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Brain injury rehabilitation in adults
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Cognitive behavioural therapy
A systematic review identified three observational studies which adopted CBT to treat challenging
behaviours. 105 No substantive treatment effects were reported across these studies. There is insufficient
evidence to recommend cognitive behavioural therapy as a treatment for challenging behaviour.
Music therapy
A systematic review of music therapy following acquired brain injury highlighted one study (n=22) which
demonstrated a positive effect of listening to live and taped music on levels of agitation. 75 The authors
concluded that there was insufficient evidence to support the use of music therapy for improving agitation
following ABI.
The family and key members of the affected individual’s social network should be provided with
education about appropriate management of behaviour and emotion.
6.1.2 PHARMACOLOGICAL INTERVENTIONS
One systematic review included six RCTs evaluating propranolol and pindolol, methylphenidate or
amantadine. 19 There was some evidence that the beta-blockers propranolol and pindolol can reduce aggressive
behaviour. The studies used very large doses, although no significant adverse effects were reported and
clinical experience suggests this is not usually a problem. It was notable that there were no included trials
reporting the use of antipsychotics or anticonvulsants. The authors concluded that there was insufficient
evidence on which to make firm recommendations regarding the use of these treatments, although betablockers
had the best evidence for efficacy.
B Propranolol or pindolol may be considered as a first line treatment option for moderate levels of
agitation/aggression.
Drug treatments should be individually tailored and commenced in very low doses. The patient’s
progress should be monitored with surveillance for possible adverse effects.
6.2 DEPRESSIoN AND ANxIETy
The emotional impact of brain injury can be profound. For many people, a process of emotional adjustment
to changed circumstances is required. Rates of disorders of emotion are high after brain injury. Although
estimates of the prevalence of depression and anxiety have varied widely, findings have indicated that rates of
mood disorder are typically considerably higher than in non-brain-injured populations and may occur at any
stage after a head injury. 108 For some people, low mood or anxiety are transient and part of the adjustment
process. For others, symptoms may persist to the extent that they can be classified as a formal mood disorder.
Levels of disability a year after a head injury are significantly related to psychological disorders rather than
physical impairment (see section 3.2). 86 There is therefore a compelling need to treat depression and anxiety
after brain injury. However, overall there is a limited body of evidence relating to the treatment of depression
and anxiety following TBI.
An important issue to consider in relation to TBI is injury severity. Although there is a broad range of severity
represented in the evidence considered, the majority of studies include participants with mild-moderate
injury. This limits the generalisability of the evidence and any recommendations, such that conclusions may
be less applicable to people with more severe injury.
Another difficulty commonly reported is emotional lability. This is the tendency for a person’s emotion to be
quick to change and to be more extreme than usual and is associated with poor self regulation of emotion.
No evidence was identified that specifically addressed the treatment of emotional lability in patients with ABI.
The literature that is relevant to the treatment of mood disorder after brain injury is varied in the extent to
which mood disorder is the primary focus of an intervention or a primary outcome measure. For example,
mood management interventions are common components of comprehensive or holistic neuropsychological
rehabilitation programmes. This presents a difficulty in relation to reviewing the evidence as the precise
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