The National Center for Evidence-Based Practice
in Communication Disorders
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Summary of Clinical Practice Guideline

Accident Compensation Corporation; New Zealand Guideline Group

Traumatic Brain Injury: Diagnosis, Acute Management, and Rehabilitation
New Zealand Guidelines Group (2006).
Wellington (New Zealand): New Zealand Guidelines Group, 244 pages.

AGREE Rating: Highly Recommended

Description:
This guideline provides recommendations for assessment and treatment of children and adults with traumatic brain injury (TBI). The target audience of this guideline is acute rehabilitation treatment providers, funding agencies, and individuals with traumatic brain injuries and their carers. Levels of evidence are provided and defined by the New Zealand Guidelines Group grading system (Grades A-C and Good Practice Point) based on the following criteria:

  • Grade A: Recommendation is supported by good evidence - studies that are valid, consistent, applicable, and clinically relevant.

  • Grade B: Recommendation is supported by fair evidence - the studies are valid, but there are concerns about the volume, consistency, applicability, and clinical relevance of the evidence.

  • Grade C: Recommendation is supported by international expert opinion.  

  • Good Practice Point:  Best practice recommendation generated by the Guideline Development Team when no evidence was available.

Recommendations:

Pediatric Dysphagia

  • Assessment/Diagnosis

    • Assessment Considerations

      • No adequate evidence exists regarding the assessment of dysphagia in children and young people post-TBI.

 
Traumatic Brain Injury (Adults)
  • Assessment/Diagnosis/Screening

    • Assessment Areas

      • Cognitive-Communication

        • Individuals should be assessed for functional deficits in several areas including: speech and swallowing, sensory function, language production and comprehension, cognition, and memory (Grade C Evidence).

      • Swallowing

        • It is recommended that individuals be assessed for swallowing impairments (Grade C Evidence).

        • “A speech-language pathologist should lead both the assessment and planning of dysphagia therapy” (p. 83; Good Practice Point).

        • Dysphagia assessment should include a detailed diagnostic assessment and “a rehabilitation-focused assessment, which addresses the need for, and potential to benefit from, rehabilitation” (p. 83).

  • Treatment

    • Cognition/Language

      • General Findings

        • Cognitive rehabilitation should include treatment in structured environments and programs should target executive difficulties (Grade A Evidence), attention and information processing skills (Grade B Evidence).

        • Treatment should take into account the individual’s pre-morbid communication style and cognitive deficits, provide opportunities to practice communication skills in natural environments (Grade C Evidence) and include communication aids when appropriate (Grade B Evidence).

      • Compensatory Treatment

        • Cognitive rehabilitation should target the use of compensatory techniques (Grade C Evidence) and external memory aids (Grade A Evidence).

        • Computers and other technology should be considered as compensatory aids (Grade C Evidence).

      • Instructional Treatment

        • “Trial and error learning should be avoided in people with memory impairment" (Grade B Evidence) (p. 98).

      • Specific Skill/Functional Training

        • Cognitive rehabilitation should be functionally-oriented (Grade B Evidence). 

    • Swallowing/Feeding

      • General Findings: “A speech-language pathologist should lead both the assessment and planning of dysphagia therapy” (p. 83; Good Practice Point).

 
Traumatic Brain Injury (Children)
  • Assessment/Diagnosis/Screening

    • Assessment Areas

      • Cognitive-Communication

        • General Findings

          • Pediatric speech-language pathologists with expertise in traumatic brain injury should assess communication abilities in children and young people post-TBI (Good Practice Point).

          • Communication assessments should be performed by speech-language pathologists in conjunction with other individuals on the rehabilitation team (Good Practice Point).

          • “The primary focus of assessment should be on the person’s participation goals, and an assessment of activity limitation and impairments should be made within this context” (Good Practice Point) (p. 80).

          • Attention, memory, complex problem solving, and social judgment should be assessed (Grade C Evidence).

          • Expressive language, language comprehension, cognitive communication disorder, acquired dyslexia, and acquired dysgraphia should be assessed (Grade C Evidence).

      • Hearing

        • General Findings

          • No adequate evidence exists regarding the assessment of hearing loss in children and young people post-TBI.

      • Speech

        • General Findings

          • Dysarthria and apraxia of speech should be assessed (Grade C Evidence).

        • AAC

          • Suitably accredited clinicians should assess the need for and prescription of augmentative communication devices (Consensus Statement).

      • Swallowing

        • Though no adequate evidence exists regarding the assessment of dysphagia in children and young people post-TBI, the following recommendation was generated: “A speech-language pathologist should lead both the assessment and planning of dysphagia therapy” (p. 83). 

  • Treatment

    • Cognitive-Communication

      • General Cognitive (Re)habilitation

        • Long-term continued monitoring and follow-up should be provided to children with clinically significant TBI (Grade C Evidence).

      • Memory Interventions

        • Educational staff who serve children with TBI should receive training pertaining to typical impairments in memory and learning, common problems with behavioral and emotional self-regulation, the high risk of academic failure in children with moderate to severe TBI, factors that influence the rate of recovery, and the ability of the rehabilitation team to help address learning problems as they arise (Grade C Evidence).

      • Swallowing

        • General Findings

          • “A speech-language pathologist should lead both the assessment and planning of dysphagia therapy” (p. 83).

 
 
Social Communication Disorders
  • Assessment/Diagnosis/Screening

    • Assessment Areas

      • Cognition/Language

        • Closed head injury, which is frequently linked to frontal lobe, anterior temporal lobe, and medial temporal lobe damage, can result in issues such as relatively weak social perception and awkward social behavior.  Implications include difficulty assessing impairments and the disability may be misinterpreted (p. 155).

        • Schools should monitor the mental health and social relationships of students with TBI after an injury, and provide counseling and support when indicated (p. 156).

Keywords:
Cognitive Rehabilitation, Brain Injury

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