10. The importance of rehabilitation

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REHABILITATION AFTER SEVERE HEAD INJURIES

patients and follow closely spontaneous improvement as it occurs, giving guidance and reassurance to both patient and relatives when this seems appropriate. In later stages of recovery some patients with mild residual difficulties may

value intensive help as they attempt to readjust to school work or cope with a job. Others with more severe residual speech and language problems will need full assessment and intensive therapy prior to eventual resettlement.

Requests for reprints should be addressed to:--A. Wallace, Edinburgh School of Speech Therapy, 7 Buccleuch Place, Edinburgh 8.

10. THE IMPORTANCE OF REHABILITATION* F. J O H N

G I L L I N G H A M , M.B.E., F.R.C.S., F.R.C.S. (EDIN.), F.R.C.P. (EDIN.)

FORTY-THREE per cent of all injured patients admitted to Edinburgh hospitals suffer from head trauma and the severity of injury and its complications are greater, more complicated, and occur

Ward 20 of the Royal Infirmary was established as a Head and Spinal Traumatic Research Unit in close association with the Accident/Emergency Department in 1960, when the new department

T a b l e L - - H E A D INJURIES COMPLICATED BY ALCOHOLIC INTOXICATION BEFORE INTRODUCTION OF

BREATHALYSER(9 OCT., 1967), 1 JAN.--8 OCT., 1967" GROUP

Drivers Passengers Pedestrians Others (sports, public place, home, work)

TOTAL ADMISSIONS IN GROUP

GROUP AS PERCENTAGE OF TOTAL ADMISSIONS(969)

PERCENTAGEOF GROUP ADMITTEDINTOXICATEDt

40 33 107

4"1 3"4 11

13'8 11"4 36"9

110

11"4

37'9

*Tables I-VII are from a computer study of 1132 head injuries admitted during 1967 sponsored by the Scottish Home and Health Department (Health Services Research and Intelligence Unit--Dr. M. A. Heasman and staff). t30 per cent of head injury cases were admitted intoxicated. T a b l e / / . - - H E A D INJURIES COMPLICATED BY ALCOHOLIC INTOXICATION AFTER INTRODUCTION OF BREATHALYSER (9 OCT., ]967), 9 OCT.--31 DEC., 1967

GROUP

Drivers Passengers Pedestrians Others (sports, public place, home, work)

TOTAL ADMISSIONS IN GROUP

GROUP AS PERCENTAGE OF TOTAL ADMISSIONS(321)

PERCENTAGE OF GROUP ADMITTED INTOXICATED*

8

7 45

2"5 2"2 14

7'7 6.7 43.2

44

13'7

42.3

*32.4 per cent of head injury cases were admitted intoxicated. (See also Table IlL) more rapidly as the result of increasing speeds of acceleration--and accidental deceleration--than they did ten years ago. *Based on a paper read at the Royal College of Surgeons of Edinburgh at a Conference on Rehabilitation organized by the Astley Ainslie Hospital in 1964.

for elective surgical neurology was opened at the Western General Hospital. We saw our opportunity to try and get to grips with this problem, and the admission and study of patients with all grades of severity of injury has led to an increasing understanding of management and has shown the next steps in planning for the future. Mortality

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INJURY: THE BRITISH JOURNAL OF ACCIDENT SURGERY

from severe injury has decreased significantly but morbidity has thereby increased, demanding thoughtful rehabilitation. The increasing magnitude of the problem is emphasized by the rise in numbers. In 1963 664 were admitted and in 1968 1770 without significantly increasing our catchment area.

Injury Oct. 1969

he might develop intracranial complications

(Tables IV, V). If all goes well, he is allowed home and our responsibilities would seem to be discharged with him. But a proportion of these patients do not do well, and we find it is a wise precaution to keep the patient off work for a few days and it is even more important to see him

Table IlL--PATIENTS ADMITTED INTOXICATED BY ALCOHOL AFTER INTRODUCTION OF BREATHALYSER (9 OCT., 1967), 9 OCT.--31 DEC. 1967 MONTH TOTAL

9-31 Oct.

Nov.

Dec.

Total admissions

89

94

138

321

Total patients admitted intoxicated

23

29

52

104

25"8

30.8

37'6

32-4

Percentage of patients admitted intoxicated

Table /V.--SUMMARY OF ADMISSIONS TO HEAD AND SPINAL INJURY UNIT, ROYAL INFIRMARY, EDINBURGH, 1 JAN.-31 DEC., 1967 INJURIES

Table //.--CAUSES OF DELAYED LOSS OF CONSCIOUSNESS IN HEAD-INJURY PATIENTS ADMITTED TO HEAD AND SPINAL INJURY UNIT, ROYAL INFIRMARY,EDINBURGH(1967)

No. OF CASES

CAUSES

NO. OF CASES

Skull fracture without intracranial space-occupying haemorrhage Skull fracture with intracranial space-occupying haemorrhage Intracranial space-occupying haemorrhage without skull fracture Posterior fossa fracture with intracranial haematoma Skull fracture with C.S.F. rhinorrhoea Skull fracture with C.S.F. otorrhoea Skull fracture with C.S.F. otorrhoea and rhinorrhoea Head injury as main injury plus mild associated spinal injury Spinal injury as main injury plus mild associated head injury Combined head and spinal injuries (major) requiring operative treatment

166 40 16 8 11 9

Extradural haematoma Subdural haematoma Intracerebral haematoma Subarachnoid haemorrhage Brain swelling or oedema Brain contusion Not known Total

2(+ 3*) 6(+ 1") 1 1

2 1(+2") 12 25

4

*Found in combination with other lesions.

54

again before he returns to work. I make no apology for discussing the minor injury within this symposium. If a patient fails to return to normal activities within a week or so, then the effect of his injury has been severe. The duration of the post-traumatic amnesia is usually a reliable guide to the severity of injury and the length of convalescence required, but even minor and temporary disruption of diencephalic function may reduce function for some days. Until the effects of concussion have fully disappeared, concentration and recent memory are impaired. This assumes more importance when there has been a previous head injury with loss of consciousness in the past, and particularly significant if severe. Physical recovery may

9 0

About one-quarter of our patients come with severe or moderately severe head injury, and about three-quarters with simple concussion. Alcoholic intoxication is, unfortunately, an important factor in a surprisingly high proportion (Tables L II, 111). It is well recognized that a concussed patient who has suffered temporary loss of consciousness should be kept in hospital for 24 or 48 hours for observation, during the important period when

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REHABILITATION

AFTER

SEVERE

appear quite complete and all may seem well but the patient is bewildered by his failure to manage his work and cope with simple intellectual or physical activities. He becomes anxious, concerned with himself, and depressed, and so he may fail. He may quickly turn to compensation and frustrating delays of settlement will add to his difficulties. Unless the situation is handled skilfully, he soon loses his self-respect and that of his family. A culmination of all these factors results in what is commonly termed the 'postconcussional syndrome ' and one or more of them may predominate in each case. Graduated return to work on a planned basis often means success and compensation is not seriously considered. He and his employers gain security in each other and all is well. In my experience co-operation between employers and doctors in this way can do great good. However, in some cases the post-traumatic psychological disability is in excess of the severity of the head injury as we estimate it, and knowledge of the patient's previous personality and environment is of particular importance. The disincentives to recovery, such as prolonged legal wrangling over compensation, may play an important part. The establishment of a follow-up routine 1 week after their accident for patients who have sustained minor head injury has resulted in a definite reduction in the so-called 'post-concussional syndrome '. Many have returned to work already. Few require to be seen again and in those who show early symptoms, reassurance by explanation of their cause and a planned return to work Table

VL--FOLLOW-UP

HEAD

145

INJURIES

ischaemic changes. These effects will be rapidly increased by hypoxia from impairment of the airway, from high central venous pressure, rapid accumulation of intracranial clot, or brain NAME

AGE ............

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ADDRESS.......................................................................................... LOCUS OF ACCIDENT TIME .............. .................................................................

CAUSE OF ACCIDENT........................................................................... T~

AbrO DATE EXAIVnNED ...............................................

NATURE OF INJt.mJES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . H / E M O R R H A G E : - - ( P u t a tick ¢ in appropriate box) MODERAT I: [] S L I G H T [] NON~ []

SEVERE []

ToLrRN~QLrETAPPLIED [ ]

TIMEAPPLIED. . . . . . . . . . . . . . . . . . . . .

STATE OF AIRWAY WHEN EXAMINED :CLEAR [ ] OB,~TRUCTEO [] VOMITING [] ACTION TAKk~N........................................... STATE OF CONSCIOUSNESS:-WJ,l,@zt,r~

ALERT AND CO-OPERATIVE UROWSVA~CO~USED

-

Wlem ~ F l l , d

ii r~ldt

[]

[]

[]

D

[]

[]

UNCONSCIOUS-

[]

[]

[]

m-

[] []

[] []

[] []

mmmc

"vArm~o Arr^cz'"

DRUGS GIVEN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . BY wliOM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Re~ARKS:-~ t a ~ s c t N~

sloNeo

Fig. 1.--The casualty card in use by ambulances in the S.E. Region of Scotland since 1960 but recently modified. OF PATIENTS

DELAY

WITH

BEFORE RETURN

CONCUSSION

TO WORK

TOTAL CASES

1 week

2weeks

1 month

1 month

Not Known

January

70

52

7

3

1

7

February

53

43

4

2

3

1

March

78

51

5

9

3

10

Totals

201

146

16

14

7

18

MONTH OF ADMISSION

No. OF

Over

ensures success in a greater proportion of patients (Table VI). In severe head injury on the other hand there is often widespread and irreparable damage to the cortical and subcortical structures by disruption of cell masses and fibre connexions and by

swelling. The organization of an efficient accident service is aimed at reducing these factors by prompt and skilled attention from the moment of injury, by better care at the roadside, improved ambulance services, and immediate hospital care (Fig. 1). It is regrettable that 16 per cent of

146

INJURY" THE BRITISH J O U R N A L OF ACCIDENT SURGERY

Injury Oct. 1969

our patients still die from failures at this level (mostly from impaired airway) or suffer the unnecessary morbidity which concerns us particularly today. Rehabilitation begins at the roadside by the prevention of the ' second accident ' and the reduction of morbidity to a minimum. There

an environment of increasing experience, accompanied by re-education with thoughtfully planned incentives, leads to increasingly rapid recovery. A skilled rehabilitation staff with good facilities and enough time to treat each patient individually as the situation demands, is the first essential.

Fig. 2.--Section of the pons and cerebellum showing a midline pontine and a high anterior cerebellar haemorrhage of a primary type.

Fig. 3.--The inferior surface of the cerebral hemispheres showing severe contusion of the frontal and temporal lobes, especially on the left. There is swelling of the left temporal lobe from an intracerebral clot, marked uncal herniation and distortion of the midbrain downwards and laterally. There are midbrain haemorrhages of the secondary type from distortion.

is still much to be done in early care as Easton and others have shown. The significance of the various pathological lesions to the patient are directly related to the severity of the injury and any complications of it, whether the brunt of the injury has fallen upon the cortex or diencephalon. The latter is far more vulnerable and important in respect of long-term recovery (Figs. 2, 3). The physiological age, previous intellectual level, and personality are also factors which will determine the speed and completeness of recovery of the patient. Nevertheless, the capacity for recovery in some of our younger patients treated during the last ten years with better care at every stage is sometimes remarkable, even after what appears to be a severe diencephalic lesion with prolonged periods of unconsciousness and decerebrate rigidity. How this happens is still a matter for conjecture. Some have reversible primary brainstem lesions and recover rapidly. There is no regeneration within the central nervous system but it may be that it is possible for a young patient to learn to use intact alternative pathways --what Earl Walker has called the ' plasticity of the central nervous system '. In our experience the placing of a patient who is beginning to show a return to consciousness in

Light and heavy workshops, a school and, more recently, a 'coal m i n e ' have been important features of the Astley Ainslie Hospital (Rehabilitation) in Edinburgh for some years. The second essential is regular neurological and physiological assessment and re-assessment of the patient so that progress can be determined and the correct steps taken in consultation with rehabilitation staff. The medical and surgical neurologist and the psychiatrist with an interest in ' o r g a n i c ' psychiatry all have a part to play in this. Specific defects of language function from cortical and immediate subcortical injury of the dominant hemisphere, require particular care from the speech therapist in conjunction with the medical psychologist. Regular working parties with all the staff concerned have been of greatest value in planning the patient's 'next steps ', both in our own department and in the Astley Ainslie Hospital. Cortical damage may also result in visual field defects, motor and sensory loss, spatial disorientation, and personality changes, all or some of which are superimposed on a diencephalic injury with associated problems of concentration,

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REHABILITATION AFTER SEVERE HEAD INJURIES

persistence, and initiative (Table Vii). The 16 per cent incidence of epilepsy during the first year after severe closed head injury must not be forgotten, although it diminishes in severity and frequency as time goes on. Sooner or later the patient goes home and then back to his job or to modified employment, or he may have to face disablement for ever. This is the most important and critical step of all and is also graduated, using out-patient rehabilitation for a whole or a half-day as required, reducing the period as the situation indicates. Success depends now much more on the patient, his adaptability and previous personality and attitude to his home and work. Residual deficits will determine what he is able to do and what his limitations will be and it is important to try and make a clear assessment of the ultimate prognosis at this stage. Finally the reaction of the patient and his wife and family to the injury and, perhaps more important, the relationship of a wife and husband to each other during the phase of recovery is allimportant. Tolerance and patience may be strained to the limit when personality change is marked. The value of the day-hospital such as Tyne Lodge of the Astley Ainslie Hospital which gives periods of relief and rest for the family in such problems as these is great indeed. It is 30 years since Cairns at Oxford and Dott in Edinburgh introduced the concept of care of the patient in depth, both in head injury and in surgical neurology in general. The use of physiotherapy, occupational and speech therapy, the advice and assistance of the medical social worker, consultation with the medical psychologist and the D.R.O. was well developed then and even more so now.

When we were planning the new Department of Surgical Neurology at the Western General Hospital some 15 years ago, it seemed a great opportunity to develop all these aspects of the work in direct association with our ward and

Table

V I L - - N E U R O L O G I C A L DEFICITS FOUND ON ADMISSION IN A SERIES OF 1 1 3 2 CASES

No. OF NEUROLOGICAL DEFICIT

Abnormal size or reaction of pupils Abnormality of other cranial nerves Motor deficit Hemi- or monoplegia ~. Hemi- or monoparesis Y Paraparesis or paraplegia Sensory deficit Abnormal reflexes Dysarthria Dysphasia

CASES

158 78 113 8 36 89 64 46

theatre accommodation for a limited number of patients with special problems. This experiment is of course open to criticism because of increasing withdrawal into the specialist field. It has nevertheless been of conspicuous benefit. Proximity has meant much economy of time. Moreover, the doctor sees his patient in action and all can study together and record the receding pattern of disease and injury--an important part of clinical research! Finally, the therapy staff cooperate in research projects, recording disability in practical ways, at intervals, as the patient improves. We also prepare them for their homes and work--management of stairs, kitchen, workshop--in many ways. Domiciliary help in modifying homes is also provided. We can prepare the way for the acceptance of permanent disability if at the end of the day we have to.

Requests for reprhffs should be addressed to:--F. John Gillingham, Department of Surgical Neurology, Royal Infirmary, Edinburgh.

11. SOCIAL ASPECTS OF REHABILITATION: THE ROLE OF THE SOCIAL WORKER P. P. LOCKHART, A.I.M.S.W. THE film A Life Worth Living ? portrays far more forcibly than I can the tragedies resulting from severe head injuries. It shows the tragedies 'affecting two families, one in which adjustment to the tragedy was satisfactory and one in which it was not. I suggest that a very large part of the

rehabilitation of these patients is in fact social rehabilitation, which sometimes continues for several years after other forms of treatment and rehabilitation have finished. It is now over 10 years since J.L.'s accident and during that time support and encouragement