Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline Clearinghouse (NGC): In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the full-text guideline document.
The grades of recommendations (A-D) and levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.
Assessment and Treatment of Mild Brain Injury
Epidemiology and Definitions
B - The diagnosis of mild traumatic brain injury (MTBI) should be made according to WHO task force operational criteria, subject to clinical judgement when complicating factors are present (e.g., skull fracture, seizures, or a haematoma).
Prognostic Factors in Adults
B - Patients presenting with non-specific symptoms following MBTI should be reassured that the symptoms are benign and likely to settle within three months.
B - Referral for cognitive (psychometric) assessment is not routinely recommended after MTBI.
Mood and Anxiety Disorders
C - As post-traumatic stress disorder (PTSD) and other psychiatric disorders may contribute to the overall burden of symptoms in some individuals following MTBI, particularly where problems persist for more than three months, mental state should be routinely examined with an emphasis on symptoms of phobic avoidance, traumatic re-experiencing phenomena (e.g., flashbacks and nightmares) and low mood.
D - Assessment and consideration of pre-existing health variables such as previous neurological disorders and substance misuse should be carried out for all patients with MTBI.
B - Cranial imaging is not routinely recommended for the assessment of post-acute mild brain injury, but should be considered in an atypical case.
Treatment of Mild Traumatic Brain Injury
C - All patients should be offered reassurance about the nature of their symptoms and advice on gradual return to normal activities after uncomplicated mild traumatic brain injury.
C - Antidepressants may be considered for symptom relief after MTBI.
C - Referral for cognitive behavioural therapy following MTBI may be considered in patients with persistent symptoms who fail to respond to reassurance and encouragement from a general practitioner after three months.
Physical Rehabilitation and Management
Gait, Balance and Mobility
Treadmill Training and Gait
C - Patients with traumatic brain injury (TBI) receiving gait training should not undergo treadmill training in preference to conventional overground training.
Task-Specific and Repetitive Task Training
B - Repetitive task-oriented activities are recommended for improving functional ability, such as sit-to-stand or fine motor control.
Spasticity and Muscle Tone
Splints, Casts, Stretches and Orthoses
C - Casts, splints and passive stretching may be considered in cases where contracture and deformity are progressive.
Botulinum Neurotoxin Therapy (BoNT)
B - BoNT may be considered to reduce tone and deformity in patients with focal spasticity.
Oral Anti-Spasticity Medication
D - Oral baclofen or tizanidine may be considered for treatment of spasticity.
D - Patients with memory impairment after TBI should be trained in the use of compensatory memory strategies with a clear focus on improving everyday functioning rather than underlying memory impairment.
- For patients with mild-moderate memory impairment both external aids and internal strategies (e.g., use of visual imagery) may be used.
- For those with severe memory impairment external compensations with a clear focus on functional activities is recommended.
B - Learning techniques that reduce the likelihood of errors being made during the learning of specific information should be considered for people with moderate-severe memory impairment.
C - Patients with attention impairment in the post-acute phase after TBI should be given strategy training relating to the management of attention problems in personally relevant functional situations.
B - Patients with TBI and deficits in executive functioning should be trained in meta-cognitive strategies relating to the management of difficulties with planning, problem solving and goal management in personally relevant functional situations.
Comprehensive/Holistic Treatment Programmes
D - In the post-acute setting interventions for cognitive deficits should be applied in the context of a comprehensive/holistic neuropsychological rehabilitation programme. This would involve an interdisciplinary team using a goal-focused programme which has the capacity to address cognitive, emotional and behavioural difficulties with the aim of improving functioning in meaningful everyday activities.
Rehabilitation of Behavioural and Emotional Disorders
Challenging or Aggressive Behaviour
B - Propranolol or pindolol may be considered as a first line treatment option for moderate levels of agitation/aggression.
Depression and Anxiety
B - Cognitive behavioural therapy should be considered for the treatment of acute stress disorder following MTBI.
B - Cognitive behavioural therapy should be considered for the treatment of anxiety symptoms following mild to moderate TBI, as part of a broader neurorehabilitation programme.
Communication and Swallowing
Managing Communication Problems
D - Patients with communication deficits post TBI should be referred to speech and language therapy for assessment and management of their communication impairments.
Assessing and Managing Dysphagia
D - Instrumental assessment of dysphagia in patients post TBI should be considered where:
- Bedside assessment indicates possible pharyngeal stage problems (which would potentially include the aspiration of food and fluid into the lungs)
- The risks of proceeding on the basis of the bedside assessment outweigh the possible benefits (the patient at very high risk of choking or aspiration if fed orally), and
- The bedside assessment alone does not enable a sufficiently robust clinical evaluation to permit the drawing up of an adequate plan for swallowing therapy.
Management of the Patient in the Minimally Conscious or Vegetative State
Assessing Changes in Conscious Level
B - The Coma Recovery Scale - Revised should be used to assess patients in states of disordered consciousness.
B - Amantadine may be considered as a means of facilitating recovery of consciousness in patients following severe brain injury.
B - For optimal outcomes, higher intensity rehabilitation featuring early intervention should be delivered by specialist multidisciplinary teams.
D - Planned discharge from inpatient rehabilitation to home for patients who have experienced an acquired brain injury (ABI) provides beneficial outcomes and should be an integrated part of treatment programmes.
D - Pre-discharge home visits should be undertaken for patients who require them.
Levels of Evidence
1++: High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias
1+: Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias
1-: Meta-analyses, systematic reviews, or RCTs with a high risk of bias
2++: High quality systematic reviews of case control or cohort studies
High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+: Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2-: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3: Non-analytic studies (e.g., case reports, case series)
4: Expert opinion
Grades of Recommendation
Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation.
A: At least one meta-analysis, systematic review, or randomised controlled trial (RCT) rated as 1++ and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D: Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+