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Introduction

A report prepared by La Société Française de Médecine Physique et de Réadaptation (SOFMER) in response to the Haute Autorité de santé in France provides clinicians and researchers with accessible, up-to-date, evidenced-based guidelines on the classification and clinical management of neurobehavioral disorders following severe traumatic brain injury (TBI). This consensus document synthesizes contributions by a multidisciplinary committee representing clinicians and investigators. Through their deliberations, this committee of TBI specialists achieved a common ground on the classification and clinical management of neurobehavioral sequelae (i.e., disorders of comportment during the post-acute and chronic stages of severe TBI). In this scholarly report, the committee has provided readers with clear definitions of the disorders.

Although a comparable document on this topic has not, to my knowledge, been disseminated in North America, the Brain Injury Association of America in association with Mount Sinai Medical Center in New York has initiated the project “Guidelines for the Rehabilitation and Chronic Disease Management of Adults with Moderate to Severe TBI”. This project is currently compiling questions to be addressed by panels of rehabilitation experts concerning issues in the behavioral, cognitive, functional, medical, and participation/vocational domains. The project is soliciting feedback from the rehabilitation community to revise questions drafted in each domain and review additional questions ( http://www.biausa.org/TBIGuidelines/tbi-rehabilitation-guidelines_feedback ).

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Recent North American projects related to the SOFMER report

Published reviews by groups working to develop guidelines or at least a consensus on clinical management of cognitive and behavioral problems from TBI include the 2006 Warden et al. seminal review of pharmacologic therapy for neurobehavioral sequelae of TBI. The authors reviewed the evidence supporting specific drugs for treatment of poor attention and slowed processing speed, other cognitive deficits, aggression, depression, anxiety, and other psychiatric conditions after TBI. At the time of their review, Warden et al. noted that the evidence was especially robust for treating attentional disturbance with methylphenidate, but they emphasized the general need for additional randomized clinical trials (RCTs) to provide a more evidenced-based approach to pharmacologic treatment. In contrast, the Frenette et al. review of dopaminergic medications for treating neurobehavioral sequelae of TBI was more critical. The authors noted the heterogeneity in methods across clinical trials (e.g., different outcome measures) and were guarded concerning whether the current evidence supported clinical guidelines for the medications that they reviewed.

Recommendations from the recent review of pharmacologic management of cognitive impairment by Arciniegas and Silver were similar to those by SOFMER, including caution about the use of neuroleptics, benzodiazapine, anticonvulsants, and anticholinergics. Arciniegas and Silver also highlighted the evidence for the effectiveness of amantadine in treating disorders of consciousness; they advocated for non-pharmacologic interventions such as environmental changes and cognitive training, a perspective consistent with SOFMER. The Wheaton et al. meta-analysis focused on treating cognitive deficit and supported methylphenidate for treating attention and slowed cognitive processing. In 2011, the US National Academy of Science published a report by a multidisciplinary panel that evaluated the evidence for cognitive rehabilitation of TBI patients, with an emphasis on mild TBI . The panel concluded that the evidence provided limited support for specific interventions to treat problems in attention, executive function, memory and communication. However, it also noted the need for clinical trials to standardize treatments using manuals that are accessible to other investigators, developing a common registry or linked registries of rehabilitation outcome data to facilitate meta-analyses, and bridging the gap between standard outcome measures and evaluation of everyday functioning.

Guidelines for the management of sports concussion have been published by the Fourth International Conference on Concussion in Sport and the American Academy of Neurology . Protocols for concussion management in North America are well established and widely followed but still lack support by rigorous RCTs. The international sports concussion literature suggests that concussion management protocols may be less widely implemented in Europe than in North America, but I am not aware of any surveys of trainers and physicians to compare practices across these continents.

The ongoing NIH-supported TRACK-TBI project is a multinational research consortium using advanced brain imaging and longitudinal follow-up of a large cohort to study the outcomes of TBI and the neural underpinnings of the sequelae . In time, this approach may extend to rehabilitation and hopefully address guidelines for clinical management of post-acute and chronic, severe TBI .

2

Recent North American projects related to the SOFMER report

Published reviews by groups working to develop guidelines or at least a consensus on clinical management of cognitive and behavioral problems from TBI include the 2006 Warden et al. seminal review of pharmacologic therapy for neurobehavioral sequelae of TBI. The authors reviewed the evidence supporting specific drugs for treatment of poor attention and slowed processing speed, other cognitive deficits, aggression, depression, anxiety, and other psychiatric conditions after TBI. At the time of their review, Warden et al. noted that the evidence was especially robust for treating attentional disturbance with methylphenidate, but they emphasized the general need for additional randomized clinical trials (RCTs) to provide a more evidenced-based approach to pharmacologic treatment. In contrast, the Frenette et al. review of dopaminergic medications for treating neurobehavioral sequelae of TBI was more critical. The authors noted the heterogeneity in methods across clinical trials (e.g., different outcome measures) and were guarded concerning whether the current evidence supported clinical guidelines for the medications that they reviewed.

Recommendations from the recent review of pharmacologic management of cognitive impairment by Arciniegas and Silver were similar to those by SOFMER, including caution about the use of neuroleptics, benzodiazapine, anticonvulsants, and anticholinergics. Arciniegas and Silver also highlighted the evidence for the effectiveness of amantadine in treating disorders of consciousness; they advocated for non-pharmacologic interventions such as environmental changes and cognitive training, a perspective consistent with SOFMER. The Wheaton et al. meta-analysis focused on treating cognitive deficit and supported methylphenidate for treating attention and slowed cognitive processing. In 2011, the US National Academy of Science published a report by a multidisciplinary panel that evaluated the evidence for cognitive rehabilitation of TBI patients, with an emphasis on mild TBI . The panel concluded that the evidence provided limited support for specific interventions to treat problems in attention, executive function, memory and communication. However, it also noted the need for clinical trials to standardize treatments using manuals that are accessible to other investigators, developing a common registry or linked registries of rehabilitation outcome data to facilitate meta-analyses, and bridging the gap between standard outcome measures and evaluation of everyday functioning.

Guidelines for the management of sports concussion have been published by the Fourth International Conference on Concussion in Sport and the American Academy of Neurology . Protocols for concussion management in North America are well established and widely followed but still lack support by rigorous RCTs. The international sports concussion literature suggests that concussion management protocols may be less widely implemented in Europe than in North America, but I am not aware of any surveys of trainers and physicians to compare practices across these continents.

The ongoing NIH-supported TRACK-TBI project is a multinational research consortium using advanced brain imaging and longitudinal follow-up of a large cohort to study the outcomes of TBI and the neural underpinnings of the sequelae . In time, this approach may extend to rehabilitation and hopefully address guidelines for clinical management of post-acute and chronic, severe TBI .