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Brain injury rehabilitation is a continuous and often long process. The recovery pathway is divided into a number of recognised processes or stages. It is important to remember that every single injured person is an individual and therefore his or her rehabilitation will also be individual, in terms of speed and process. For many of the individuals with brain injury there will be similar recognisable stages and these stages are helpful and important for them to achieve the best from their rehabilitation.
The injured person is in a state of coma often in an intensive therapy unit. They are completely reliant upon medical assistance. The family at this stage are bearing the brunt of all the emotional and psychological stresses, including shock, denial, helplessness and confusion.
Second and third stages
During this stage the injured person is waking from the coma state. They will often be confused, aggressive, and restless or they may be in a persistent vegetative state. As the patient moves into the third stage they will become fully conscious. However, at this time they will have difficulties with memory, problem solving and attentional behaviours. Sometimes this is difficult to assess due to the lingering effects of various drugs, which have been used in the ITU. The patient will often focus on physical injuries at this time and be unaware of other "brain injury issues". It is also important to point out that if a patient has been admitted with other multiple traumas that the brain injury issues may be completely undiagnosed this point.
Survival rates following severe brain injury have improved dramatically in recent years due to the advances in acute care. -Patel H, Bouama O, Woodford M, King A, Yates D, on behalf of the Trauma and research network, trends in head injury outcome from 1989-2003:Lancet 2005:336; 1538-43)
During this stage the patient is more aware of the problems they are experiencing with memory, attention, rational thought and planning. They will often become agitated and frustrated because of this realisation may lead to degrees of anxiety and depression. They may appear relatively” normal" and be aware of their personal responsibilities surrounding work and family. This stage is usually characterised by the brain injured persons’ overestimation of their abilities and their underestimation of their problems. Frustrations and emotions at this stage may be at the forefront of their outward appearance to their family, friends and colleagues.
This stage often coincides with some improvements of the patient's mental abilities. Although still experiencing issues with memory, problem solving, linguistic and emotional behaviours. Often reliance upon structure in the routine of their hours, days, weeks can help people get "back to their old self". This can also mask inadequacies. A good example of this is the patient on the ward who is still undiagnosed as having a head injury because of the heavily structured nature of life and routine in a hospital ward situation.
The patient is "found out" when the structure is removed from a work or home environment. This recognition of the difficulties at this stage often represents the first occasion at which the injured person begins to face up to the issues. This can be emotionally a very difficult time for all involved, again leading to more likelihood of anxiety and depression.
This stage sees a gradual acceptance of the deficits and an understanding of compensatory methods of working around the issues. Cognitive issues still remain to some degree but are less severe. Occasionally the patient may regress back to stages four and five, however these become less apparent. The injured person is able to accept that their life may have changed somewhat but that they have the tools to be able to cope.
The need for comprehensive and effective rehabilitation programs for these individuals is therefore ever increasing.
(ACNR, vol6, no2 May/June 2006, Seeley M, Hutchinson P)