Institutional members access full text with Ovid®

Share this article on:

Management of Spasticity in Moderate and Severe Traumatic Brain Injury: Evaluation of Clinical Practice Guidelines

Pattuwage, Loyal MBBS, MPH; Olver, John MBBS, MD, FAFRM (RACP); Martin, Caius MBBS; Lai, Francis MBBS; Piccenna, Loretta PhD; Gruen, Russell MBBS, PhD; Bragge, Peter PhD

The Journal of Head Trauma Rehabilitation: March/April 2017 - Volume 32 - Issue 2 - p E1–E12
doi: 10.1097/HTR.0000000000000234
Focus on Clinical Research and Practice, Part 1

Introduction: Moderate to severe traumatic brain injury (TBI) can result in development of spasticity, which adversely affects function and quality of life. Given the foundation of optimal clinical practice is use of the best available evidence, we aimed to identify, describe, and evaluate methodological quality of evidence-based spasticity clinical practice guidelines (CPGs).

Methods: A comprehensive search for CPGs encompassed electronic databases and online sources. Eligible CPGs were evaluated using the validated Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument.

Results: Five CPGs were eligible for review; 2 were specific to acquired brain injury and 1 to TBI. The 3 brain injury-specific CPGs contained 423 recommendations overall, but only 8 spasticity recommendations. On the basis of AGREE appraisals, all CPGs performed well in the areas of reporting scope and purpose; clearly presenting recommendations; including various stakeholders in the CPG development process; and reporting conflict of interest. However, only one CPG performed adequately on describing facilitators and barriers to implementation, advice, and tools on how to implement recommendations and provision of audit criteria. Intraclass correlation coefficient (ICC) for agreement between raters showed high agreement (ICC > 0.80) for most guidelines.

Conclusion: Given the unique etiological features and treatment challenges associated with managing spasticity after TBI, more TBI-specific spasticity CPGs are required. These should incorporate information on the facilitators and barriers to implementation, advice on implementing recommendations, and audit criteria.

Supplemental Digital Content is Available in the Text.

National Trauma Research Institute, Monash University, Alfred Hospital, Melbourne, Victoria, Australia (Dr Pattuwage); Epworth Hospital, Monash University, Richmond, Victoria, Australia (Dr Olver); Monash Health, Melbourne, Victoria, Australia (Dr Lai); Monash University, Melbourne, Victoria, Australia (Dr Martin); School of Allied Health, La Trobe University, Melbourne, Victoria, Australia (Dr Piccenna); Nanyang Technological University, Singapore (Dr Gruen); and Monash Sustainability Institute, Monash University, Melbourne, Victoria, Australia (Dr Bragge).

Corresponding Author: Loyal Pattuwage, MBBS, MPH, National Trauma Research Institute, Monash University and the Alfred Hospital, Level 1, 549 St Kilda Rd, Melbourne, Victoria 3004, Australia (

This project was funded by the Victorian Transport Accident Commission as part of a project entitled “Harnessing Victoria's Neurotrauma Expertise: Promoting Excellence and Realising Value.”

John Olver does consulting work and teaching for Ipsen and Allergan.

Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

The authors declare no conflicts of interest.

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.