Time for Change in Acquired Brain Injury. The Lancet, 2019
Time for change in acquired brain injury
David K Menon, Chris Bryant, MP. The Lancet, Neurology, CORRESPONDENCE| VOLUME 18, ISSUE 1, P28, JANUARY 01, 2019
https://doi.org/10.1016/S1474-4422(18)30463-0
The term acquired brain injury includes several conditions that affect clinical outcome and quality of life in survivors. The most common causes include traumatic brain injury, stroke, and hypoxic-ischaemic encephalopathy after cardiac arrest. Acquired brain injury is a rapidly growing public health problem, resulting in nearly 1000 hospital admissions each day in the UK, with about a 10% increase in incidence over the past decade. Although improvements in emergency care (eg, through major trauma centres, stroke units, and bystander cardiopulmonary resuscitation) have resulted in improvements in survival, neurorehabilitation provision for survivors is inadequate, and their reintegration into society is limited by a poor understanding of the consequences of acquired brain injury among non-specialists and the public.
In this context, Time for change,1 the report produced by the UK All-Party Parliamentary Group on Acquired Brain Injury (APPG-ABI), argues for a better link between acute and post-acute care and makes a series of recommendations about other policy areas that need to be addressed. The APPG-ABI consists of UK Members of Parliament who have come together, with organisational support from the UK Acquired Brain Injury Foundation, to gather input from patients, patient support organisations, and health professionals.
Acquired brain injury leaves survivors with a considerable burden of physical, cognitive, and psychosocial sequelae, and can also increase the risk of late neurodegenerative disease. Early neurorehabilitation is cost-effective and can minimise residual disability. However, neurorehabilitation resources across the UK are patchy and inadequate, implementation of past recommendations is poor, and the use of rehabilitation prescriptions is inconsistent. The report recommended a national review of neurorehabilitation provision and better recording of numbers of patients presenting at emergency departments with acquired brain injury.
Many survivors of acquired brain injury are children and young people. However, many education professionals do not have awareness and understanding of acquired brain injury, which hampers educational progress and neglects an important opportunity for rehabilitation in the school environment. The report recommends inclusion of acquired brain injury in the Special Educational Needs and Disability Code of Practice, and that education professionals should have a minimum level of awareness and understanding about acquired brain injury, with additional training for named lead professionals.
Children and young people with traumatic brain injury are more likely to develop behavioural problems that are linked to an increased propensity to criminal offending. Individuals in custody report a higher incidence of brain injury than the general population, but acquired brain injury is rarely considered in the justice system during police or court interviews, sentencing, or while assessing rehabilitative needs. Identifying and managing the consequences of acquired brain injury at an early stage could have substantial individual, societal, and financial benefits. The report indicated that these gains could be realised by better awareness of acquired brain injury among the professionals in the criminal justice system, assessment of individuals for brain injury when they enter the system, and ensuring that all stakeholders working in this context check that the rehabilitative needs of such individuals were appropriately addressed.
Sport-related concussion is probably the most common cause of traumatic brain injury, and the small proportion of patients who have persistent post-concussional symptoms beyond 2 weeks is still a large number of patients. Repeated concussion might also predispose patients to late neurodegenerative disease. The report highlights the need for clear guidelines to establish the management, recovery, and safe return to play after a sport-related concussion.
Furthermore, the report noted that many acquired brain injury survivors lose employment and income at a time when they are especially vulnerable. These difficulties are accentuated by the complexity of processes involved in accessing welfare benefits, which are challenging to acquired brain injury survivors, many of whom have cognitive problems. These problems can be compounded by poorly informed assessors with poor knowledge of acquired brain injury. The report recommended increasing assessment intervals and improving training of assessors.
This report was published almost exactly a year since The Lancet Neurology Commission on traumatic brain injury2 was launched, with the aims of influencing research funders and policy makers. The first of these aims has been substantially realised through interactions with the International Initiative for Traumatic Brain Injury Research. The engagement of policy makers and patient organisations has resulted in outputs more slowly, but the report from the APPG-ABI is a very welcome step in the right direction.
