Ontario Neurotrauma Foundation

Clinical Practice Guideline

For the rehabilitation of Adults with Moderate to Severe TBI

Ontario Neurotrauma Foundation INESSS

About the guideline

Guidelines are tools for improving health care and assisting health care professionals to make clinical decisions based on scientific evidence and expert opinions. The most important benefit of CPGs are their potential to improve both the quality and consistency of care provided by healthcare professionals and resulting patient health outcomes. Their beneficial effects, however, are contingent on not only a methodologically rigorous guideline development process that incorporates the best evidence available, but also successful implementation of the resulting recommendations and associated tools.

The INESSS-ONF Guideline was designed to provide evidence based recommendations for rehabilitation services for adults having sustained a moderate to severe traumatic brain injury (TBI). The guideline:

  • Contains recommendations for rehabilitative care provided to adults with TBI and is not focused on care for children and adolescents.

  • Does not pertain to assessment and management of individuals who have sustained concussion (mild traumatic brain injury).

  • Is focused primarily on Ontario and Quebec, but can be of use across Canada.  Several previous guidelines for rehabilitation of persons with TBI exist, but were not recently developed or adapted to the Canadian context.

  • Was developed to inform rehabilitative care provided in acute settings (early rehabilitation) and rehabilitation facilities (post-acute inpatient or outpatient services) within the publicly funded sector.

  • Is also applicable to the provision of community based rehabilitation, whether such services are publicly funded, or 3rd party funded and privately delivered.

  • Contains many recommendations that are pertinent to the continuum of rehabilitative care.

Target Population and Audience

The present guideline is appropriate for use with adults (i.e. 18 to 65 years old) who have sustained a moderate to severe traumatic brain injury (TBI).

The primary users targeted by the INESSS-ONF Guideline are  healthcare professionals and managers providing rehabilitation services to individuals having sustained a moderate to severe TBI, in both:

  • Acute care settings (early rehabilitation)

  • Rehabilitation facilities (post-acute inpatient or outpatient services)

The Guideline is also applicable to providers in community-based rehabilitation, and support workers who provide rehabilitation and medical care for traumatic brain injury patients:

  • Rehabilitation professionals working in the private sector with patients who have sustained a moderate to severe TBI

  • Social workers, nurses, family physicians and other specialists (e.g., psychiatrists, physiatrists, urologists, etc.) who provide psychosocial and medical care to patients after they have completed formal rehabilitative care. 

  • Community workers and other paraprofessionals working in brain injury associations and support groups with individuals with moderate to severe TBI and their families/caregivers.

The Guideline may also be used by other stakeholders (policy makers, funding bodies) and adult individuals with moderate to severe TBI and their families/caregivers who may wish to know more about best practices in rehabilitation. 

Directives for Use

The INESSS-ONF Guideline is divided in two sections: Section I: Components of the Optimal TBI Rehabilitation System and Section II: Assessment and Rehabilitation of Brain Injury Sequelae.

A subset of 11 of the 266 recommendations are identified as "fundamental" to optimal rehabilitation service delivery for this clientele, while another group of 106 recommendations are categorized as "priority" practices to be put in place in order to improve service quality and effectiveness. Original recommendations newly developed by the expert panel (i.e. not adapted from existing CPG’s) are identified as “novel”. Each section presents the list of recommendations accompanied by short discussions concerning the rationale, the system implications, suggested key indicators and the summary of evidence supporting the recommendations.  Ongoing development of the guideline will allow the addition of tools and implementation resources.  Note that these pertain to the section as a whole.

Users wanting to find recommendations pertaining to a specific issue can click on any subsection in Sections I or II, which are further divided into numbered components. Users wanting to find recommendations on specific topics can also use the Search Function to enter by keyword, or can click one or more of the Tags listed below to limit or filter the information being sought.  Recommendations that are relevant to the keyword search or the tags will appear.

Users will have the opportunity to print off specific sections or searches through the “Save or print this page” option.  The full guideline can be found as a pdf format document in the “Guideline Components” menu bar, under Recommendations. (this is a large document). Also available as a pdf document are all fundamental and priority recommendations.  

Limitations of Use

The content of these guidelines are based on the scientific knowledge available at the time of their finalization (2015) as well as on the opinion of the experts who participated in the development of the guidelines.  Choices reflected in these guidelines do not preclude the possibility of other approaches or practices also being valid and relevant. Healthcare professionals must at all times use their clinical judgment and consider other factors such as patient preferences and resource availability in applying these recommendations. Moreover, healthcare professionals must at all times respect the legal and normative regulations of the regulatory bodies, in particular with regards to scopes of practice and restricted/protected activities, as these may differ provincially.  

Clinicians should use caution in using most published standardized, norm-referenced tests for the evaluation and assessment of persons with traumatic brain injury. Many of the tests recommended by publishers, distributors, and clinicians were not developed for persons with traumatic brain injury and do not address traumatic brain injury in their development or standardization.

The developers, contributors and supporting partners shall not be liable for any damages, claims, liabilities, costs or obligations arising from the use or misuse of this material, including loss or damage arising from any claims made by a third party.

Continuous improvements and updates

This Guideline was issued in September 2016 and will be reviewed in 2020 or sooner if new evidence becomes available.

INESSS and ONF invite user feedback to the Guideline through a Feedback Form available on most pages on the website.  Any errors identified or need to amend the guideline due to changes in evidence will be considered by ONF and INESSS on a quarterly basis.  Changes made to the guideline as a result will be identified as revised content on the website.