Rehabilitation after moderate to severe traumatic brain injury

Traumatic brain injuries are classified as mild, moderate or severe using loss of consciousness, the Glasgow Coma Scale and the length of post-traumatic amnesia. Headway gives moderate injury as loss of consciousness of 30 minutes or more, post-traumatic amnesia of 24 hours or more and a Glasgow Coma Scale score of 9 to 12, and severe injury as the same duration criteria with a score of 3 to 8. A loss of consciousness longer than 6 hours is described as coma.

These categories guide treatment but not destiny. Headway stresses that everyone is different and classification does not always measure long-term effects. A new classification system, CBI-M, adds pupil response, symptoms, imaging and blood biomarkers, but is at an early stage.

Headway explains that, unlike most cells, brain cells do not regenerate when destroyed, but this does not mean no recovery occurs. The brain is flexible and can reorganise: other areas take over activities of damaged regions and new nerve pathways are established using undamaged cells. Engaging in activity helps these alternative pathways develop.

Rehabilitation aims to help the brain learn alternative ways of working, minimise the long-term effects of injury and help the person and family cope with remaining disabilities. Headway warns against the idea of a fixed window of two years, saying people may continue to improve for many years.

In a specialist setting a multidisciplinary team assesses physical, cognitive, emotional, behavioural and social difficulties, then agrees short- and long-term goals with the person and family, taking account of their cultural background, pre-injury lifestyle and interests. Headway describes the roles: the clinical neuropsychologist for thinking, emotional and behavioural problems; the occupational therapist for daily tasks and return to work planning; the speech and language therapist for communication and swallowing; the physiotherapist for movement and balance; nurses; social workers; and, in private referrals, case managers.

NICE guideline NG252 says rehabilitation needs should be identified as early as possible, a holistic needs assessment should be done in partnership with the person and those important to them, rehabilitation should not wait for the assessment to finish, and a single point of contact and a plan agreed with goals, timing, intensity and review points should follow.

Headway lists inpatient rehabilitation for people not ready to return home, outpatient rehabilitation at a local hospital or rehabilitation centre, and community rehabilitation, including residential transitional living units for developing independent living skills and community or outreach teams who visit the home. The NHS or private units may provide services, most units accept NHS referrals, and other funding routes include local authorities, insurance, compensation claims and self-funding.

Headway notes that places and waiting lists vary, services cannot admit before funding is authorised, and choosing a unit should involve the clinical team, patient and family. NICE says that when moving from acute to longer-term rehabilitation, needs, goals and interventions should be reviewed and the plan updated.

In the first month or two after a severe injury, only a guess can be made at the length and outcome of recovery. Headway says recovery takes months or years rather than weeks, the picture is clearer after six months, and it is wise to wait about a year before important decisions about the future. After a year the eventual degree of physical recovery is reasonably clear, though psychological recovery can take much longer, and the subtle psychological problems often cause the longer-term difficulties, particularly for families.

Common effects include mobility issues, fatigue, headaches and dizziness, difficulties with attention, memory, planning and word-finding, depression, anxiety, anger, loss, and behavioural changes such as impulsiveness and irritability. These may improve over time or the person may learn to adapt.

Headway says family members have an important role, and research suggests that those who make the best recovery tend to be those whose families are actively involved and can maintain skills learned in rehabilitation at home. It also stresses that relatives should not become therapists and should focus on providing love and affection. NICE asks teams to offer family and carers support if wanted, and to discuss who is important to the person and how they would like them involved.

Families may need to act as advocates when the person lacks capacity to make decisions, and decision support follows mental capacity principles.

As recovery plateaus, attention turns to return to work or education, driving, relationships, emotional health and fatigue, which our other guides describe. NICE asks that when rehabilitation ends, teams agree whether follow-up is needed and who will start it, considering future needs and the support available from family and voluntary organisations. Open access to the service, so the person can come back if needs change, is a recognised principle of good practice.