Traumatic Brain Injury Clinical Guidelines

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Introduction

Research and resulting evidence-based recommendation in ABI field impose great difficulties on best practice and clinical guideline development. According to “Rehabilitation following brain injury guideline” the challenges include:

• the marked heterogeneity with respect to the patient group, the intervention and setting, and to the outcomes that are relevant at each stage of recovery
• the small numbers group, ethical considerations, due to many patients with ABI lacking the mental capacity to give fully informed consent confounding the application of randomised controlled trial designs 
• the ethical problem with randomisation of patients to ‘no treatment’ or even ‘standard’ care since the expanding body of evidence of the effectiveness of multidisciplinary rehabilitation in other conditions (particularly stroke) become available
• the funding issues of long-term projects whilst length of time over which rehabilitation may have its effects (often months or years) is usually longer than any funded research.

Due to those limitations having a significant impact on the research design and quality, the guidelines also utilise significant degree of expert opinion and existing consensus-based documents. 

[null Level of Evidence]	Type of Evidence	Grade of Recommendation
Ia	Meta-analysis of randomised controlled trials (RCTs)	A
Ib	At least one RCT	A
IIa	At least one well-designed controlled study, but without randomisation	B
IIb	At least one well-designed quasi-experimental design	B
III	At least one non-experimental descriptive study (eg. comparative, correlation or case study)	B
IV	Expert committee reports, opinions and/or experience of respected authorities	C

Table.1 Generally used classification of evidence and recommendations whilst developing clinical guideline 

Degrees of Recommendation
A	At least one meta-analysis, systematic review or clinical trail classified as 1++ and directly applicable to the target population of the guideline; or a volume of scientific evidence composed of studies classified as 1+ and with great consistency among them
B	A volume of scientific evidence composed of studies classified as 2++, directly applicable to the target population of the guideline and showing great consistency between them; or scientific evidence extrapolated from studies classified as 1++ or 1+
C	A volume of evidence composed of studies classified as 2+, directly applicable to the target population of the guideline and showing great consistency between them; or scientific evidence extrapolated from studies classified as 2++
D	Scientific evidence level 3 or 4 or scientific evidence extrapolated from studies classified as 2+
Good Clinical Practice
Recommended practice, based on clinical experience and consensus of the group of experts

Table. 2 Degrees of recommendation according to Scottish Intercollegiate Guidelines Network

Clinical guidelines are not always exhaustive form of evidence-based practice. Other sources like Cochrane Collaboration or evidence database like PEDro are recommended in sourcing clinically valuable assessment and treatment approaches and organisational principles, especially in such heterogeneous population like traumatic brain injury survivors. Therefore, synthesis of established guidelines’ knowledge with clinical findings about individual with traumatic brain injury and clinically reasoned judgment of treating therapist / clinician is the most effective approach to management of individual with traumatic brain injury. 

Guidelines

Head Injury: Assessment and Early Management

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References

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