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Acquired Brain Injury (ABI) Care Pathway Overview

Brain injuries, often referred to as Acquired Brain Injuries (ABI), can be caused by a traumatic or non-traumatic event. Common traumatic causes include incidents on the road, assaults and falls which cause violent movement of the brain within the skull.

In these cases, primary damage is caused by the ricochet effect of the brain hitting the inside surface of the skull. However, the secondary damage, caused by consequent bleeding and increased pressure within the enclosed skull, can often be more damaging, and treatment may be required for the brain injury. There is a high incidence of traumatic brain injury in young men aged 17-24.

Non-traumatic causes of brain injury includes strokes, tumours, haemorrhage, aneuysm, asphyxiation and the effects of toxic substances. The effect of these processes is that the brain becomes starved of oxygen, causing irreparable brain cell damage (this is also known hypoxis or hypoxic brain injury) that results in a need for brain injury treatment/management.

Whether the brain injury is traumatic or non-traumatic, the physical, cognitive and behavioural consequences can be complex and difficult to manage. In these instances, the person suffering will often require brain injury rehabilitation from a specialist rehabilitation team in order to maximise their future quality of life and ability to function to their maximum capability.

Consequences of ABI often require a major life adjustment around the person's new circumstances, and making that adjustment is a critical factor in recovery and rehabiltiation. While the outcome of a given injury depends upon the nature and severity of the injury itself, appropriate treatment plays a vital role in determining the level of recovery and this pathway is intended to provide guidance to those treating patients with an acquired brain injury.

 

Please click the relevant flowchart box to be taken directly to textual information.

 

Presentation

Symptoms may include:

  • headache
  • dizziness
  • tinnitus
  • blurred vision
  • balance problems and lack of coordination
  • nausea and vomiting
  • fatigue
  • phonophobia and photophobia
  • hearing difficulties
  • numbness
  • seizures
  • insomnia
  • other transient neurologic symptoms

  • feeling like in a fog
  • attention and concentration problems
  • memory
  • processing
  • slowed reaction times
  • judgment
  • hallucinations
  • executive function

  • anger
  • apathy and loss of motivation
  • impulsivity and self-control problems
  • mood swings
  • restlessness
  • anxiety
  • depression
  • irritability
  • personality changes

  • domestic activities and everyday life problems
  • driving difficulties, which may lead to loss of license and reduced independence
  • employment problems, e.g. inability to carry out previous duties effectively, slowness in carrying out tasks, finding work more tiring
  • family demands problems
  • independence loss
  • personal and sexual relationship problems
  • self-esteem problems
  • social interaction problems

Loss of consciousness (occurs in 10% of concussions), or amnesia

Red Flags
Adult patients with any of the following signs and symptoms should be referred to an appropriate hospital for further investigation of potential brain injury:
  • Glasgow Coma Scale (GCS) of less than 15 at initial observation (if this is thought to be alcohol-related, observe for 2 hours, and refer if GCS score remains less than 15 after this time)
  • post traumatic seizure (generalised or focal)
  • focal neurological signs
  • signs of a skill fracture (including cerebrospinal fluid (CSF) from nose or ears, haemotympanum, boggy haematoma, post-auricular or periorbital bruising)
  • loss of consciousness
  • severe and persistent headache
  • repeated vomiting (two or more occasions)
  • post-traumatic amnesia for more than 5 minutes
  • retrograde amnesia for more than 30 minutes
  • high risk mechanism of injury (road traffic accident/significant fall)
  •  coagulopathy, where drug induced or other
  • significant medical co-morbidity (e.g. learning difficulties, autism, metabolic disorders)
  • social problems or cannot be supervised by a responsible adult
  • a mild head injury and taking antiplatelet medication (e.g. aspirin, clopidogrel)
  • re-presenting with ongoing or new symptoms (headaches not relieved by simple analgesia, vomiting, seizure drowsiness, limb weakness)

Practice Point

Please see the "Urgent Care: general" section on G-care for SWAST's guidance on Requesting Ambulance Transport (999 or Urgent).

Differential Diagnosis

Causes of loss of consciousness that can lead to falls and secondary head trauma include:

  • seizure
  • intoxication
  • syncope
  • non-traumatic intracranial haemorrhage
    • subarachnoid haemorrhage
    • subdural haematoma
    • intracerebral haemorrhage
  • dehydration
  • overtraining
  • sleep deprivation
  • anaemia
  • anorexia nervosa
  • learning disabilities
  • depression
  • more severe intracranial injury (such as subarachnoid haemorrhage, subdural haematoma, epidural haematoma
Initial Primary Care Assessment

In patients with more severe signs or symptoms, assess using the Glasgow Coma Scale- (GCS) which provides a practical method for assessment of impairment of conscious level in response to defined stimuli.

  • Best possible score 15 points 

FEATURE

SCALE RESPONSE

SCORE

 

Eye opening

  • spontaneously
  • to verbal commands
  • to pain
  • none
  • 4 points
  • 3 points
  • 2 points
  • 1 point

Best motor response

 

  • follows verbal command
  • localises painful stimuli
  • normal flexion to painful stimuli
  • abnormal flexion to painful stimuli
  • decerebrate posturing to painful stimuli
  • none
  • 6 points
  • 5 points
  • 4 points
  • 3 points
  • 2 points
  • 1 point

Best verbal response

  • oriented conversation
  • disoriented conversation
  • inappropriate words
  • incomprehensible words
  • incomprehensible sounds
  • none
  • 5 points
  • 4 points
  • 3 points
  • 2 points
  • 1 point

Ask about:

  • detailed information of events around injury
    • mechanisms of injury
    • duration and severity of alteration of consciousness
    • immediate symptoms
    • prior treatment
    • signs and symptoms that would indicate potential neurosurgical emergency
    • previous episodes
    • premorbid conditions
    • comorbid conditions
    • patient's perceptions of symptoms
  • patient's current symptoms
    • frequency
    • intensity and nature of symptoms
    • impact on social and occupational functioning
    • sleep patterns and sleep hygiene
    • impact on activities of daily living (determine safety for activities such as child care, driving)
  • symptoms which may present sub-acutely, including:
    • sleep disturbances
    • depression
    • anxiety
    • agitation
    • irritability
    • impulsivity
    • emotional lability
    • aggression
  • appearance of symptoms may be delayed for several hours after concussive event
  • in most cases, cognitive recovery overlaps with time course of symptom recovery
  • self-reporting is appropriate assessment of patient with concussion/mild traumatic brain injury if history is consistent with injury event and subsequent alteration in consciousness.

Review current medication history

Ask about pre-existing mental health disorders including history of attention deficit hyperactivity disorder (ADHD), learning disorder, seizure disorder, migraine.

Brain Injury Team - GHNHSFT

Consider referral for adult (16 years or over) patients with Acquired Brain Injury (ABI) that embraces acute (rapid onset) non-degenerative brain injury of any cause, including:

  • trauma
  • subarachnoid haemorrhage
  • cerebral anoxia
  • other toxic or metabolic insult (e.g. hypoglycaemia)
  • infection (e.g. meningitis, encephalitis) or other inflammation (e.g. vasculitis)
  • brain tumour when new deficits post excision

Practice Point

The remit does not include stroke as stroke is covered by a separate stroke service in Gloucestershire. Please see the Stroke Pathway for further information.

The Brain Injury Team is a multidisciplinary therapy team (i.e. no medical input) based at Gloucestershire Royal Hospital. They offer in and outpatient assessment and therapy for adults (16 years+) who have had an acquired brain injury and who are a resident in Gloucestershire with a Gloucestershire GP. The team offers intensive acute therapy immediately post injury, through community rehabilitation and outpatient follow up, sometimes years after the brain injury. They cover the spectrum of mild to severe brain injuries.

The team is based at Gloucestershire Royal Hospital but is a countywide service. The team is able to offer specialist assessment of patients in possible low arousal states using the Sensory Modality Assessment and Rehabilitation Technique (SMART) assessment tool.

The team provides outpatient services in patient’s homes, residential accommodations, nursing homes etc. The specific therapies within the team are detailed below. The therapists are supported by Brain Injury Therapy Technicians.

The team work between the hours of 8:30 and 4:30pm Monday to Friday. Referrals can be made by telephoning 0300 422 5138 or 0300 422 5139.

Written referrals can be made to: Brain Injury Team, Ground Floor, Beacon House, Gloucestershire Royal Hospital, Gloucester, GL1 3NN.

Mild Head Injury Clinic – GHNHSFT

This clinic is run by the Brain Injury Team and is suitable for everyone who attends the Emergency Department or has a brief inpatient stay following a head injury, and has residual problems.  The aim is to offer them at least one appointment at the ‘mild head injury clinic’ within a few weeks of their discharge.

GPs can also refer directly to this clinic for patients who have had a mild head injury. This may be associated with a brief loss of consciousness and/or a period of time for which the patient has no recollection. Scans may have detected no abnormalities as yet.

For many people there can be a range of unsettling symptoms including fatigue, headaches, dizziness, word finding difficulties, irritability and memory problems, which can persist for some time after the injury. There is evidence from two randomised controlled studies that an early brief intervention can reduce the severity of such symptoms several months later. The initial appointment includes information provision about the common consequences of head injury and subsequent recovery, and suggestions about reducing their impact. Such suggestions range from fatigue management and advice about returning to work and other activities, to specific strategies relating to concentration and memory difficulties. For many people the duration and impact of the head injury symptoms are exacerbated by understandable anxiety and frustration relating to these unfamiliar symptoms, and addressing such concerns can be an important element of early intervention.

In addition to the mild head injury clinic providing follow-up for patients who attend hospital, it can be a useful first contact for people even years after their head injury, as it can provide a brief assessment and inform subsequent referrals to appropriate head injury specialists when required.

The mild head injury clinic is run by the GHNHSFT Brain Injury Team’s clinical neuropsychologist.  There is also a clinic  once a month run by the physiotherapist and the psychologist. Patients are seen by the physiotherapist to address difficulties primarily with balance and dizziness.  A common consequence of a brain injury is dizziness, feelings of vertigo and poor balance. The team’s physiotherapist runs a clinic specialising in the identification of the source of the symptoms and the development of treatment programs to reduce patient’s difficulties (vestibular rehabilitation). Dizziness may also be assessed as part of a wider brain injury assessment in specific physiotherapy sessions.

Clinic appointments are held at the Outpatients Department at Gloucestershire Royal Hospital.

Please refer to:

Brain Injury Team (Mild Head Injury Clinic)
Ground Floor
Beacon House
Gloucestershire Royal Hospital
Gloucester GL1 3NN

Tel: - 0300 422 5139
Fax: - 0300 422 5133

Ongoing Secondary Care - Brain Injury Team - GHNHSFT

Brain Injury Team at GHNHSFT:

The Intensive Community Specialist Rehabilitation/ Early Discharge Programme is suitable for any in-patient who is currently receiving team input who would benefit from high intensity, continued therapy within their home environment.

Or

A patient who is currently receiving therapy at an out of county unit, whose therapy goals would be better met within their home environment.

Patients will be reviewed by the community based rehabilitation service to ensure the referral is appropriate and the service has capacity to deliver the required level on input/support.

The early discharge programme provides up to twelve weeks of home based intensive therapy which is delivered in two six week blocks. The intensity of therapy is higher in the first six weeks than in the second. A goal review meeting with the patient and the family takes place after the first six weeks of therapy to ensue the therapy plan is being effective.

Patient Inclusion Criteria for Intensive Community Specialist Rehabilitation/Early Discharge Programme:

  • medically stable and tracheostomy out (unless permament)
  • out of Post Traumatic Amnesia (PTA)
  • no risk to self or others. At low level on head injury risk assessment or manageable at a higher level, or unlikley to change with further inpatient stay.
  • to be able to transfer with assistance of one
  • appropriate feeding regimen in situ
  • appropriate support available at setting discharged to, e.g. family, care package
  • required specialist brain injury therapy input

Patient Exclusion Criteria for Intensive Community Specialist Rehabilitation/Early Discharge Programme:

  • patients with pre-existing conditions which would prevent them from engaging in the intensity of specialist rehabilitation provided by this service or whose needs are already being met by other appropriate services
  • stroke

In addition to Intensive Community Specialist Rehabilitation/Early Discharge Programme, GHNHSFT has a Brain Injury Group which provides an educational forum to support patients (aged 16 or over) and their family members/carers in the management of cognitive difficulties after head injury. During six sessions of two hours duration, it promotes an understanding of normal cognitive function and builds on this knowledge to ptovide strategies to help in the management of some of the common consequences of brain injury. Attendees need to have the ability to engage in group discussions and participate actively with tasks facilitated by a clinical psychologist and an occupational therapist. The aim of the group is to help patients reduce the impact of their symptoms on activities associated with daily living such as work. Quantitative and qualitative outcome measures around improved understanding of strategies to help manage ongoing difficulties, a reduction in carer burden, and an increased perceived ability to cope have been positive.

The GHNHSFT Brain Injury Team also runs a Fatigue Management Group which provides education, information and support for the patient (aged 16 or over) and their family members/carers relating to brain injury fatigue. The aim of the group is to reduce the impact of fatigue on daily life. Attendees need to have the ability to engage in group discussions facilitated by occupational therapists who provide information around fatigue management strategies, rest and relaxation, sleep hygiene, diet, stress, anxiety and fatigue, goal setting and how to manage relapses or setbacks.

The role of the physiotherapist after a brain injury is to assess the physical capabiltiies of a person, develop an appropriate treatment plan, provide advice to patient and carers and supply mobility aids if required.

Physiotherapy Assessment

Physiotherapy assessment may include:-

  • pain
  • sensation
  • proprioception
  • co-ordination
  • movement
  • strength
  • balance
  • tone/spasticity
  • transfers/gait
  • function

As part of the assessment we complete standardised outcome measures to monitor progress.

Vestibular assessment (may be completed as part of the Mild Head Injury Clinic Physiotherapy Service).

Physiotherapy Treatment

This may include the following and can either be a series of sessions or advice and review:

  • manual therapy techniques
  • exercise programmes to increase strength, balance, co-ordination
  • tone management
  • gait re-eduction
  • building stamina-endurance
  • home exercise programmes
  • vestibular rehabilitation

Treatment duration and timing is tailored to the individual patient need.

Patients may be transferred or referred to other relevant services such as orthotics, musculo-skeletal physiotherapy, pain management, botulinum toxin clinic etc.

Physiotherapists work and occupational therapists work together in order to support the patient to return to their normal functioning level where possible and provide splints or orthotics to assist with this. 

The role of the occupational therapist is to assess the functional impact of a brain injury on everyday life which can be physical, cognitive, behaviouralor communication difficulties which may impact on their ability to care for themselves, return to work or continue leisure/social activites.

The occupational therapist may:

  • help people to learn new ways of doing things, e.g. supporting someone with reduced stamina and fatigue to develop a structured routine to pace activities effectively and reduce the impact of fatigue on daily life.
  • give advice on how the home or workplace environment can be adapted to promote independence, e.g. ensuring wheelchair ramps are installed.
  • provide therapy sessions focusing on functional activities often alongside the physiotherapist in order to promote rehabilitation of previous skills, e.g. showering or preparing a meal.
  • adapt materials or eqipment to enable independence, e.g. adjusting a knife for someone with reduced hand dexterity.
  • provide therapy sessions focusing on upper limb range of movement, dexterity and co-ordination in order to promote functional recovery.
  • assess posture and seting and provide specialist equipment to promote good positioning and functional recovery, e.g. specialist wheelchair, splints.
  • assist a person to integrate back into the community using functional skills, e.g. shopping in the local supermarket using public transport, returning to leisure or social activities.
  • assist a person back to meaningful occupation; this may involve a return to work, starting a training course or volunteering

The role of the speech and language therapist is to provide specialist assessment, differential diagnosis, management and treatment od communication difficulties and swallowing problems (dysphagia) following a brain injury.

Communication

To assess, diagnose and treat oral and written communication problems such as:

  • cognitive communication disorders- commuication difficulties caused by cognitive impairments
  • receptive dysphasia- difficulty in understanding the spoken word
  • expressive dysphasia- difficulty in expressing thoughts and ideas
  • dysarthria- slurred or unclear speech
  • dyspraxia- difficulty with voluntary movements of the mouth, lips and tongue
  • dysgraphia- difficulty with writing
  • dyslexia- difficulty with reading
  • dysfluency- when the flow of speech is disrupted

The speech and language therapists may also be involved with the provision of communication charts, switches and high-tech communication equipment for patients whose verbal communication is not effective in all settings.

When a patient is unable to communicate, the speech and language therapists will be involved at the pre-verbal level, for example, in setting up programs to assess for consistent responses which, if successful, may then be used as a method of access for a communication device..

Dysphagia

To provide specialist assessment, differential diagnosis, management and treatment of dysphagia and make appropriate recommendations. This may include altering food or drink textures, looking at a patient's positioning or using compensatory strategies. Recommendations made will be regularly reviewed as required. Onward referral to videofluoroscopy (VF) and fibreoptic investigation of swallowing (FEES) as required.

In some cases patients may require alternative feeding such as a nasogastric tube (NG) or percutaneous endoscopic gastrostomy (PEG). Alternative feeding may be required for only a short period of time, if necessary, can be a permanent measure dependent on a patient's swallow recovery and level of alertness.

The role of the clinical psychologst within the Brain Injury Team focuses on two main areas; cognition and emotion.

The wide range of cognitive difficulties that can result from an acquired brain injury (including difficulties wih concentration, memory, organisation/planning and inhibition of behaviours) often have a significant impact upon a patient's ability to undertake activities of daily living, including work and family role, and upon their social interactions. Cognitive assessment can be undertaken by a clinical psychologist in order to identify particular areas of impairment along with areas of residual strength, in order to be able to recommend/implement appropriate management strategies, be that to the patient, their family, or their place of employment/education.

The emotional consequences of brain injury are an important aspect of aftercare, as they are in any long-term condition. Adjusting to a new set of abilities and limitations is often very distressing and frustrating, and in the context of cognitive difficulties this can be made even more difficult for patients and their families. Anxiety and depression are over-represented in this client group. In many cases the usual approaches to 'talking therapy' need to be tailored to take into account consequences of the brain injury. Both cognitive and emotional difficulties have an impact upon family members and loved ones as well as the person who has had the brain injury, and part of the role of the clinical psychologist is to offer information and support the family members.

It can sometimes be unclear as to when generic mental health services would be well placed to intervene regarding emotional sequelae post brain injury and when specialist brain injury input would be indicated, and often discussion with both agencies inform the most appropriate referral pathway. Recent literature indicated that brain injury is a client group in which the complexities of the presentation can make manualised/'standard' application of psychological intervention ineffective or harmful. There are certain situations in which it is likely that the referral process would be steered towards clinical neuropsychology within the Brain Injury Team. These would include evident congitive impairment (including language difficulties), evident neurobehavioural difficulties (e.g. impulsivity, disinhibition or aggression), the presence of existing brain injury team input (allowing for a multidisciplinary approach)

Patients with organic brain injury alongside psychological sequelae present with a complex mixture of neuropsychological, emotional, behavioural, family and systemic factors. If the patient has existing mental health difficulties pre-dating the brain injury it will be important for mental health services to be involved and liaise with the brain injury team in order to arrive at a joined-up plan of action.

Acute Neurology Service - GHNHSFT

The Gloucestershire Neurology Service aims to provide a patient-centred service to those with acute and chronic neurological illness, in both inpatient and outpatient settings. The team consists of medical, nursing and support staff, based at Gloucestershire Royal Hospital with outreach, where possible, to the entire Gloucestershire community.

Please follow the resource link below for contact information and useful information for GP's on Shared Care and Aids to Diagnosis.

Mental Health Services

                                                

While discussion of individual cases is often required, there is a precedent for mental health services to be able to manage anxiety and/or depression in the months following brain injury in the absence of any evidence neuropsychological constraints (e.g. cognition, communication, behaviour). Similarly, if anxiety and/or depression unrelated to the brain injury occurs a long time after the brain injury event there may be no need for specialist brain injury input  in the absence of neuropsychological constraints. If the neuropsychological constraints are mild enough that they do not hamper a more standardised approach then the patient may be able to engage with general mental health services, which may be advantageous to the patient where the onset of emotional difficulties is not related to brain injury.

If there is significant substance misuse which limits the patient’s ability to engage in rehabilitation, referral to substance misuse services for advice/intervention in the first instance may be more appropriate.

Referral to psychiatric services for mental health assessments should be made via 2G contact centre. Contact details and referral advice can be found here.

Headway Gloucestershire

Headway Gloucestershire was established to respond to the needs of acquired brain injury survivors, who are aged 18 or over and their families/carers in Gloucestershire.

The service does not offer any clinical services but provides long term therapeutic care in the years following a brain injury by delivering the following services:

Headway House provides a range of activities designed to support survivors of moderate to severe brain injury as they work towards their individual recovery goals.  Each day is structured with learning opportunities such as independent living skills, communication skills, cognitive skills, managing anger, relaxation, building self-esteem, multimedia skills, as well as offering practical courses such as woodwork and arts and crafts.  Headway aims to support survivors in their long term recovery and ongoing self-management and maintenance as well as provide an opportunity for respite from the caring role for family members.

Community Link advisers provide support to anyone in Gloucestershire who has had an acquired brain injury. This may include working closely with the family, friends, employers, colleagues and carers.  Advisers can provide recovery advice and information, assist with practical issues such as welfare benefits and housing, and support survivors to find opportunities for activity such as employment, volunteering, sports and leisure groups, in their own communities.

Headway facilitates a range of meetings and support groups to enable people with acquired brain injury, their families and carers to meet new people, share experiences, support one another and learn more about brain injury.

GPs can refer using this referral form, self-referral is also accepted from acute brain injury (ABI) survivors and carers via email or phone:

Headway House,
Great Western Road,
Gloucester,
GL1 3EP

Telephone: 01452 312713
Fax: 01452 310728
Email: admin@headwaygloucestershire.org.uk

Please see the Headway website for further information.

Gloucestershire’s Rehabilitation Commissioning Pathway for Adults with ABI

Please follow the resource link below for Gloucestershire’s Rehabilitation Commissioning Pathway for adults with ABI.

Ongoing Primary Care Management

Driving

All drivers are required by law to report any condition that may affect their ability to drive to the DVLA. Failure to do so can result in a £1,000 fine, invalidate their insurance and lead to possible prosecution if the person is involved in an accident. GP's have a vital role to play in ensuring that patients adhere to these rules.

If you have any reason at all to suspect that the injury will affect a patient's ability to drive you should tell them this and provide the number for the DVLA Drivers Medical Group. Please see the Headway Driving after Brain Injury information leaflet.

Further information can be found on the DVLA website: https://www.gov.uk/head-injury-and-driving.

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