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. 2021 Mar 6;32(2):223–238. doi: 10.1016/j.pmr.2021.01.001

Table 1.

Managing the sequelae of acquired brain injury

Symptoms Nonpharmacologic Management Pharmacologic Management Telehealth Consideration
Mood (Anxiety/Depression) CBT, neuropsychology,51 exercise & diet, breathing/relaxation techniques, Acupuncture SSRI, SNRI, atypical antidepressants, TCA, serotonin modulators, MOAs Patients with anxiety/depression shown to prefer telehealth visits vs F2F.52 Cochrane database review found telerehab for depressive symptoms poststroke to be noninferior to in-person.50
Agitation/Irritability Same as abovementioned, anger management, behavioral modification Beta-blockers have best evidence for reducing agitation,53, 54, 55 (propranolol best CNS penetration56) atypical antipsychotics,57 (seroquel and olanzapine) mood stabilizing AEDs,58 (valproic acid and carbamazepine) Less likely to provoke patients with external stimuli. Increased safety for patient and provider.
Video CBT shows significant and clinically meaningful reductions in anger.59
Posttraumatic Headaches Physical therapy, ice/heat packs, CBT, biofeedback, massage therapy Prophylaxis vs abortive, NSAIDs, APAP, ASA, triptans, beta-blockers, AEDs, TCAs Please refer to the Don McGeary and Cindy McGeary’s article, “Telerehabilitation for Headache Management,” in this issue within this book.
Insomnia/Sleep Sleep hygiene, sleep study to rule out OSA, CBT Melatonin, hypnotics, antidepressants, antipsychotics, antihistamines Assess bedroom with patient's permission to consider environment modifications.
Tele-CBT shown to decrease insomnia severity index and be effective at improving sleep.60
Fatigue Address sleep as abovementioned, aquatic therapy, exercise & diet, self-management strategies Methylphenidate and modafinil,61 melatonin51 Telehealth visits can save up to 3 h per visit.16
Telerehab exercise programs show statistically significant improvements in fatigue.62
Cognitive Dysfunction Neuropsychology evaluation,51 speech therapy, compensatory strategies Neurostimulant for attention, concentration, processing speed, initiation, orientation, verbalization (amantadine63, 64, 65, 66 and methylphenidate57,58,63,67), donepezil for memory61 Can reduce stress related to visit and save time from reduced transportation.16
Systematic review found telecognitive rehabilitation to be effective when compared with in-person rehabilitation.68
Vestibular (Balance) Deficits Vestibular rehabilitation, balance training, habituation techniques, DME (Cane, FWW) Should avoid chronic use.69 If needed acutely, antihistamines, anticholinergics, TCAs, SSRIs, and CCBs Reduced fall risk. Can observe in home environment. Virtual reality rehab has been found to out-perform gait and balance training compared with conventional rehab.70
Visual Dysfunction Neuro-ophthalmology referral, vision rehabilitation, visual scanning techniques, corrective eyewear Ask if screen is causing any visual disturbance (headache, blurriness), consider phone visit if severe. Meta-analysis for screening for certain eye conditions found be effective using tele-ophthalmology services.71
Auditory Dysfunction Audiology referral, hearing devices, white-noise generators, tinnitus CBT, environmental modifications, tinnitus retraining therapy Can have patient wear headphones to modify volume and improve communication during visit or using text-based communication. Patients show high satisfaction in web-based services for hearing health.72
Motor Dysfunction/Deficits Both telerehab and in-person physical therapy, occupational therapy; orthotics/bracing, electrical stimulation Antispasmodics, fluoxetine, or other SSRIs potentially,73 botox Systematic review of telerehab interventions for motor deficits after stroke were found to have equal or better effects when compared with in-person therapy.74

Abbreviations: ADLs, activities of daily living; AEDs, antiepileptic drugs; APAP, acetaminophen; ASA, aspirin; CBT, cognitive behavioral therapy; CCB, calcium channel blockers; DME, durable medical equipment; F2F, face-to-face visit; FWW, front wheel walker; MOA, monoamine oxidase inhibitor; NSAIDs, nonsteroidal antiinflammatory drugs; OSA, obstructive sleep apnea; SNRI, serotonin norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant.