CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF ... · Research Excellence on Psychosocial Rehabilitation in Traumatic Brain Injury 2017 Publisher: Murdoch Childrens Research Institute

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CLINICAL PRACTICE GUIDELINEFOR THE MANAGEMENT OFCOMMUNICATION AND SWALLOWINGDISORDERS FOLLOWING PAEDIATRICTRAUMATIC BRAIN INJURY

© Murdoch Childrens Research Institute and the National Health and Medical Research Council Centre of Research Excellence on Psychosocial Rehabilitation in Traumatic Brain Injury 2017

Publisher: Murdoch Childrens Research Institute

Publication date: February 2017

ISBN Print: 978-0-9876209-0-3

ISBN Online: 978-0-9876209-1-0

Suggested citation: Morgan A, Mei C, Anderson V, Waugh M-C, Cahill L, & the TBI Guideline Expert Working Committee. Clinical Practice Guideline for the Management of Communication and Swallowing Disorders following Paediatric Traumatic Brain Injury. Melbourne: Murdoch Childrens Research Institute; 2017.

Steering committee:

Angela Morgan Mary-Clare Waugh

Vicki Anderson Louise Cahill

Project coordinator:

Cristina Mei

Expert working committee:

Jeanette BakerKatie BanerjeeMandy BeatsonCandice BradyKate BrommeyerPetrea CahirCathy CatroppaCynthia Christianto

Suzi DrevensekDonna FallonJane FongRob ForsythMatthew FrithPatricia GrillinzoniFlora HaritouSophie Huntley

Tamara Kelly Kate OslandJessica PalmerClaire Radford Damien RobertsAdam ScheinbergJillian Steadall

Contact:

Murdoch Childrens Research Institute Flemington Road, Parkville Victoria 3052 AustraliaPhone: +61 (3) 8341 6200Fax: +61 (3) 8341 6212Email: [email protected]

Acknowledgements

Sincere thanks to all members of the steering and expert working committees for their invaluable input into developing this guideline. We kindly thank the individuals and organisations that provided feedback on the draft versions of the guideline. This guideline was developed and published by researchers at the Murdoch Childrens Research Institute in collaboration with The Children’s Hospital at Westmead, Lady Cilento Children’s Hospital, The Royal Children’s Hospital (Melbourne), Sydney Children’s Hospital, Auckland District Health Board, Townsville Hospital, Women’s and Children’s Hospital (Adelaide), Newcastle University (UK), Hunter New England Health, Novita Children’s Services, and the Victorian Paediatric Rehabilitation Service.

Disclaimer

This document is a general guide, to be followed subject to the clinician’s judgment and the patient’s preference in each individual case. The guideline is designed to provide information to assist decision-making and is based on the best evidence available at the time of development.

Publication Approval

The guideline recommendations on pages 5–13 of this document were approved by the Chief Executive Officer of the National Health and Medical Research Council (NHMRC) on 13 November 2016 under section 14A of the National Health and Medical Research Council Act 1992. In approving the guideline recommendations, NHMRC considers that they meet the NHMRC standard for clinical practice guidelines. This approval is valid for a period of five years.

NHMRC is satisfied that the guideline recommendations are systematically derived, based on the identification and synthesis of the best available scientific evidence, and developed for health professionals practising in an Australian health care setting.

This publication reflects the views of the authors and not necessarily the views of the Australian Government.

Supporting documents available online at www.mcri.edu.au/TBI-guideline

> Guideline> Administrative Report> Technical Report> Public Consultation Submissions Summary

TABLE OF CONTENTS

Guideline Development Committee 4

1. Summary 5

2. Recommendations for Clinical Question 1: Predictors 5

3. Recommendations for Clinical Question 2: Health Professionals 6

4. Recommendations for Clinical Question 3: Timing of Assessment 7

5. Recommendations for Clinical Question 4: Areas to Assess 8

6. Recommendations for Clinical Question 5: Assessment Tools 9

7. Recommendations for Clinical Question 6: Treatment 10

8. Recommendations for Clinical Question 7: Timing of Treatment 12

9. Recommendations for Clinical Question 8: Information for Parents 13

Clinical Practice Guideline for the Management of Communication and Swallowing Disorders following Paediatric Traumatic Brain Injury

4

Guideline Development CommitteeSteering Committee

A/Prof Angela Morgan (Chair) Speech Pathologist, Murdoch Childrens Research Institute, Victoria

Dr Louise Cahill Speech Pathologist, Lady Cilento Children’s Hospital, Children’s Health Queensland Hospital & Health Service, Queensland

Dr Mary-Clare Waugh Rehabilitation Consultant, Children’s Hospital at Westmead, New South Wales

Professor Vicki Anderson Neuropsychologist, Murdoch Childrens Research Institute, Victoria

Project Coordinator

Dr Cristina Mei Speech Pathologist, Murdoch Childrens Research Institute, Victoria

Expert Working Committee

Ms Jeanette Baker Consumer, New South Wales

Dr Katie Banerjee Rehabilitation Consultant, Children’s Hospital at Westmead, New South Wales

Ms Mandy Beatson Speech Pathologist, Auckland District Health Board, New Zealand

Ms Candice Brady Speech Pathologist, Children’s Hospital at Westmead, New South Wales

Ms Kate Brommeyer Speech Pathologist, Royal Children’s Hospital, Victoria

Ms Petrea Cahir Speech Pathologist, Royal Children’s Hospital, Victoria

A/Prof Cathy Catroppa Psychologist, Murdoch Childrens Research Institute, Victoria

Ms Cynthia Christianto Speech Pathologist, Sydney Children’s Hospital, New South Wales

Ms Suzi Drevensek Speech Pathologist, Children’s Hospital at Westmead, New South Wales

Ms Donna Fallon Physiotherapist, Townsville Hospital, Queensland

Ms Jane Fong Speech Pathologist, Women’s and Children’s Hospital, South Australia

Dr Rob Forsyth Neurologist, Newcastle University, England

Mr Matthew Frith Speech Pathologist, Hunter New England Health, New South Wales

Ms Patricia Grillinzoni Consumer, Victoria

Ms Flora Haritou Speech Pathologist, Royal Children’s Hospital, Victoria

Ms Sophie Huntley Dietitian, Royal Children’s Hospital, Victoria

Ms Tamara Kelly Speech Pathologist, Novita Children’s Services, South Australia

Ms Kate Osland Speech Pathologist, Children’s Hospital at Westmead, New South Wales

Ms Jessica Palmer Speech Pathologist, Townsville Hospital, Queensland

Ms Claire Radford Speech Pathologist, Lady Cilento Children’s Hospital, Queensland

Mr Damien Roberts Speech Pathologist, Royal Children’s Hospital, Victoria

A/Prof Adam Scheinberg Paediatric Rehabilitation Specialist, Statewide Medical Director, Victorian Paediatric Rehabilitation Service, Victoria

Ms Jillian Steadall Speech Pathologist, Royal Children’s Hospital, Victoria

SHORT FORM GUIDELINE 5

1. Summary

This document provides a summary of the recommendations for managing communication and swallowing disorders following paediatric traumatic brain injury (TBI). Recommendations were developed by a multidisciplinary guideline development committee. The committee consisted of national and international health experts within the field, and consumers represented by parents of a child with TBI. The methods used to develop the recommendations are detailed in section 1.8 of the guideline document and in the Technical Report available at www.mcri.edu.au/TBI-guideline. Recommendations were developed based on a systematic review of the available evidence and a Delphi survey completed by the guideline development committee. The systematic review provided the basis for evidence-based recommendations (EBRs) and the Delphi survey informed the development of consensus-based recommendations (CBRs).

The developed recommendations for each clinical question are provided below. The following is listed for each recommendation:

• Recommendation type: consensus-based recommendation (CBR) or evidence-based recommendation (EBR)

• The NHMRC grade for each EBR

• The section and page number of the guideline document that provides further information about the recommendation

2. Recommendations for Clinical Question 1: Predictors

What factors (e.g., injury or child related) predict the likelihood of developing a speech, language or swallowing disorder following a TBI compared to children with a TBI who do not develop these disorders or typically developing children?

Recommendation Type Grade Section Page

Prognostic data is limited to guide speech, language and swallowing disorders. The following variables may be considered by speech-language pathologists and medical specialists when determining prognosis:

• Extent and severity of brain damage (including size and site of lesion(s)) and other proxy measures e.g., Glasgow Coma Scale score, length of ventilation and intubation, loss of consciousness and length of post traumatic amnesia, brain surgery required post-injury, raised intracranial pressure

• Cause of TBI

• Cranial nerve involvement/palsy (speech and swallowing only)

• Presence of seizures or other co-morbid medical conditions (e.g., loss of hearing or smell)

• Extent of broader motor system involvement

• Additional physical/facial injuries (speech and swallowing only)

• Trajectory of recovery post-injury (i.e., rapid vs. slow recovery in early phases)

• Cognition (including visual and auditory system integrity, memory, attention, initiation, level of insight)

• Compliance to recommendations

• Age/developmental stage at injury and pre-morbid functioning

• Psychosocial support and pre-morbid family and social environment

CBR N/A 3 24


6


Language recommendations

Children with severe TBI show the poorest language outcomes (moderate to high risk of bias). We suggest that speech-language pathologists should screen and monitor children with severe TBI for language deficits (see clinical question 3 for timing of assessment).

EBR C 3 24

Variables specific to predicting language disorders include the extent of damage to key brain regions underpinning language function (e.g., left hemisphere, corpus callosum, arcuate fasciculus, inferior frontal and temporal regions) and the presence of mutism.

CBR N/A 3 24

Speech recommendations

Variables specific to predicting speech disorders include the extent of damage to key brain regions underpinning speech/motor function (e.g., supplementary motor area, motor cortex, corticobulbar/corticospinal tract) and presence of mutism. Research shows left posterior limb of the internal capsule injury predicts poorer chronic speech outcome.

CBR N/A 3 24

Swallowing recommendations

The evidence suggests that the presence of dysphagia is associated with severe TBI and a longer ventilation period (>1.5 days) (low to moderate risk of bias). Evidence also suggests that children with dysphagia have a longer hospitalisation period and are more likely to have motor impairments than controls (low risk of bias). In addition, the resolution of dysphagia is correlated with the resolution of cognitive functioning and oral motor impairment (moderate risk of bias). We suggest that children with severe TBI and a ventilation period of greater than 1.5 days be screened by a speech-language pathologist for swallowing deficits (see clinical question 3 for timing of assessment).

EBR D 3 24

Variables specific to predicting swallowing disorders include the extent of damage to key brain regions underpinning swallowing function (e.g., brainstem, primary motor and sensory cortices). Research has shown that a Glasgow Coma Scale score of <8.5 and ventilation period of >1.5 days predicts the presence of dysphagia.

CBR N/A 3 24

3. Recommendations for Clinical Question 2: Health Professionals

Which health professionals (medical and allied health) should be involved in assessment and treatment of speech, language and swallowing disorders, and at what time/stage during recovery should a referral be made to each professional group, compared to routine clinical care, to improve children’s outcomes?


Speech-language pathologists and medical specialists and staff (e.g., doctors and nurses) are essential for the management of speech, language and swallowing disorders, and should be referred during the acute stage. Children with a moderate or severe TBI should be referred by a medical or health professional to a speech-language pathologist during the acute phase (0 to 2 weeks) as per clinical question 3.

CBR N/A 4 27



Other health professionals that are important depending on the child’s presentation and referral include:

• Neuropsychologist or psychologist (referred by a medical or health specialist once patient is medically stable)

• Occupational therapist (referred by a medical or health specialist from acute only if indicated)

• Physiotherapist (referred by a medical or health specialist from acute only if indicated)

• Ear, nose and throat specialist (referred by a medical or health specialist only if indicated for swallowing or speech patients post-extubation)

• Dietitian (referred by a medical or health specialist only if indicated for swallowing patients or weight management)

• Radiologist (referred by a speech-language pathologist only if indicated for swallowing patients e.g., videofluoroscopy)

• Music therapist (referred by a medical or health specialist from acute only if indicated).

CBR N/A 4 27

4. Recommendations for Clinical Question 3: Timing of Assessment

At what time and/or stage (e.g., intensive care, acute care vs pre- and post-discharge) during the first year of recovery should children at risk of speech, language and swallowing disorders be assessed for these impairments to improve children’s outcomes in speech, language and swallowing?


Children with a moderate or severe traumatic brain injury should be assessed by a speech-language pathologist for speech, language and swallowing during the acute phase of care (typically 0 to 2 weeks). Regular monitoring (i.e., on referral and transfer to rehabilitation, and prior to discharge) should continue throughout inpatient and community rehabilitation.

CBR N/A 5 28

For language, an informal assessment should occur by a speech-language pathologist (SLP) within the first 2 days of admission or once the child is alert and medically stable, to track recovery and assist in therapy planning. Children should then be monitored by a SLP at least weekly for informal language performance.

CBR N/A 5 28

For speech, children should be screened by a speech-language pathologist (SLP) within the first 2 days of admission or once the child is alert and medically stable, to track recovery and assist in therapy planning. Children should then be monitored by a SLP at key transition points (from paediatric intensive care unit to inpatient ward, from inpatient ward to day hospital/rehab, to outpatients).

CBR N/A 5 28

Speech-language pathologists (SLP) should not administer a standardised language assessment earlier than 6 to 8 weeks post emergence from post-traumatic amnesia. Speech and language assessment (where clinically indicated) should then occur at key transition points by a SLP (e.g., discharge from inpatient ward, hospital discharge back to the community). Speech and language review may be required at 3 to 6 months post-discharge, and then annually if deficits are ongoing. Formal language assessment is recommended prior to primary school, and then again before entry to high school, or when concerns are identified by the family or the rehabilitation team.

CBR N/A 5 28


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For swallowing, an initial assessment by a speech-language pathologist (SLP) should occur within the first 2 days post-extubation and once the patient is alert and medically stable. If a swallowing disorder is present, the patient should then be monitored by a SLP at least weekly throughout the acute and inpatient rehabilitation phases and assessed on discharge. SLPs should then review the child as needed if there are persistent feeding difficulties on discharge (e.g., consider objective assessment on discharge and review again at 12 months depending on recovery).

CBR N/A 5 28

5. Recommendations for Clinical Question 4: Areas to Assess

What are the specific areas of speech, language and swallowing that should always be assessed in children with TBI with disorders in these areas during the first year following TBI (compared to children with TBI without these disorders) to enable an accurate diagnosis?


Language recommendations

When assessing a child, speech-language pathologists (SLPs) might take into consideration that TBI can affect multiple areas of language and cognitive abilities underpinning language. During the child’s initial assessment (0 to 2 weeks post-injury as per clinical question 3), we suggest that SLPs conduct a brief assessment into all areas of language in all children following moderate and severe TBI (i.e., semantics, syntax, morphology, phonology and pragmatics) including narrative and word finding skills.

EBR D 6 30

Speech-language pathologists should assess the following areas of language via formal or informal assessment during the time frames specified under clinical question 3 or as applicable:

• Pre-verbal communication skills (depending on the patient’s age and level of functioning)

• Spoken and written expressive and receptive language including:

− Discourse and narratives

− Attention, memory, executive functioning

− Impact on social skills and learning

− Word finding ability

• Functional communication (e.g., conversational and social skills)

• Ability to use augmentative and alternative communication if necessary

• Patient’s insight into deficits where appropriate (after approximately 4 years of age)

CBR N/A 6 30

Speech recommendations

When assessing a child, speech-language pathologists (SLPs) might take into consideration that TBI can affect multiple areas of speech. During the child’s initial assessment (0 to 2 weeks post-injury as per clinical question 3), we suggest that SLPs conduct a brief assessment of all areas of speech in all children following moderate and severe TBI (i.e., articulation, oral motor function, respiration, resonance, prosody, phonation, fluency).

EBR D 6 30



Speech-language pathologists should assess the following areas of speech via formal or informal assessment during the time frames specified under clinical question 3 or as applicable:

• Speech sound development relative to peers (articulation and phonological ability)

• Voice disorder

• Motor speech (i.e., presence of dysarthria, apraxia of speech or stuttering, oral motor functioning)

• Overall intelligibility of speech

• Insight and self-monitoring where appropriate (after approximately 4 years of age)

CBR N/A 6 30

Swallowing recommendations

When assessing a child, speech-language pathologists (SLPs) might take into consideration that TBI can affect multiple areas of swallowing. During the child’s initial assessment (0 to 2 weeks post-injury as per clinical question 3), we suggest that SLPs assess core oral-pharyngeal phases of swallowing in all children following moderate and severe TBI (i.e., oral preparation, oral and pharyngeal).

EBR D 6 30

Speech-language pathologists should assess the following areas of swallowing via formal or informal assessment during the time frames specified under clinical question 3 or as applicable:

• Cognitive-behavioural (including medical state, level of alertness/fatigue, behaviour, self-monitoring/insight and pace of eating)

• Posture/positioning and tone

• Respiratory function

• Bulbar and oral motor assessment (feeding and non-feeding)

• Oral phase (particularly for effectiveness of oral transit)

• Pharyngeal phase (particularly for swallow initiation and signs of aspiration)

• Need for non-oral feeding

CBR N/A 6 30

6. Recommendations for Clinical Question 5: Assessment Tools

What assessment tools are available to accurately diagnose speech, language and swallowing disorders in the first year following TBI when compared against a reference standard or in the absence of a reference standard?


Speech-language pathologists may use a range of informal and formal measures to assess speech, language and swallowing. Assessment of dysarthria should include perceptual and (where appropriate and available to the centre) instrumental methods.

CBR N/A 7 34

Instrumental assessments of voice or swallowing disorder (including Fiberoptic Endoscopic Evaluation of Swallowing or videofluoroscopy) should be used if clinically indicated (e.g., signs of aspiration). Voice may also be assessed on Visi-Pitch or other similar systems.

CBR N/A 7 34

Outcome measures (including Australian Therapy Outcome Measures (AusTOMS), Dysphagia Management Staging Scale, Oropharyngeal Swallow Efficiency, Goal Attainment Scales) should be used to document speech, language and swallowing outcomes pre- and post-therapy.

CBR N/A 7 34


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7. Recommendations for Clinical Question 6: Treatment

What are the effective treatment strategies and techniques to treat speech, language and swallowing disorders in the first year following TBI, and the particular deficits within each of these areas compared to no treatment, to improve children’s speech, language and swallowing outcomes?


A number of guiding principles are key across management of speech, language and swallowing including: use it or lose it, use it and improve it, specificity, repetition matters, intensity matters, time matters, salience matters, age matters, transference, and interference (Kleim & Jones, 2008).

CBR N/A 8 36

Language disorders should be managed by speech-language pathologists (see clinical question 7 for timing) using the most efficacious evidence-based approach for the specific area of deficit, some strategies may include:

• Pre-verbal/early communication

− Language stimulation

− Vocabulary intervention

• Spoken and written expressive and receptive language

− Scaffolding techniques (including binary choices, prompting, cues, priming (semantic, phonemic), sentence completion, visual supports/information, chunking information, errorless teaching)

− Semantic, syntactic programs (including semantic feature analysis, concept mapping)

− Word finding intervention (including confrontation naming)

− Literacy intervention (including reading and writing, narratives, parsing whole paragraphs, reading comprehension, use of iPads/laptops)

− High level language skills

• Functional communication

− Social skills training (e.g., Stop-think-do, Topic Talk)

− Gesturing

− Picture boards

− Functional tasks

• Augmentative and alternative communication (e.g., communication board) if required

• Other

− Cognitive therapy (can be delivered by a speech-language pathologist. Where possible, this should occur in consultation with a psychologist)

− Communication partner education and training

− Education to school staff, teacher aide support

− Medications indicated by medical staff (e.g., stimulants) to assist attention and concentration

CBR N/A 8 36



Speech disorders should be managed by speech-language pathologists (see clinical question 7 for timing) using the most efficacious evidence-based approach for the specific area of deficit, some strategies may include:

• Articulation or phonological therapy (i.e., speech sound disorder therapy) if indicated

• Dysarthria or dyspraxia therapy (i.e., motor speech therapy) e.g., Lee Silverman Voice Treatment, Nuffield and compensatory strategies such as slow rate, over articulate, stress syllables

• Augmentative and alternative communication

• Activity and participation

• Communication partner education and training

CBR N/A 8 36

Swallowing disorders should be managed by speech-language pathologists (see clinical question 7 for timing) using the most efficacious evidence-based approach for the specific area of deficit, some strategies may include:

• Postural/positioning modifications

• Environmental set-up/supports

• Cognitive (managed by a speech pathologist with referral to other health professionals where warranted)

− Management of behaviour, impulsivity, fatigue, awareness/cognition

− Pacing and timing strategies

Oral preparatory phase

• Oral motor stimulation and exercises, systematic desensitization, jaw support, visual feedback for chewing

• Modification of utensils/specialised feeding

• Texture/consistency/food/fluid modification

Oral phase

• Verbal prompts (e.g., take smaller mouthfuls, multiple swallows to clear residue)

• Texture/consistency/food/fluid modification

Pharyngeal phase

• Texture/consistency/food/fluid modification, nil by mouth

• Swallow maneuvers/postures (including head turn, chin tuck, multiple swallows, supraglottic swallow, effortful swallow, mendelsohn maneuver, strong swallowing)

• Supplemental/alternate feeding options (e.g., nasogastric tube, gastrostomy) if indicated by relevant multidisciplinary team (e.g., dietitian, nurse, medical officer)

Other

• Parent/caregiver and staff education/training (e.g., around feeding modifications or strategies)

CBR N/A 8 36


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8. Recommendations for Clinical Question 7: Timing of Treatment

What time frame and/or stage (acute vs rehabilitation) should treatment for speech, language and swallowing occur for children with impairments in these areas in the first year following TBI to improve their outcomes?


Speech-language pathologists should commence treatment for speech, language and swallowing disorders in the acute stage once the patient is medically stable. In the early stages post-injury, priority may be given to swallowing and functional communication.

CBR N/A 9 40

For speech and language disorders, treatment (i.e., cueing and educating families about interventions) can occur whilst the child is in post-traumatic amnesia (where appropriate). Formal treatment directed towards the child’s impairment should commence after the patient has emerged from post-traumatic amnesia. The patient should receive regular therapy from local services post-rehab discharge (if available).

CBR N/A 9 40

For swallowing disorders, treatment should occur post-extubation, when the patient is alert and able to manage their own secretions, and is responding appropriately to automatic movements. Treatment may commence with a tracheostomy in situ (if a child is chronically unable to manage their own secretions) with treatment focusing on tracheostomy management and education.

CBR N/A 9 40


9. Recommendations for Clinical Question 8: Information for Parents

What information about the management and prognosis of speech, language and swallowing disorders would parents benefit from during the first year of recovery compared to routine or no information to improve children’s speech, language and swallowing outcomes?


Speech-language pathologists and medical specialists should provide parents/caregivers and educators with accurate information tailored to the child to support their recovery. This information should be provided following the child’s initial assessment with a speech-language pathologist or as appropriate. Parents/caregivers would benefit from the following forms of information about speech, language and swallowing disorders during the first year of recovery:

• Explanation of aetiology and possible impacts for speech, language and swallowing (e.g., injury severity, impact of cognitive deficits, physiology for swallowing in regard to motor abilities) so family or teachers can understand the 'why' of what they see

• Define speech, language and swallowing as relevant, and explain the patient’s specific diagnoses and specific likely difficulties and what to expect over the coming year, including:

− Managing social isolation

− Managing fatigue for speech, language and swallowing

− Rate of recovery

• Impact on social skills and importance of socialising, play dates, thinking games, conversational scaffolding and practice, and encouraging development

• When to intervene and factors that help predict outcomes into the longer term (where known) including patient engagement in treatment

• Impact of monitoring and supporting

• How to be a supportive communication partner and how to monitor, seek help, and support and advocate for their child

• How to integrate back to school

CBR N/A 10 40

CLINICAL PRACTICE GUIDELINEFOR THE MANAGEMENT OFCOMMUNICATION AND SWALLOWINGDISORDERS FOLLOWING PAEDIATRICTRAUMATIC BRAIN INJURY

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CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF ... · Research Excellence on Psychosocial Rehabilitation in Traumatic Brain Injury 2017 Publisher: Murdoch Childrens Research Institute