APPENDIX 24
Memorandum by The Royal College of Surgeons
of England (H 52)
There are three groups of patients who sustain
a head injury and who require rehabilitation. The two groups should
be considered separately.
1. REHABILITATION
OF ADULT
PATIENTS WITH
MINOR HEAD
INJURIES
Whilst there is no doubt that patients who sustain
intermediate and severe head injuries experience more serious
consequences most of the time, there is a large and growing body
of evidence which is emphasising the importance of disability
after relatively mild traumatic brain injury. Rimel and her colleagues
in Virginia (Neurosurgery, 9, 221-229, 1981) found that three
months after a minor head injury, defined as unconsciousness of
20 minutes or less, 34 per cent of those who had been gainfully
employed before the injury were still unemployed. Those who were
employed, despite a normal neurological examination, had neuro
psychological deficits in attention, concentration, memory or
judgement. In addition they showed emotional stress but their
problems were not related to compensation or litigation.
The current evidence supports the view that
the outcome of such mild traumatic brain injuries can be improved
by providing suitable rehabilitation. Recent evidence clearly
indicates that in these patients, even in those who have suffered
no loss of consciousness, there is often neuro-pathological, neuro-radiological
and neuro-psychological evidence of organic impairment of brain
function. Many people with mild head injuries experience the so-called
Post-Concussional Syndrome. This consists of a number of subjective
symptoms such as headache, dizziness, noise intolerance, impaired
concentration, fatiguability, depression, irritability, sleep
disturbance, memory difficulties, loss of sexual drive, low tolerance
to alcohol and general restlessness. Although the symptoms pass
in the majority of these patients within one to three months,
they continue in a significant minority. One of the main problems
relates to reduced information processing capacity. This gives
rise to difficulty analysing simultaneous information and leads
to slowness, distractibility, forgetfulness, inattention and fatigue.
These difficulties have a major effect on employment, family life
and recreational pursuits. Dickmen and colleagues (Arch.Phys.Med.Rehabil,
67, 507-513, 1986) found that 79 per cent of patients with minor
head injuries had returned to work without any problem at one
year, a further ten per cent had returned to work but were suffering
significant problems and ten per cent had not yet returned to
work. Over a third of their patients were having difficulty resuming
previous recreational and lesser interest. It was clear, given
the large number of people who suffer a mild head injury every
year that the impact of the associated morbidity would represent
a significant burden on rehabilitation services if those with
problems were helped. They can be helped and the rehabilitation
needs should be provided.
It is now well established that perhaps the
majority of patients following a minor head injury have significant
short-term problems even when the head injury is not sufficiently
severe to warrant hospital admission. Problems with memory and
attention seem to be particularly prevalent. In the majority of
patients these symptoms persist for up to three months but in
a significant minority they extend for much longer.
A study carried out in Glasgow showed that the
frequency of symptoms six months after head injury was virtually
the same in those who presented with major, moderate and mild
traumatic brain injury. The burden of disease caused by mild head
injury is clearly much greater than that inflicted by the more
devastating severe injuries and it is important, therefore, that
adequate rehabilitation is provided for this group of patients.
2. REHABILITATION
OF ADULT
PATIENTS AFTER
INTERMEDIATE AND
SEVERE HEAD
INJURIES
As with minor head injuries, there are currently
insufficient resources for rehabilitation and additional resources
are urgently needed. Patients with intermediate and severe head
injuries wait in acute hospital beds which delays their treatment,
makes subsequent treatment more difficult and protracted and probably
adversely affects the outcome. Patients in neuro-science units
requiring further rehabilitation should be transferred directly
to a rehabilitation unit and not to a general surgical or medical
unit while awaiting a bed. It is unacceptable for patients to
spend prolonged periods on acute surgical or medical wards awaiting
a place at a dedicated rehabilitation unit thus not only affecting
their outcome but also utilising an acute bed inappropriately
which otherwise could be used for patients undergoing elective
surgery etc. If there is any delay in transferring patients to
a suitable unit, rehabilitationists and neuro-psychologists should
become involved in their management whilst they are still in an
acute bed and prior to their discharge. There should also be early
liaison with local education authorities where patients require
rehabilitation. The expenditure of additional resources on rehabilitation
units will make more acute hospital beds available for emergencies
and patients on waiting lists.
Patients needing neuro rehabilitation required
expertise of trained rehabilitationists working in an adequately
resourced multi-disciplinary rehabilitation unit. All rehabilitationists
who are involved in the management of head injuries should be
adequately trained in head injury rehabilitation as part of their
training programme.
Rehabilitation of patients with head injuries
is a multi-disciplinary and specialised process and should start
early so as to minimise the development of physical and behavioural
complications. The provision of additional resources for rehabilitation
would be cost effective in reducing the long-term morbidity for
head injured patients, allowing more of them to make a useful
recovery. Additional resources would also reduce the complications
associated with severe morbidity, such as the loss of employment,
marriage breakdown, loss of accommodation and dependence on social
services.
While the majority of head injured patients
do not require a formal rehabilitation programme, there should
be a structure to identify their rehabilitative needs, even people
with less severe injuries can have long lasting symptoms which
require treatment. Patients with significant cognitive and physical
impairment benefit from the early input of a multi-professional
rehabilitation team. Whatever the severity of their brain injury,
patients require individual assessment of their needs. Where specialist
medical help was required, in either primary care or hospital
settings, specialists in rehabilitation medicine have the requisite
training and skills, and the time and resources, to take on the
management of these patients. There is a shortage of suitably
trained specialists and rehabilitation requires not only resources
for the necessary facilities but also for the training and appointment
of the additional staff.
With improving standards of pre-hospital and
hospital care, a greater number of very severely injured patients
are now surviving. The rehabilitation of very severely disabled
people and those in low awareness and vegetative states requires
professionals with particular skills and special facilities. This
also applies to people with significant and complex behavioural
difficulties. Because such rehabilitation facilities are expensive,
a structure of specialised units should be established for tertiary
referral.
Patients with moderately severe and severe injuries
should be transferred to specialised units as rapidly as possible
where clear patient and carer-centred goals can be identified
and implemented. Some of these goals may be initiated in a neuro-sciences
unit but, as considerable time may have elapsed before the full
extent of a patients needs become apparent, specialists in rehabilitation
medicine are at help and should be involved at an early stage.
This has particular importance in the prevention of late complications,
which have a profound effect on the patients later functioning.
Once patients are medically and surgically stable, their continued
stay in an acute unit is clinically counter productive and the
simple act of a transfer to the calmer, quieter atmosphere of
a rehabilitation unit has benefits on cognition and outcome.
Problems faced by patients with mild to moderate
disabilities are often psychological and, where this is the case,
there care should be managed by clinical neuro-psychologists.
Where medical help is required, consultants in rehabilitation
are best fitted to work with the patient's general practitioner
and have the requisite skills to manage these patients, together
with their multi-professional team colleagues. Most such patients
are managed by their general practitioners in the community and
the use of specialist medical help and clinical psychologist,
working in conjunction with community based health staff and local
authority professionals, will ensure better clinical and social
outcomes. Community rehabilitation should include the family as
well as the patient, whenever necessary.
Some patients may suffer the consequence of
a head injury for prolonged periods and many may have continued
needs for professional care, albeit on an intermittent basis,
for life.
The evidence would suggest that at the moment,
there is a woeful lack of facilities for the rehabilitation of
head injury patients or indeed patients with any form of brain
damage.
The ideal is to have the rehabilitation service
linked in directly to the Neuroscience service and for the services
to be administrative linked. Most neurosurgery units at any one
time will have significant number of their beds locked by patients
who do not require the services of a neurosurgeon and who are
awaiting transfer to a rehabilitation unit. It would be useful
to try and obtain precise figures for the proportion of neurosurgery
beds that are blocked by this type of patient. It is likely to
average at least ten per cent and in some Units may indeed be
more.
3. REHABILITATION
OF CHILDREN
For children, rehabilitation may be undertaken
either at home or in hospital, depending upon circumstances. Rehabilitation
services for children should be co-ordinated by community paediatricians
who should take specialist advice from the local rehabilitation
unit. Special attention must be paid to educational needs. A search
for hearing loss must be made in all children after moderate or
severe head injuries. Local protocols should be developed including
Health Authorities, Social Services and Local Education Authorities.
There needs to be greater clarification of the
need for training in the management of head injuries by paediatricians
who now manage the majority of head injured children admitted
to hospital.
In parallel with the adult experience, the biggest
problem in the management of head injuries in children is a still
insufficient number of intensive care beds for children. A lack
of research indicating outcomes from moderate to severe head injury
in children and a very marked lack of neuro rehabilitation facilities.
FOLLOW-UP
All patients seen in hospital for head injury
should be followed up, initially by the general practitioner,
and local arrangements for this should be established. This includes
patients with minor head injuries not requiring inpatient admittance.
The minimum follow up is a neurological and neuro-psychological
assessment, which should be carried out two to three months after
the injury to determine whether the patient has been left with
any ongoing symptoms. These assessments should usually be undertaken
by neuro-psychologists and specialist nurses all of whom must
be trained in brain injury rehabilitation, including the ability
to advise on wheel chairs, spasticity and neuromuscular control,
and the interaction between physical and neuro-behavioural components.
At the moment the system does not exist and its development and
implementation is dependent on the provision of adequate numbers
of suitably trained neuro-psychologists and specialist nurses.
February 2001
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