common neurological disorders occurring today. For individuals who experience persistent symptoms following mild TBI, consequences can include functional disability, stress and time away from ones occupation. The objective of the study was to evaluate the quality of clinical practice guidelines (CPGs) that include recommendations on the care of persons who have sustained mild TBI and associated persistent symptoms. Methods: A minimum of four appraisers used the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument to evaluate seven CPGs found via a systematic search of bibliographic databases and internet resources. Results: High AGREE scores were obtained for the domains Scope and Purpose and Clarity and Presentation. The CPGs fared less well on Rigour of Development, Stakeholder Involvement, Editorial Independence and Applicability. The number of recommendations addressing the care of persistent symptoms following mild TBI was meager, with the exception of military guidelines. Conclusions: There is considerable variability in the quality of guidelines addressing mild TBI and, overall, the CPGs reviewed score lower on Rigour of Development than CPGs for other medical conditions. There is a clear need for clinical guidance on the management of individuals who experience persistent symptoms following mild TBI.

Quality of guidelines for cognitive rehabilitation following traumatic brain injury.

Introduction:Cognitive rehabilitation following traumatic brain injury can aid in optimizing function, independence, and quality of life by addressing impairments in attention, executive function, cognitive communication, and memory. This study aimed to identify and evaluate the methodological quality of clinical practice guidelines for cognitive rehabilitation following traumatic brain injury. Methods:Systematic searching of databases and Web sites was undertaken between January and March 2012 to identify freely available, English language clinical practice guidelines from 2002 onward. Eligible guidelines were evaluated using the validated Appraisal of Guidelines for Research and Evaluation II instrument. Results:The 11 guidelines that met inclusion criteria were independently rated by 4 raters. Results of quality appraisal indicated that guidelines generally employed systematic search and appraisal methods and produced unambiguous, clearly identifiable recommendations. Conversely, only 1 guideline incorporated implementation and audit information, and there was poor reporting of processes for formulating, reviewing, and ensuring currency of recommendations and incorporating patient preferences. Intraclass correlation coefficients for agreement between raters showed high agreement (intraclass correlation coefficient > 0.80) for all guidelines except for 1 (moderate agreement; intraclass correlation coefficient = 0.76). Conclusion:Future guidelines should address identified limitations by providing implementation information and audit criteria, along with better reporting of guideline development processes and stakeholder engagement.

The relationship between coping styles and affective/behavioural symptoms among individuals with an acquired brain injury

Primary objective: To evaluate the impact of combined Axis I and II emotional profiles, demographic and psychosocial variables on coping responses in an Acquired Brain Injury (ABI) population using the Personality Assessment Inventory (PAI) and the Coping Response Inventory (CRI). Research design: This was a retrospective study examining the relationship between coping styles with affective, demographic and psychosocial variables using a multi-dimensional profile analysis. Methods and procedures: Participants completed the PAI and CRI during a regular clinical visit at the ABI Program (n = 100). Profile data was divided into seven established sub-types and analysed with coping responses. Traumatic (TBI; n = 78) and non-traumatic (n = 24) brain-injured individuals comprised the sample. Main outcomes and results: Previous findings were confirmed showing that highly symptomatic patients primarily use negative coping strategies. Also, affective symptoms, gender, relationship status, perceived stress and psychosocial supports mediate the use of different negative coping responses. Interesting, anxiety-based symptoms were associated with positive responses similar to asymptomatic ABI patients. Conclusions: Coping strategies adopted by brain-injured individuals are mediated by Axis I and II symptoms as well as psychosocial support, stress, marital status and gender. As a result, this has implications for developing treatment strategies.