Rehabilitation Program

Physical Therapy

Severe episodes of ADS may preclude or delay any of the components of a contemporary, multidisciplinary rehabilitation program. Physical therapy sessions may have to be held episodically because labile blood pressure, ICP, heart rate, and temperature may prevent participation. Of course, it is preferable to continue not only with passive range of motion (PROM) but also with as much of the functional program as possible; monitor these symptoms during therapy.

A study by Sorek et al found that after 8 weeks of rehabilitation in children with severe TBI, the cardiac autonomic control system (CACS) underwent a partial recovery. Specifically, heart rate variability (HRV) in response to autonomic tests (handgrip and paced breathing tests) increased, although the HRV values at rest did not change from the pre-rehabilitation values.^[12]

Occupational Therapy

Continue occupational therapy as regularly as possible, with the same considerations as for physical therapy.

Speech Therapy

Patients with ADS usually have severe impairment of alertness. Thus, speech therapy may not yet be appropriate.

Medical Issues/Complications

Severe muscle rigidity can result in muscle rupture or in rhabdomyolysis. Fever is viewed as a source of secondary injury in individuals with TBI, because marginal cerebral blood flow fails to provide for normal brain cooling. This may result in a brain temperature that is higher than the measured core temperature. The resulting increase in metabolic demand may not be met by increasing blood flow, so local areas of hypoxia and further neuronal dysfunction and death ensue.

Hypertension and tachycardia could theoretically increase the risk of developing hemorrhage from injured blood vessels. Prolonged, severe diaphoresis may result in dehydration and in electrolyte abnormalities.

Surgical Intervention

Surgery is not part of the treatment for ADS.

Consultations

Consultation from infectious disease experts is appropriate, but it is not always necessary in this context.

Medication

Howard L, Dumkrieger G, Chong CD, Ross K, Berisha V, Schwedt TJ. Symptoms of Autonomic Dysfunction Among Those With Persistent Posttraumatic Headache Attributed to Mild Traumatic Brain Injury: A Comparison to Migraine and Healthy Controls. Headache. 2018 Oct. 58 (9):1397-1407. [QxMD MEDLINE Link].
Baguley IJ, Heriseanu RE, Cameron ID, et al. A critical review of the pathophysiology of dysautonomia following traumatic brain injury. Neurocrit Care. 2008. 8(2):293-300. [QxMD MEDLINE Link].
Baguley IJ. The excitatory:inhibitory ratio model (EIR model): An integrative explanation of acute autonomic overactivity syndromes. Med Hypotheses. 2008. 70(1):26-35. [QxMD MEDLINE Link].
Srinivasan S, Lim CC, Thirugnanam U. Paroxysmal autonomic instability with dystonia. Clin Auton Res. 2007 Dec. 17(6):378-81. [QxMD MEDLINE Link].
Blackman JA, Patrick PD, Buck ML, et al. Paroxysmal autonomic instability with dystonia after brain injury. Arch Neurol. 2004 Mar. 61(3):321-8. [QxMD MEDLINE Link]. [Full Text].
Fernandez-Ortega JF, Baguley IJ, Gates TA, Garcia-Caballero M, Quesada-Garcia JG, Prieto-Palomino MA. Catecholamines and Paroxysmal Sympathetic Hyperactivity after Traumatic Brain Injury. J Neurotrauma. 2017 Jan 1. 34 (1):109-14. [QxMD MEDLINE Link].
Rabinstein AA. Paroxysmal sympathetic hyperactivity in the neurological intensive care unit. Neurol Res. 2007 Oct. 29(7):680-2. [QxMD MEDLINE Link].
Baguley IJ, Nicholls JL, Felmingham KL. Dysautonomia after traumatic brain injury: a forgotten syndrome?. J Neurol Neurosurg Psychiatry. 1999 Jul. 67(1):39-43. [QxMD MEDLINE Link]. [Full Text].
De Tanti A, Gasperini G, Rossini M. Paroxysmal episodic hypothalamic instability with hypothermia after traumatic brain injury. Brain Inj. 2005 Dec 20. 19(14):1277-83. [QxMD MEDLINE Link].
Hinson HE, Schreiber MA, Laurie AL, Baguley IJ, Bourdette D, Ling GS. Early Fever As a Predictor of Paroxysmal Sympathetic Hyperactivity in Traumatic Brain Injury. J Head Trauma Rehabil. 2017 Jan 5. [QxMD MEDLINE Link].
Lucca LF, De Tanti A, Cava F, et al. Predicting outcome of acquired brain injury by the evolution of Paroxysmal Sympathetic Hyperactivity signs. J Neurotrauma. 2020 Dec 28. [QxMD MEDLINE Link].
Sorek G, Gagnon I, Schneider K, et al. Changes in the cardiac autonomic control system during rehabilitation in children after severe traumatic brain injury. Ann Phys Rehabil Med. 2023 Mar. 66 (2):101652. [QxMD MEDLINE Link].
Baguley IJ, Cameron ID, Green AM, et al. Pharmacological management of dysautonomia following traumatic brain injury. Brain Inj. 2004 May. 18(5):409-17. [QxMD MEDLINE Link].
Becker R, Benes L, Sure U, et al. Intrathecal baclofen alleviates autonomic dysfunction in severe brain injury. J Clin Neurosci. 2000 Jul. 7(4):316-9. [QxMD MEDLINE Link].
Baguley IJ, Heriseanu RE, Gurka JA, et al. Gabapentin in the management of dysautonomia following severe traumatic brain injury: a case series. J Neurol Neurosurg Psychiatry. 2007 May. 78(5):539-41. [QxMD MEDLINE Link].
Chiolero RL, Breitenstein E, Thorin D. Effects of propranolol on resting metabolic rate after severe head injury. Crit Care Med. 1989 Apr. 17(4):328-34. [QxMD MEDLINE Link].
Rossitch E, Bullard DE. The autonomic dysfunction syndrome: aetiology and treatment. Br J Neurosurg. 1988. 2(4):471-8. [QxMD MEDLINE Link].
Russo RN, O'Flaherty S. Bromocriptine for the management of autonomic dysfunction after severe traumatic brain injury. J Paediatr Child Health. 2000 Jun. 36(3):283-5. [QxMD MEDLINE Link].
Baguley IJ, Slewa-Younan S, Heriseanu RE, et al. The incidence of dysautonomia and its relationship with autonomic arousal following traumatic brain injury. Brain Inj. 2007 Oct. 21(11):1175-81. [QxMD MEDLINE Link].
Henden PL, Sondergaard S, Rydenhag B, et al. Can baroreflex sensitivity and heart rate variability predict late neurological outcome in patients with traumatic brain injury?. J Neurosurg Anesthesiol. 2014 Jan. 26(1):50-9. [QxMD MEDLINE Link].
Pozzi M, Conti V, Locatelli F, et al. Paroxysmal Sympathetic Hyperactivity in Pediatric Rehabilitation: Clinical Factors and Acute Pharmacological Management. J Head Trauma Rehabil. 2014 Oct 13. [QxMD MEDLINE Link].
Wright AD, Smirl JD, Bryk K, van Donkelaar P. Systolic and Diastolic Regulation of the Cerebral Pressure-Flow Relationship Differentially Affected by Acute Sport-Related Concussion. Acta Neurochir Suppl. 2018. 126:303-8. [QxMD MEDLINE Link].