Ontario Neurotrauma Foundation

Clinical Practice Guideline

For the rehabilitation of Adults with Moderate to Severe TBI

Ontario Neurotrauma Foundation INESSS
SECTION 2: Assessment and Rehabilitation of Brain Injury Sequelae > T. Medical / Nursing Management

T. Medical / Nursing Management

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Individuals with traumatic brain injury (TBI) present with a number of medical and nursing complications whose management has a significant impact on outcomes.

Medications should be considered in the context of the identified impairments while taking into account the concurrent advantage of the medication for other impairments (e.g. Epival for seizure prophylaxis and need for mood stabilization), as well as the potential for adverse effects.

Bladder and bowel incontinence is a common complication in as many as 62% of individuals with moderate to severe TBI but can be managed with a carefully planned program. Incontinence has a negative impact on quality of life and can influence caregiver burden.

Post-traumatic seizure is defined as an initial or recurrent episode not attributable to another obvious cause after TBI; they can be further defined as immediate (occurring within the first 24 hours), early (within the first week of injury) and late (after the first week). Prophylactic anti-seizure medications are helpful in preventing early seizures (first week) but are not indicated after one week. Anti-convulsants can routinely result in significant cognitive side effects, and so their use must be carefully monitored.

Deep venous thromboembolism is common in the context of immobility, lower limb paresis and multi-trauma. Deep vein thrombosis (DVT) and pulmonary emboli (PE) can contribute to a significant amount of morbidity and mortality, and prophylaxis, especially with low-molecular weight heparin (LMWH), can be safe and effective. The risk of developing a DVT in the absence of prophylaxis is estimated to be approximately 20% post TBI.

Neuroendocrine disorders, particularly hypopituitarism and growth hormone deficiencies are common particularly following moderate to severe injuries with 27-40% of patients having at least one deficiency and 10-15% with more than one deficiency. Endocrine abnormalities may not appear until 3-6 months post TBI and the gold standard for diagnosis is serum tests assessing hormonal function. Abnormalities of antidiuretic hormone and adrenal insufficiency are the most commonly reported abnormalities.

Heterotopic ossification (HO) is the formation of pathological bone within soft tissues, often muscles, where bone formation does not usually occur. It can symptomatically occur in 10-15% of patients and can be quite painful and limit joint mobility thereby impeding rehabilitation progress. Once developed, treatment of HO (usually surgical) can be challenging.

A number of secondary medical complications occur after a moderate to severe TBI. Bladder and bowel incontinence require early assessment followed by a highly coordinated program of nursing care, medications, behavioural scheduling, and in some cases, urodynamic and use of catheters. At the same time, any continence program must involve patients and their caregivers to ensure any program of care can be carried through at home. Management of seizures and deep venous thromboses involve standardized treatment regimens including early prophylaxis in high risk cases. Heterotopic ossification and neuroendocrine dysfunction require careful monitoring and access to appropriate laboratory testing and bone scans. 

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Some individuals acquire secondary medical complications post TBI. The management of excretory systems, seizure prevention, thrombosis, and heterotopic ossification requires extensive co-ordination between rehabilitation teams, caregivers and the patient. Treatments should be administered as soon as appropriate and should be given prophylactically, if possible.

Bladder and bowel function should be assessed shortly after admission. As many as 62% of patients with TBI experience incontinence on admission to rehabilitation (Chua, Chuo, & Kong, 2003). Urinary disturbances are associated with impaired cognitive functioning and motor difficulties (Moiyadi, Devi, & Nair, 2007). Fecal incontinence frequency has been shown to be correlated with the severity of brain injury (Foxx-Orenstein et al., 2003). Promisingly, a case series found that recovery of bowel and bladder function could predict favourable functional outcomes following a TBI (Kushner & Johnson-Greene, 2014). In general, antibiotic treatment of asymptomatic bacteriuria is not recommended but cognitive or physical deterioration could be considered as a complication of urinary tract infection (Colgan et al., 2006; Lin & Fajardo, 2008).

Following a TBI, patients are susceptible to developing seizures. When managing seizures there are several pharmacological treatments available; however, these carry the risk of adverse effects. Intramuscular midazolam has been shown to be effective for acute seizure cessation (Wroblewski & Joseph, 1992). In terms of seizure prophylaxis, phenytoin is the most commonly studied medication. Numerous studies have found phenytoin to be only as effective as a placebo (McQueen, Blackwood, Harris, Kalbag, & Johnson, 1983; Temkin et al., 1990; Young et al., 1983). The use of anticonvulsants for treatment of late post traumatic seizures has been shown to increase seizure occurrence (Formisano et al., 2007), and have longer hospital stays and worse functional outcomes (Bhullar et al., 2014). Phenytoin and levetiracetam have comparable efficacies in terms of seizure rates (Inaba et al., 2013; Kruer et al., 2013), complications (Jones et al., 2008), mortality rates (Inaba et al., 2013) and length of stays (Kruer et al., 2013). A meta-analysis by (Zafar, Khan, Ghauri, & Shamim, 2012) also concluded that there was no superiority of either drug at preventing early seizures. However, phenytoin use is associated with greater days of fever (Gabriel & Rowe, 2014), adverse reactions (Inaba et al., 2013), and worse neurological status (Szaflarski, Sangha, Lindsell, & Shutter, 2010).

The reader is referred to the ERABI for more detailed review http://www.abiebr.com/module/10-post-traumatic-seizure-disorder.

Deep vein thrombosis (DVT) is a common complication following TBI; the risk of developing a DVT in absence of prophylaxis is estimated to be 20% after a TBI (Haddad & Arabi, 2012). Low-molecular weight heparin (LMWH) has been shown to reduce the risk of DVTs and PEs within the first 48 hours after injury (Glassner et al., 2013; Norwood, Berne, Rowe, Villarreal, & Ledlie, 2008). LMWH medications are also popular because they can be injected subcutaneously allowing for ease of administration and dosage adjustment; however, these drugs are expensive (Watanabe TK & MO., 2001). When comparing LMWH to low-dose unfractionated heparin (LDUH) in a mixed trauma population, a study found that patients receiving LDUH were more likely to experience DVT compared to those receiving LMWH (Geerts et al., 1996). Physical methods for venous thromboprophylaxis are still limited. One study found that sequential compression devices are not that effective in reducing the risk of developing DVT or pulmonary embolism after a TBI (Gersin et al., 1994). However, the use of compression stockings combined with LMWH has been shown to be more effective in preventing venous thromboembolism than stockings alone (Agnelli et al., 1998).

Endocrine disorders such as hypopituitarism can evolve over time post ABI; therefore, screening should be conducted as soon as possible. During the acute stage of recovery, cortisol levels of less than 7.2 µg/dL may indicate adrenal insufficiency (Bernard, Outtrim, Menon, & Matta, 2006). Treatment should also be considered and initiated in those cases where hyponatremia, hypotension and hypoglycemia are present and cortisol levels are between 7.2 and 18 µg/dL (Schneider, Kreitschmann-Andermahr, Ghigo, Stalla, & Agha, 2007). In the acute stage of recovery it is not necessary to assess growth, gonadal or thyroid hormones as there is no evidence to suggest that supplementation of these hormones during this phase is beneficial (Ghigo et al., 2005; Schneider et al., 2007); however, during the post recovery stage, at 3-6 months, a clinical assessment for hypopituitarism should be completed (Powner & Boccalandro, 2008; Powner, Boccalandro, Alp, & Vollmer, 2006; Schneider et al., 2007). This is especially important if any of the following symptoms are noted: loss of secondary hair, impaired sexual function, weight changes, polydipsia, or amenorrhea. Hormonal screening should include 0900 AM serum cortisol, fT3, fT4, TSH, FSH, LH, testosterone in men and E2 in women, prolactin, and Insulin-like Growth Factor (IGF-I). In patients with polyuria or suspected diabetes insipidus, urine density, sodium and plasma osmolality should also be evaluated. Low IGF-I levels strongly predict severe GH deficiency (in the absence of malnutrition). Normal IGF-I levels may be found in patients with GH deficiency; therefore, provocative tests are necessary in patients with another identified pituitary hormone deficit. Provocative testing is recommended if IGF-I levels are below the 25th percentile of age related normal limits (Ghigo et al., 2005).

Studies have found that following a TBI disruptions to salt and water levels can lead to inappropriate secretion of antidiuretic hormone (Doczi, Tarjanyi, Huszka, & Kiss, 1982; Makulski, Taber, & Chiou-Tan, 2008). Restricting fluid intake has proven effective, but studies are conflicting about the amount of fluid that should be limited; Doczi et al. (1982) suggest limiting daily fluid intake to less than 600 to 800 mL, whereas Born, Hans, Smitz, Legros, and Kay (1985)suggest limiting intake to 250 to 500 ml.

A review by Estes and Urban (2005) notes that for those who sustain a mild TBI, growth hormone deficiency has been identified during regular blood work, but no other symptoms have appeared. The authors suggest waiting 3 years post trauma before beginning treatment in attempt for the endocrine system to correct itself. However, if there is a clear indication of anterior or posterior pituitary dysfunction, consulting an endocrinologist is strongly recommended.

Heterotopic ossification (HO) is another common complication following TBI. Among individuals with TBI the most commonly sites of HO are the soft tissues around the hip, elbow, shoulder and knee (Garland, 1991; Garland, Blum, & Waters, 1980; van Kampen, Martina, Vos, Hoedemaekers, & Hendricks, 2011; Vanden Bossche & Vanderstraeten, 2005). The hip is the most frequent site of ossification (Dizdar et al., 2013; Vanden Bossche & Vanderstraeten, 2005), with total ankylosis of the joint occurring in 5-16% of affected hips (Stover, Niemann, & Tulloss, 1991). HO of the shoulder has been found to affect 5% of individuals with a brain injury (Cipriano, Pill, & Keenan, 2009), while the knee is a less common site for HO following a head injury (Sarafis, Karatzas, & Yotis, 1999). Of the joints affected by HO after head injury, ankylosis is most likely to occur in the posterior elbow (Garland et al., 1980). Triple phase technicium-99 bone scan is gold standard for diagnosing HO (Freed, Hahn, Menter, & Dillon, 1982).

Etidronate has been used as a prophylaxis for HO in other disease populations, but its use in TBI is understudied. A study found that Etidronate usage did significantly lower incidence of HO when compared to a control (Spielman, Gennarelli, & Rogers, 1983). Similar to Etidronate, the effects of nonsteroidal anti-inflammatory drugs (NSAIDS) as a prophylaxis are not well studied in the TBI literature.

There are few treatments for HO post ABI. Range of motion exercises are beneficial for treating HO post TBI. Studies have found that forceful manipulation is not only useful in maintaining motion but also aids in the prevention of bony ankylosis and does not appear to exacerbate the ossification process (Ellerin et al., 1999; Garland, Razza, & Waters, 1982; Garland & Varpetian, 2003). Anaesthesia may be needed to help differentiate between spasticity and ankylosis and to allow sufficient muscle relaxation to perform the joint manipulation (Garland & Varpetian 2003).

Surgical excision is also a treatment option for HO post ABI. A systematic review by Lee, Namdari, Hosalkar, Keenan, and Baldwin (2013) focused specifically on the surgical excision of HO in the elbow and found it resulted in improvements in range of motion with low levels of recurrence (14.3%). However, complications such as fracture, infection, nerve palsies, wound complications and loss of motion without recurrence were found in 27.5% of cases (Lee et al., 2013). In many studies, the recurrence of HO was evaluated months following the initial operation, with rates ranging from 0 to 27% (Fuller, Mani, & Keenan, 2013; Fuller, Mark, & Keenan, 2005; Ippolito, Formisano, Caterini, Farsetti, & Penta, 1999; Ippolito, Formisano, Farsetti, Caterini, & Penta, 1999; Moore, 1993). The majority of the studies did not specify what qualified as recurrence; however, a study by Kolessar, Katz, and Keenan (1996) found recurrence rates differed based on the classification system utilized (23.8% versus 4.8% using the Brooker classification and the Stover and colleagues classification, respectively). Overall, the surgical excision of HO resulted in improved range of motion, although, one study noted a decrease in range of motion for a small portion of participants (Ippolito, Formisano, Farsetti, et al., 1999). Improvements in activities of daily living and ambulation were also reported (Fuller et al., 2005; Ippolito, Formisano, Caterini, et al., 1999; Ippolito, Formisano, Farsetti, et al., 1999; Melamed et al., 2002). Although therapy was provided after the surgery in many of the studies, only one study formally evaluated its effectiveness; (Lazarus, Guttmann, Rich, & Keenan, 1999) found that patients who had continuous passive range of motion exercises post operatively made significantly greater gains compared to those individuals who did not (57.9° versus 24.1°, p=0.04).

Agnelli, G., Piovella, F., Buoncristiani, P., Severi, P., Pini, M., D'Angelo, A., . . . Brambilla, G. (1998). Enoxaparin plus compression stockings compared with compression stockings alone in the prevention of venous thromboembolism after elective neurosurgery. N Engl J Med, 339(2), 80-85.

Bernard, F., Outtrim, J., Menon, D., & Matta, B. (2006). Incidence of adrenal insufficiency after severe traumatic brain injury varies according to definition used: clinical implications. British journal of anaesthesia, 96(1), 72-76.

Bhullar, I. S., Johnson, D., Paul, J. P., Kerwin, A. J., Tepas III, J. J., & Frykberg, E. R. (2014). More harm than good: antiseizure prophylaxis after traumatic brain injury does not decrease seizure rates but may inhibit functional recovery. Journal of Trauma and Acute Care Surgery, 76(1), 54-61.

Born, J., Hans, P., Smitz, S., Legros, J., & Kay, S. (1985). Syndrome of inappropriate secretion of antidiuretic hormone after severe head injury. Surgical neurology, 23(4), 383-387.

Brain Trauma Foundation, B. (2007). Guidelines for the management of severe traumatic brain injury. J Neurotrauma, 24 Suppl 1, S1-106.

Chua, K., Chuo, A., & Kong, K. H. (2003). Urinary incontinence after traumatic brain injury: incidence, outcomes and correlates. Brain Inj, 17(6), 469-478.

Cipriano, C. A., Pill, S. G., & Keenan, M. A. (2009). Heterotopic ossification following traumatic brain injury and spinal cord injury. J Am Acad Orthop Surg, 17(11), 689-697.

Colgan, R., Nicolle, L. E., McGlone, A., & Hooton, T. M. (2006). Asymptomatic bacteriuria in adults. Am Fam Physician, 74(6), 985-990.

Dizdar, D., Tiftik, T., Kara, M., Tunc, H., Ersoz, M., & Akkus, S. (2013). Risk factors for developing heterotopic ossification in patients with traumatic brain injury. Brain Inj, 27(7-8), 807-811.

Doczi, T., Tarjanyi, J., Huszka, E., & Kiss, J. (1982). Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) after head injury. Neurosurgery, 10(6 Pt 1), 685-688.

Ellerin, B. E., Helfet, D., Parikh, S., Hotchkiss, R. N., Levin, N., Nisce, L., . . . Moni, J. (1999). Current therapy in the management of heterotopic ossification of the elbow: A review with case studies. American Journal of Physical Medicine and Rehabilitation, 78(3), 259-271.

Estes, S. M., & Urban, R. J. (2005). Hormonal replacement in patients with brain injury-induced hypopituitarism: Who, when and how to treat? Pituitary, 8(3-4), 267-270.

Evidence-Based Review of Moderate To Severe Acquired Brain Injury (ERABI). (2016). www.abiebr.com/.;

Formisano, R., Barba, C., Buzzi, M. G., Newcomb-Fernandez, J., Menniti-Ippolito, F., Zafonte, R., . . . Spanedda, F. (2007). The impact of prophylactic treatment on post-traumatic epilepsy after severe traumatic brain injury. Brain Injury, 21(5), 499-504.

Foxx-Orenstein, A., Kolakowsky-Hayner, S., Marwitz, J. H., Cifu, D. X., Dunbar, A., Englander, J., & Francisco, G. (2003). Incidence, risk factors, and outcomes of fecal incontinence after acute brain injury: findings from the Traumatic Brain Injury Model Systems national database. Arch Phys Med Rehabil, 84(2), 231-237.

Freed, J. H., Hahn, H., Menter, R., & Dillon, T. (1982). The use of the three-phase bone scan in the early diagnosis of heterotopic ossification (HO) and in the evaluation of Didronel therapy. Paraplegia, 20(4), 208-216.

Fuller, D. A., Mani, U. S., & Keenan, M. A. (2013). Heterotopic ossification of the shoulder in patients with traumatic brain injury. J Shoulder Elbow Surg, 22(1), 52-56.

Fuller, D. A., Mark, A., & Keenan, M. A. E. (2005). Excision of heterotopic ossification from the knee: a functional outcome study. Clinical orthopaedics and related research, 438, 197-203.

Gabriel, W. M., & Rowe, A. S. (2014). Long-Term Comparison of GOS-E Scores in Patients Treated With Phenytoin or Levetiracetam for Posttraumatic Seizure Prophylaxis After Traumatic Brain Injury. Annals of Pharmacotherapy, 48(11), 1440-1444.

Garland, D. E. (1991). A clinical perspective on common forms of acquired heterotopic ossification. Clin Orthop Relat Res(263), 13-29.

Garland, D. E., Blum, C. E., & Waters, R. L. (1980). Periarticular heterotopic ossification in head-injured adults. Incidence and location. J Bone Joint Surg Am, 62(7), 1143-1146.

Garland, D. E., Razza, B. E., & Waters, R. L. (1982). Forceful joint manipulation in head-injured adults with heterotopic ossification. Clinical orthopaedics and related research, No. 169, 133-138.

Garland, D. E., & Varpetian, A. (2003). Heterotopic Ossification in Traumatic Brain Injury.

Geerts, W. H., Jay, R. M., Code, K. I., Chen, E., Szalai, J. P., Saibil, E. A., & Hamilton, P. A. (1996). A comparison of low-dose heparin with low-molecular-weight heparin as prophylaxis against venous thromboembolism after major trauma. New England Journal of Medicine, 335(10), 701-707.

Gersin, K., Grindlinger, G. A., Lee, V., Dennis, R. C., Wedel, S. K., & Cachecho, R. (1994). The efficacy of sequential compression devices in multiple trauma patients with severe head injury. J Trauma, 37(2), 205-208.

Ghigo, E., Masel, B., Aimaretti, G., Leon-Carrion, J., Casanueva, F. F., Dominguez-Morales, M. R., . . . Urban, R. (2005). Consensus guidelines on screening for hypopituitarism following traumatic brain injury. Brain Inj, 19(9), 711-724.

Glassner, S., Srivastava, K., Cofnas, P., Deegan, B., DeMaria, P., Denis, R., & Ginzburg, E. (2013). Prevention of Venous Thrombotic Events in Brain Injury: Review of Current Practices. Rambam Maimonides Medical Journal, 4(1), e0001.

Haddad, S. H., & Arabi, Y. M. (2012). Critical care management of severe traumatic brain injury in adults. Scand J Trauma Resusc Emerg Med, 20, 12.

Inaba, K., Menaker, J., Branco, B. C., Gooch, J., Okoye, O. T., Herrold, J., . . . Demetriades, D. (2013). A prospective multicenter comparison of levetiracetam versus phenytoin for early posttraumatic seizure prophylaxis. Journal of Trauma and Acute Care Surgery, 74(3), 766-773.

Ippolito, E., Formisano, R., Caterini, R., Farsetti, P., & Penta, F. (1999). Operative treatment of heterotopic hip ossification in patients with coma after brain injury. Clin Orthop Relat Res(365), 130-138.

Ippolito, E., Formisano, R., Farsetti, P., Caterini, R., & Penta, F. (1999). Excision for the treatment of periarticular ossification of the knee in patients who have a traumatic brain injury. J Bone Joint Surg Am, 81(6), 783-789.

Jones, K. E., Puccio, A. M., Harshman, K. J., Falcione, B., Benedict, N., Jankowitz, B. T., . . . Okonkwo, D. O. (2008). Levetiracetam versus phenytoin for seizure prophylaxis in severe traumatic brain injury. Neurosurg Focus, 25(4), E3.

Kolessar, D. J., Katz, S. D., & Keenan, M. A. (1996). Functional outcome following surgical resection of heterotopic ossification in patients with brain injury. Journal of Head Trauma Rehabilitation, 11(4), 78-87.

Kruer, R. M., Harris, L. H., Goodwin, H., Kornbluth, J., Thomas, K. P., Slater, L. A., & Haut, E. R. (2013). Changing trends in the use of seizure prophylaxis after traumatic brain injury: a shift from phenytoin to levetiracetam. J Crit Care, 28(5), 883.e889-813.

Kushner, D. S., & Johnson-Greene, D. (2014). Changes in cognition and continence as predictors of rehabilitation outcomes in individuals with severe traumatic brain injury. J Rehabil Res Dev, 51(7), 1057-1068.

Lazarus, M. D., Guttmann, D., Rich, C. E., & Keenan, M. A. E. (1999). Heterotopic ossification resection about the elbow. NeuroRehabilitation, 12(2), 145-153.

Lee, E. K., Namdari, S., Hosalkar, H. S., Keenan, M. A., & Baldwin, K. D. (2013). Clinical results of the excision of heterotopic bone around the elbow: a systematic review. J Shoulder Elbow Surg, 22(5), 716-722.

Lin, K., & Fajardo, K. (2008). Screening for asymptomatic bacteriuria in adults: evidence for the U.S. Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med, 149(1), W20-24.

Makulski, D. D., Taber, K. H., & Chiou-Tan, F. Y. (2008). Neuroimaging in posttraumatic hypopituitarism. Journal of computer assisted tomography, 32(2), 324-328.

McQueen, J. K., Blackwood, D. H. R., Harris, P., Kalbag, R. M., & Johnson, A. L. (1983). Low risk of late post-traumatic seizures following severe head injury: Implications for clinical trials of prophylaxis. Journal of Neurology Neurosurgery and Psychiatry, 46(10), 899-904.

Melamed, E., Robinson, D., Halperin, N., Wallach, N., Keren, O., & Groswasser, Z. (2002). Brain injury-related heterotopic bone formation: treatment strategy and results. Am J Phys Med Rehabil, 81(9), 670-674.

Moiyadi, A. V., Devi, B. I., & Nair, K. P. (2007). Urinary disturbances following traumatic brain injury: clinical and urodynamic evaluation. NeuroRehabilitation, 22(2), 93-98.

Moore, T. J. (1993). Functional outcome following surgical excision of heterotopic ossification in patients with traumatic brain injury. J Orthop Trauma, 7(1), 11-14.

Norwood, S. H., Berne, J. D., Rowe, S. A., Villarreal, D. H., & Ledlie, J. T. (2008). Early venous thromboembolism prophylaxis with enoxaparin in patients with blunt traumatic brain injury. J Trauma, 65(5), 1021-1026; discussion 1026-1027.

Powner, D. J., & Boccalandro, C. (2008). Adrenal insufficiency following traumatic brain injury in adults. Current opinion in critical care, 14(2), 163-166.

Powner, D. J., Boccalandro, C., Alp, M. S., & Vollmer, D. G. (2006). Endocrine failure after traumatic brain injury in adults. Neurocritical Care, 5(1), 61-70.

Sarafis, K. A., Karatzas, G. D., & Yotis, C. L. (1999). Ankylosed hips caused by heterotopic ossification after traumatic brain injury: a difficult problem. J Trauma, 46(1), 104-109.

Schneider, H. J., Kreitschmann-Andermahr, I., Ghigo, E., Stalla, G. K., & Agha, A. (2007). Hypothalamopituitary dysfunction following traumatic brain injury and aneurysmal subarachnoid hemorrhage: a systematic review. Jama, 298(12), 1429-1438.

Sesmilo, G., Halperin, I., & Puig-Domingo, M. (2007). Endocrine evaluation of patients after brain injury: what else is needed to define specific clinical recommendations? Hormones (Athens), 6(2), 132-137.

Spielman, G., Gennarelli, T., & Rogers, C. (1983). Disodium etidronate: its role in preventing heterotopic ossification in severe head injury. Arch Phys Med Rehabil, 64(11), 539-542.

Stover, S. L., Niemann, K. M., & Tulloss, J. R. (1991). Experience with surgical resection of heterotopic bone in spinal cord injury patients. Clin Orthop Relat Res(263), 71-77.

Szaflarski, J., Sangha, K., Lindsell, C., & Shutter, L. (2010). Prospective, randomized, single-blinded comparative trial of intravenous levetiracetam versus phenytoin for seizure prophylaxis. Neurocritical Care, 12.

Temkin, N. R., Dikmen, S. S., Wilensky, A. J., Keihm, J., Chabal, S., & Winn, H. R. (1990). A randomized, double-blind study of phenytoin for the prevention of post-traumatic seizures. N Engl J Med, 323(8), 497-502.

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T1. Assessment of Continence

P Priority F Fundamental New Level of evidence A B C
T 1.1 C

Full assessment of bladder and bowel functions should be undertaken over a period of days following admission to rehabilitation. The physical, cognitive and emotional function of the person with traumatic brain injury should be considered.

(Adapted from SIGN 2013, 4.4, p. 19)

T2. Management of Incontinence

P Priority F Fundamental New Level of evidence A B C
T 2.1 P C

The rehabilitation plan for urinary incontinence following traumatic brain injury should include:

  • A regular monitoring program

  • Strategies for alerting the caregivers to the person’s need to pass urine where there are communication problems

  • A toileting regimen based on reinforcement in cases of cognitive impairment

  • Bladder re-education

(Adapted from NZGG 2006, 6.1.3, p. 93)

T 2.2 P C

Individuals with traumatic brain injury with continence problems should not be discharged home until continence aids and services have been arranged at home and caregivers have been adequately prepared.

(Adapted from NZGG 2006, 6.1.3, p. 93)

T 2.3 C

Anticholinergic medication for continence problems for individuals with traumatic brain injury should only be prescribed after demonstration of an overactive bladder. Use of urodynamic assessment is considered optimal.

(Adapted from NZGG 2006, 6.1.3, p. 93)

Note: Anticholinergic medications are associated with complications including memory and cognitive impairments.

T 2.4 C

Intermittent catheterisation should be considered for use in individuals with traumatic brain injury who are shown to have an elevated post-micturition residual volume.

(Adapted from NZGG 2006, 6.1.3, p. 93)

T 2.5 C

Long-term catheters can be considered as part of a planned catheter management program for individuals with traumatic brain injury. Supra-pubic catheters should, however, be considered as a preferred alternative to long-term urethral catheters.

(Adapted from NZGG 2006, 6.1.3, p. 93)

T 2.6 C

In the case of constipation following traumatic brain injury, an active bowel management regimen should be instituted as soon as possible, which includes:

  • Ensuring sufficient fluid intake

  • The use of natural laxatives, stimulants, or simple bulk laxatives

  • Exercise and standing, where possible

  • Avoiding medications which slow gut motility

  • Maximum privacy and comfort during defecation

  • Supported sitting up for defecation at the earliest safe opportunity, and at a regular time each day

  • Where the rectum is full but no spontaneous evacuation occurs, rectal stimulation may be used

(Adapted from NZGG 2006, 6.1.3, p. 93)

T 2.7 C

Bladder and bowel management plans for individuals with traumatic brain injury should be developed with the full knowledge and support of the person’s primary caregiver.

(Adapted from NZGG 2006, 6.1.3, p. 94)

T 2.8 C

Asymptomatic bacteriuria should only be treated with antibiotic therapy in exceptional circumstances following traumatic brain injury (i.e., pregnancy, pending urologic procedure, worsening cognitive status).

(INESSS-ONF, 2015)


- Lin and Fajardo (2008)
- Colgan et al. (2006)

T3. Seizures

Medications should only be prescribed by qualified physicians, and guideline users should consult the section on "Principles of medication management" before prescribing.
P Priority F Fundamental New Level of evidence A B C
T 3.1 C

Acute seizures during rehabilitation following traumatic brain injury should be managed according to established protocols.

(Adapted from ABIKUS 2007, G79, p. 28)

T 3.2 C

Anticonvulsants, particularly phenytoin and levetiracetam, are indicated to reduce the incidence of post-traumatic seizures in the first 7 days post-injury. Routine use of anticonvulsants to prevent late post-traumatic seizures after 7 days post-injury is not recommended.

(INESSS-ONF, 2015)

Suggested tool: Health Canada Indications of Use


- Brain Trauma Foundation (2007)

T 3.3 P C

In the event that use of anticonvulsant medications is indicated in the acute and chronic phases of traumatic brain injury, consideration should be given to choosing medications with the most favourable side effect profiles, as these medications have significant neuropsychological and other side effects.

(INESSS-ONF, 2015)

Note: For example, phenytoin may have negative effects on cognitive performance and recovery, although phenytoin may still be considered a first-line drug for early seizures in the acute period in view of ease of administration and monitoring. Clinicians should be particularly vigilant for adverse cognitive side effects of anticonvulsant medications and not assume that these drugs are without risk of impairment of cognitive, behavioural, physical, and neuroendocrine function, as well as having potential negative impacts on long-term recovery.

Suggested tool: Health Canada Indications of Use


- ERABI Module 10- Post-Traumatic Seizure Disorder, p.12, 10.4

T4. Deep Vein Thrombosis

Medications should only be prescribed by qualified physicians, and guideline users should consult the section on "Principles of medication management" before prescribing.
P Priority F Fundamental New Level of evidence A B C
T 4.1 P B

Venous thromboprophylaxis should be initiated as soon as medically appropriate following traumatic brain injury.

(INESSS-ONF, 2015)


- Glassner et al. (2013)

T 4.2 C

Low-molecular-weight heparin (LMWH) is preferred over unfractionated heparin (UFH) for venous thromboprophylaxis after traumatic brain injury (TBI).

(Adapted from ABIKUS 2007, G77, p. 28)

Note: Much of the evidence supporting this recommendation is derived from the trauma/medical literature not specifically focused on individuals with TBI.

Suggested tool: Health Canada Indications of Use

T 4.3 B

When pharmacological venous thromboprophylaxis is contraindicated or delayed after traumatic brain injury, physical methods (i.e., intermittent pneumatic compression stockings) should be utilized.

(Adapted from ABIKUS 2007, G77, p. 28)

T5. Screening for Neuroendocrine Complications

P Priority F Fundamental New Level of evidence A B C
T 5.1 P C

Screening of the hypothalamic pituitary axis should occur at 3-6 months post traumatic brain injury (TBI) or when symptoms are suggestive of a hormonal imbalance or deficiency. Screening should include a.m. cortisol, serum glucose, thyroid hormone (Free T4), thyroid-stimulating hormone (TSH), prolactin, estrogen or a.m. testosterone (T), follicle-stimulating hormone (FSH), luteinizing hormone (LH) and insulin-like growth factor-1 (IGF-1). Clinicians should be aware that a low or normal thyroid-stimulating hormone (TSH) does not rule out pituitary insufficiency with thyroid hormone deficiency.

(INESSS-ONF, 2015)

Note: Hypothalamic pituitary axis dysfunction is common post TBI and may vary in the acute, subacute or chronic phase. This dysfunction may affect the anterior pituitary system, the posterior pituitary, or both. Individuals with severe TBI commonly develop disorders of the anterior pituitary during the acute, subacute or chronic phase post-injury, which results in neuro-hormonal disturbances.


- ERABI Module 9-Neuroendocrine Disorders, p.14
- Sesmilo et al. (2007)

T6. Neuroendocrine Complications

P Priority F Fundamental New Level of evidence A B C
T 6.1 P C

Individuals with traumatic brain injury and hyponatremia should have an assessment of their hydration status, serum electrolytes with urinary electrolytes and sodium excretion. Restricting fluid intake and salt supplementation should be considered in managing the electrolyte disturbance in those with syndrome of inappropriate antidiuretic hormone secretion (SIADH) or hyponatremia due to cerebral salt wasting in individuals.

(INESSS-ONF, 2015)


- ERABI Module 9-Neuroendocrine Disorders, p.17
- Sesmilo et al. (2007)

T 6.2 P C

Individuals with traumatic brain injury (TBI) with an identified neuroendocrine abnormality on screening should be referred, where appropriate, to an endocrinologist familiar with this TBI population, particularly if stimulation testing may be required to further evaluate complex hormonal imbalance such as growth hormone (GH) deficiency and replacement.

(INESSS-ONF, 2015)


- ERABI Module 9-Neuroendocrine Disorders, p.30

T7. Screening for Heterotopic Ossification

P Priority F Fundamental New Level of evidence A B C
T 7.1 P C

Individuals with traumatic brain injury (TBI), especially those with severe injury, should be regularly assessed for the possible presence of heterotopic ossification. The sites most frequently affected following TBI are the hips, elbows, shoulders and knees.


T 7.2 B

Early diagnosis of heterotopic ossification following traumatic brain injury should involve a three-phase bone scan.

(Adapted from ABIKUS 2007, G75, p. 28)

T8. Treatment of Heterotopic Ossification

Medications should only be prescribed by qualified physicians, and guideline users should consult the section on "Principles of medication management" before prescribing.
P Priority F Fundamental New Level of evidence A B C
T 8.1 C

Once heterotopic ossification (HO) has developed in individuals with traumatic brain injury, treatment should include etidronate and/or non-steroidal anti-inflammatory drugs.

(Adapted from ABIKUS 2007, G75, p. 28)

Suggested tool: Health Canada Indications of Use

T 8.2 P C

Passive range-of-motion exercises following traumatic brain injury are important to maintain joint range of motion (ROM) and do not worsen heterotopic ossification (HO). ROM must be gentle and within available range, as aggressive ROM beyond the available joint range can exacerbate HO.

(INESSS-ONF, 2015)


- ERABI Module 11- Heterotopic Ossification and Venous Thromboembolism post ABI, p.9, 11.3.1

T 8.3 C

Manipulation of joints under anaesthesia can be considered as a treatment to increase range of motion in individuals with heterotopic ossification (HO) following traumatic brain injury.

(Adapted from ABIKUS 2007, G76, p. 28)

T 8.4 B

Surgical excision of heterotopic ossification (HO) should be considered at a later stage in individuals with traumatic brain injury.

(Adapted from ABIKUS 2007, G75, p. 28)

T9. Principles of Medication Management (Neuropharmacology)

Medications should only be prescribed by qualified physicians, and guideline users should consult the section on "Principles of medication management" before prescribing.
P Priority F Fundamental New Level of evidence A B C
T 9.1 P C

Pharmacological treatment of neurobehavioural / mental health symptoms following traumatic brain injury should be based upon individual factors and symptom severity and comorbidity; and will often represent only one component of a multimodal treatment strategy.

(INESSS-ONF, 2015)

Suggested tool: Health Canada Indications of Use

T 9.2 P C

Specific target symptoms/behaviours should be clearly defined and monitored during pharmacological treatment following traumatic brain injury (TBI), along with expected treatment outcomes. The serial use of validated rating scales appropriate for TBI and other methods of objective assessment are recommended.

(INESSS-ONF, 2015)

Suggested tool: Health Canada Indications of Use

T 9.3 P C

Careful drug selection and monitoring are required when initiating pharmacological interventions to minimize potential adverse effects on arousal, cognition, motivation and motor coordination following traumatic brain injury. Use of medications that target more than one brain-injury-related symptom/syndrome is recommended, if possible (e.g., one agent targeting both mood and insomnia, or headache and insomnia).

(INESSS-ONF, 2015)

Suggested tool: Health Canada Indications of Use

T 9.4 C

Individuals with traumatic brain injury and their surrogate decision makers should be made aware when use of medication is “off label” and the consent-to-treatment process should be modified accordingly.

(INESSS-ONF, 2015)

Note: The consent process should include discussion of the rationale with respect to target symptoms/syndrome, the published evidence for the selected treatment, side effects, risks, potential benefits, etc.

Suggested tool: Health Canada Indications of Use

T 9.5 P C

The introduction of medications for individuals with traumatic brain injury should be started at the lowest effective dose and be titrated slowly upwards, based upon tolerability, clinical response and situational urgency. Drug trials should allow adequate duration and dosing. Therapeutic goals should be clearly established and serve as indicators for the efficacy. If those goals are not met, ending the use of medication must be considered.

(INESSS-ONF, 2015)

Suggested tool: Health Canada Indications of Use

T 9.6 C

Serum drug levels in the person with traumatic brain injury should be monitored as necessary to prevent toxicity.

(Adapted from NZGG 2006, 14.4.10. 3, p. 182)

Suggested tool: Health Canada Indications of Use

T 9.7 C

Clinicians should avoid making more than one medication change at a time for a person with traumatic brain injury (i.e., when adding new medications or changing doses). Doing “one thing at a time” will enable more accurate assessment of drug benefits and potential adverse effects (when possible).

(INESSS-ONF, 2015)

Suggested tool: Health Canada Indications of Use


- Brain Trauma Foundation (2007) Section 8. Persistent Mental Health Disorders, Ref 8.7.c


T 9.8 C

Due to potential limits in self-awareness of the patient with traumatic brain injury, collaboration with family and/or significant others, if possible and accepted by the patient, may be useful to monitor the efficacy and side effects of treatment.

(INESSS-ONF, 2015)

Suggested tool: Health Canada Indications of Use

T 9.9 C

Pharmacological treatment of neurobehavioural / mental health or other symptoms following traumatic brain injury should be used with caution and with the knowledge that studies suggest that many medications, including neuroleptics, anxiolytics, and anticonvulsants are associated with slowed recovery after brain injury.

(Adapted from ABIKUS 2007, G15, p. 19)

Suggested tool: Health Canada Indications of Use


- Bhullar et al. (2014)
- Szaflarski et al. (2014)
- Bogner et al. (2015)
- Bhatnagar et al. (2016)
- Plantier and Luauté (2016)

T 9.10 C

If the decision is made to prescribe medication to enhance arousal/awareness in a person with traumatic brain injury, a therapeutic trial (A-B-A design), should be employed, using a single agent at a time, with emphasis on formal monitoring to observe the impact of the medication.

(Adapted from RCP 2013, Section 2; 2.8, p. 34)

Note: A-B-A design refers to a specific type of research design in which there is a baseline period where no treatment is given and/or no variable is introduced (A), followed by a period in which the treatment or variable is introduced (B), and then a period in which the treatment is removed so the behaviour can be observed a second time (A). This way, behaviour can be measured before treatment, during treatment and once treatment is removed.

Suggested tool: Health Canada Indications of Use

T 9.11 C

A person with traumatic brain injury with significant challenging behaviours may require a combination of non-pharmacological and pharmacological approaches for optimal treatment. If possible, a sequenced approach should be used to avoid confounding data and to determine effective components.

(Adapted from NZGG 2006, 6.1.7, p. 103)

Suggested tool: Health Canada Indications of Use

T 9.12 C

Physicians are directed to consult their funder’s formulary for each medication under consideration to determine access to medication and eligibility for funding, as this varies by jurisdiction and funder, and some medications recommended in this guideline may not be funded by the insurer.

(INESSS-ONF, 2015)

Suggested tool: Health Canada Indications of Use

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