Behavioral disorders after severe traumatic brain injury represent common important sequelae. They can occur at any time during the evolution phases and interfere in all domains of life and relationships with others. They represent a subjection for families, societies and impair the quality of the reinsertion. They often constitute a reason for refusing to admit or even excluding patients from healthcare, medicosocial, family and professional structures. The management of these disorders is not simple nor standardized and it is being confronted to the diversity and low efficacy of the usual therapeutics. Several actors in the healthcare, social, work, evaluation and justice fields have expressed their disarray concerning the management of these patients and have requested a protocol or guidelines to approach in a logical manner these behavioral disorders and treat them in the best way possible.
The French Society of Physical Medicine and Rehabilitation (SOFMER) evaluated the importance of this issue and initiated a 2-step process. The first step was a conference in Nantes in October 2011 on the topic “behavioral disorders after traumatic brain injury: what are the therapeutic options?” that gathered 25 speakers and 250 participants. The second step was writing Best Practices Recommendations following the requests of the UNAFTC family association (Union Nationale des Associations de famille des Traumatisés Crâniens), France Brain Injury (France Traumatisme Crânien) and the Association for the Reinsertion of Patients with Traumatic Brain Injury in the Atlantic Region (ARTA) under the auspices of the French High Authority for Health.
Best practices recommendations (BPR) are defined in the healthcare field as “recommendations developed according to a strict methodology to help physicians and patients seek the most appropriate care according to a given clinical circumstance. There are numerous stakes concerning the quality of the healthcare and medicosocial care as well as the economic approach. These best practices recommendations are geared towards improving care management quality and safety”. The following 6 articles are the essence of this work, each of them being the expression of an answer given to one of the 6 questions previously formulated in a Scoping Letter validated by the French High Authority for Health (HAS) Committee.
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Methodology
Best practices recommendations were designed according to the methodology defined by the HAS (see: http://www.has-sante.fr/portail/jcms/c_431294/recommandations-pour-la-pratique-clinique-rpc; the website of the French High Authority for Health (HAS) gives access to these documents in English). Writing these guidelines involves several steps and must abide by procedures and interventions of several different, independent actors without any conflicts of interest. Here are the main modalities.
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The first step is writing a Scoping Letter defining the heart and contours of the subject, its objectives and limitations. Between November 2011 and July 2012 a “Steering Committee” wrote this Scoping Letter proposing 6 objectives or questions validated by the HAS commission of care management strategies and best practices. 1. What are the types of disruptive symptoms accessible to treatment? 2 Which evaluations should be used? 3 Which non-pharmacological care techniques and interventions can we propose? 4. What pharmacological treatments can we recommend? 5. Can we define care management strategies? 6. How to prevent and organize the follow-up of these behavioral disorders?
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The Systematic Literature Review and synthesis yielded and selected articles, reviews and books representing the recent synthesis of the knowledge on the questions asked, updated in 2012. It was conducted with the help of a librarian from the HAS. She used the Medline database covering the period from January 1990 to February 2012. The research combinations, detailed in each of the articles of this special issue crossed inclusion keywords with exclusion ones. The Medline search was not only limited to relevant meta-analyses. Other references were consulted such as systematic reviews of the literature like Cochrane, national or international guidelines from governmental or independent agencies not financially supported by the industry, such as the Alzheimer’s clinical practices guidelines from the HAS, and non-periodical publications with references pertaining to the previous articles. In fine the analysis of titles, abstracts and reputation of authors allowed the reduction of references following the Prisma Flow Diagram. For each article an independent additional research was conducted by the authors to include important articles that could have been published between 2012 and June 2015.
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Each article selected was analyzed by theme and according to the principles of the critical reading of the literature using reading grids, in order to attribute to each article a scientific evidence grade ( Table 1 ).
Table 1
Levels of evidence and grades of recommendations.Related posts:
Behavioral disorders after traumatic brain injury: Why a special issue in the Annals of Physical and Rehabilitation Medicine?
The evaluation of behavioural changes in brain-injured patients: SOFMER recommendations for clinical practice
Drugs for behavior disorders after traumatic brain injury: Systematic review and expert consensus leading to French recommendations for good practice
Behavioral and affective disorders after brain injury: French guidelines for prevention and community supports
France establishes guidelines for treating neurobehavioral disorders following traumatic brain injury
Care management of the agitation or aggressiveness crisis in patients with TBI. Systematic review of the literature and practice recommendations
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