Select Committee on Health Appendices to the Minutes of Evidence


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.


  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.


  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.


  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.


  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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