Pituitary Dysfunction and Hormone Replacement Therapy in Traumatic Brain Injury Rehabilitation
Smith, Michael PhD
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1. Purpose: Pituitary dysfunction is an exceedingly predominant complication of traumatic brain injury (TBI) with a prevalence of up to 30%. Symptoms of a pituitary disorder, such as fatigue, concentration difficulties, depression, and hormone deficiencies, can often appear nonspecific and consequently are overlooked. Such profound deficits may impose a negative impact on patients' recovery and ultimate quality of life. Currently no protocol exists for the screening of pituitary function or hormone replacement therapy (HRT) due to critical research gaps in the area of brain injury rehabilitation. The purpose of this project was to draft a set of evidence-based recommendations regarding pituitary screening and hormone replacement therapy in TBI patients. 2. Methods: A multidisciplinary team of research personnel and clinicians who specialize in treating TBI was established to include physiatry, neuropsychology, physical therapy (PT), occupational therapy (OT), speech language pathology (SLP), and therapeutic recreation (TR). Clinicians created a research question in PICO format (Population, Intervention, Comparison, Outcome). Next, research staff conducted a systematic review using the key terms "brain injuries, pituitary screen, pituitary testing, pituitary evaluation, hormone replacement therapy." PubMed, CINAHL, PSYCInfo, and Allied Health Evidence databases were utilized. The multidisciplinary team reconvened to assess quality of evidence for each article using a modified-Oxford scale and created draft recommendations using a modified-GRADE format. 3. Results: 20 articles were assessed and deemed to have good quality of evidence in support of pituitary screening, particularly in patients with severe TBI and within the first 12 months of injury. 6 articles were assessed for hormone replacement therapy and deemed to have fair quality of evidence surrounding HRT, particularly growth hormone. 4. Conclusion: We strongly recommend that pituitary screening should be routinely performed on all patients with TBI, especially moderate to severe TBI. While further study of HRT is warranted, the available research supports a weak conditional recommendation for growth hormone replacement.