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Brain injury rehabilitation in adults 4.1.6 WALkING AIDS 16 | No evidence was identified relating to use of walking aids and recovery of mobility post TBI. Similar to guidance for people with stroke in SIGN 118, 5 it is suggested that individual patients with TBI may benefit from using a walking aid. If walking aids improve confidence, gait efficiency, balance, functional independence, and safety, they could provide a cost-effective intervention. However, walking aids may have adverse effects on gait pattern, safety and the achievement of independent walking (without an aid). At present there is insufficient evidence to assess the size of these potential impacts. Walking aids should be considered only after a full assessment of the potential benefits and harms of the walking aid in relation to the individual patient’s physical status and cognitive ability. 4.2 SPASTICITy AND MuSClE ToNE Data regarding the prevalence of spasticity post TBI are limited, however incidence rates of up to 75% in people with severe TBI have been reported. 59 There are other motor disorders associated with TBI ranging from non-specific walking and balancing difficulties through to severe problems affecting cerebellar or extra-pyramidal pathways. Spasticity does not always require treatment, for example some patients with lower limb spasticity develop adaptive gait patterns which rely upon spasticity for postural stability. When it is a problem, spasticity in TBI can be both severe and difficult to manage, requiring multifocal interventions arising from multidisciplinary collaboration. In TBI spasticity has similar pathophysiology to that found in certain diseases which cause the upper motor neurone syndrome, such as stroke. It is less similar to that found in spinal cord diseases and in multiple sclerosis. Cognitive considerations also impact on physical therapy treatments. These differences are reflected in the individualised approach to the patient’s problems. The multidisciplinary team in spasticity management will include input from nursing, physiotherapy, occupational therapy, orthotists, pharmacy and surgical and medical staff and many patients will receive multiple treatment modalities. Control of pain and review of posture and seating are vital first considerations in spasticity management. Further details are contained in the British Society of Rehabilitation Medicine guideline for specialised wheelchair seating. 60 4.2.1 SPLINTS, CASTS, STRETCHES AND ORTHOSES Splints are generally fashioned from plastic or metal and are removable. Casts encase a limb and are made of resin or plaster. Both casts and splints, together with regular passive stretching are employed in management of spasticity and in the mitigation of resulting deformities. Five systematic reviews of different stretching treatments were identified. 50,55,61-63 The quality of reviews was good, however the quality of the studies examined in these reviews was highly variable as were the interventions and target populations. The evidence shows that whilst clinically significant improvements are made in short term outcome measures at some joints using each of these types of treatment these benefits are quickly lost once treatment is discontinued. Further evidence has reinforced that beneficial effects of physical rehabilitation interventions for spasticity are often not preserved in the medium or long term. One trial (n=26) showed that casting reduced elbow flexion contracture by an average of 22 degrees (95% confidence interval (CI) 13 to 31 degrees; p
One further RCT (n=35) compared two interventions, lower leg casting plus injections with either saline or botulinum toxin, to controls receiving usual care. 65 Casting with or without botulinum neurotoxin therapy (BoNT) was more effective in reducing spasticity and plantigrade contracture at the ankle than usual care alone. Outcomes were assessed immediately at the end of the period of treatment but long term outcomes were not reported. 50, 55 Hand splinting has been reported to be ineffective. C Casts, splints and passive stretching may be considered in cases where contracture and deformity are progressive. 4.2.2 BOTULINUM NEUROTOxIN THERAPy Botulinum neurotoxin therapy is a widely adopted treatment for focal spasticity. Most of the evidence to support its use derives from before and after studies in various populations, including patients with TBI. Whether the improvements in joint position or spasticity scores seen are clinically important or cost effective have not been addressed in clinical trials. Much use remains outwith the product licence and is customised in a multidisciplinary team (MDT) setting to the needs of the individual. One RCT (n=15) reported gait improvement following treatment of elbow flexion deformities in TBI patients. 66 The BoNT group demonstrated a statistically significant increase in walking velocity after treatment (p=0.037) and mean modified Ashworth score was significantly reduced from 2.6 before treatment to 1.4 after treatment (p=0.00003). One RCT randomised 40 patients with brain injury or stroke to receive either rehabilitative motor therapy alone (control) or motor therapy plus BoNT (intervention). 67 Fugl-Mayer Assessment scores (measuring physical ability) were higher in the intervention group at one and three months post injection (mean ±standard deviation) (23.36±10.69 and 35.36±11.36) than the control group (20.55±10.22 and 30.33±10.96; p
Page 1 and 2: SIGN 130 • Brain injury rehabilit
Page 3 and 4: Scottish Intercollegiate Guidelines
Page 5 and 6: Contents 1 Introduction ...........
Page 7 and 8: 1 Introduction 1.1 THE NEED foR A G
Page 9 and 10: 1.3.3 BRAIN INjURy SEVERITy Long te
Page 11 and 12: Functional therapies tend to be saf
Page 13 and 14: Prior to any prescribing, the licen
Page 15 and 16: 3 Assessment and treatment of mild
Page 17 and 18: False positives on cognitive testin
Page 19 and 20: 3 • Assessment and treatment of m
Page 21: 4.1.3 TASk-SPECIFIC AND REPETITIVE
Page 25 and 26: 4.4 CoNTINENCE PRoBlEMS 4 • Physi
Page 27 and 28: It has been argued that there are v
Page 29 and 30: 6 Rehabilitation of behavioural and
Page 31 and 32: elationship between specific compon
Page 33 and 34: 7 Communication and swallowing 7.1
Page 35 and 36: 7.1.6 TRAINING COMMUNICATION PARTNE
Page 37 and 38: No evidence was identified relating
Page 39 and 40: 8 • Vocational rehabilitation The
Page 41 and 42: 9.1.2 MINIMALLy CONSCIOUS STATE A p
Page 43 and 44: A Cochrane review of evidence for m
Page 45 and 46: 10.2 CoMMuNITy REHABIlITATIoN 10.2.
Page 47 and 48: of improvement. There were no signi
Page 49 and 50: Evidence has also suggested the pot
Page 51 and 52: 11 Provision of information This se
Page 53 and 54: or has mental health or addiction p
Page 55 and 56: 12 • Implementing the guideline y
Page 57 and 58: y therapies to improve disordered s
Page 59 and 60: Guideline development and literatur
Page 61 and 62: Dr killian Welch Consultant Neurops
Page 63 and 64: NMES neuromuscular electrical stimu
Page 65 and 66: 5. What is the evidence for the eff
Page 67 and 68: 15. Is there any evidence of improv
Page 69 and 70: 31. Bryant RA, Harvey AG. Relations
Page 71 and 72: 94. Goverover Y, Johnston MV, Togli
Page 73 and 74:
157. Practice parameters: assessmen
Page 75:
ISBN 978 1 905813 98 8 www.sign.ac.
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