F-28 Acute neurological disorders

Stroke is the archetypal acute neurological condition needing rehabilitation, and research into rehabilitation after stroke has greatly improved rehabilitation generally, not simply for people with stroke. Yet the organisational drive is for separate specialist stroke services, not involving rehabilitation experts. This drive extends to specialist separate services for people with traumatic brain injuries and many other conditions. The knowledge and skills needed for this competency cover neurological expertise and some knowledge of acute medical matters; while hyperacute, specific medical or surgical treatments will always be the responsibility of other specialities, rehabilitation teams are increasingly involved in hyperacute rehabilitation, starting with days of the acute incident. Thus, the team needs to be alert to treatable disease-related complications or late developments such as hydrocephalus after subarachnoid haemorrhage.

The acute neurological competency

The rehabilitation expert needs to be able to assess rehabilitation needs, give rehabilitation advice, and take rehabilitation responsibility for any patient with an acute-onset neurological condition from its onset. The additional document that can be downloaded shows the behaviours associated with this competency, the knowledge and skills needed, and some references. Further description of the competency including indicators and references can be downloaded here.

Introduction: acute neurological disorders

Patients with acute neurological conditions will have either peripheral nerve damage or disruption of the central nervous system. Peripheral nerve problems will be discussed less here. Within the central nervous system, acute spinal cord conditions, including but not restricted to spinal cord injuries, are covered in a separate competency.

The brain’s acute conditions are broadly localised or generalised (diffuse) and metabolic (e.g., hypoglycaemia) or non-metabolic (e.g., traumatic, vascular). These differences influence rehabilitation needs and prognosis. The primary exemplar conditions to know about are stroke, hypoxic brain damage, and traumatic brain injury.

Neurological knowledge.

Rehabilitation of people with neurological damage, acute or long-term, requires knowledge of neuroanatomy and neurophysiology, what functions are located where, and the nature of the functioning. For example, knowing that language function is located in the left cerebral hemisphere in about 90% of people alerts you to language loss in anyone with focal left hemisphere damage.

I was once asked to see someone after a traumatic brain injury who was wandering about the ward, apparently lost and had been diagnosed as being in post-traumatic amnesia requiring inpatient rehabilitation. One feature of his wandering had been observed but not considered; he always found his way back to his bed and never tried to get onto any other bed. This is incompatible with significant post-traumatic amnesia. The clue was in his acute CT brain scan; he had an intracerebral haemorrhage in his left temporal lobe.

It was then easy to show that he had significant aphasia. The problem was that nurses gave him instructions and pointed vaguely where he should go, but he could not understand what they were trying to tell him. Adapting communication to his abilities resolved the wandering, and he recovered spontaneously over the next seven days.

Another person I was asked to see after traumatic brain injury was referred to as someone destructive and aggressive, needing inpatient treatment in a secure behavioural unit. He had broken the sink off the wall of his room and turned his bed on its side with the wheels against a sidewall. Moreover, whenever anyone entered the room, he would scream at them to be careful. The diagnosis was disturbed visual perception, with his visual orientation flipped through 90 degrees. When I saw him, a colleague had just told me how, after her coronary artery bypass graft, she had experienced this for about four days and, being a curious investigator, she had asked other patients if they had had the same problem. Several admitted they had but were afraid to tell anyone in case they were considered mad.

Neurological experience

The best way to learn of usual and unusual neurological phenomena is to listen to the patient carefully; too often, we ignore or do not hear the most unusual symptoms.

A research colleague, John Marshall, listened to one person who described a supernumerary limb, now reported. Since then (1993), I have identified several similar patients, including one who believed his arm was a cow’s leg and another who apologised to me, in front of several people unknown to him, that he had left his other arm on the ward he came from.

One quick way to learn much about acute neurological disabling illness is to gain experience in the local acute stroke service. You will see much acute neurology and signs, better understand the natural history of stroke, and teach the stroke team about rehabilitation. It also helps to spend time in a neurological intensive care unit to gain experience with the most common acute neurological conditions.

Some essential skills

Patients with acute neurological conditions face not simply death but the prospect of long-term brain damage, which is, for most people, a frightening prospect, and it threatens a change in the person; most other acute conditions do not threaten identity so directly.

Thus, one skill is the ability to discuss concerns about identity, loss, and changing cognitive abilities. This can be a challenge. It requires humility and empathy (not sympathy).

Another skill is recognising and confronting rehabilitation’s cultural, ethical, and legal aspects. Many patients lose their mental capacity to make decisions in the acute phase, and some will face long-term severe disability. You are likely to be involved in the early stages, and you are responsible for raising questions about whether specific treatments are what the person would want. You must be familiar with using the Mental Capacity Act 2005.

Third, many patients presenting with acute neurological illness have functional neurological disorders. Often, this is not recognised by the acute medical service. Recognising that someone’s acute illness is functional is a vital skill.

Keeping a broad view.

Training in neurology takes 4-5 years; knowing about neurological disease can seem daunting to a rehabilitationist. It should not be. It helps to realise two things.

First, patients are much more concerned about and interested in their rehabilitation. While they appreciate a neurologist’s expertise in diagnosing and managing the acute phase, they are more worried about their future. Therefore, you need to acquire as much information about prognosis as possible and remember that you have unique expertise that most neurologists lack.

Second, PubMed and Google will rapidly give you the specific information you need. For example, I recently encountered someone with Alternating Hemiplegia of Childhood. I had never encountered it before and had never heard of it. Nevertheless, 30 minutes of searching and reading found enough to guide rehabilitation.

Thus, when seeing someone for rehabilitation after an acute illness, you should:

Listen to the history of its onset and progression to:
- Learn about the condition
- Check the diagnosis is correct
Be person-centred and take a broad perspective:
- Consider the long-term; discover the likely prognosis
- Consider the wider personal sequelae of the acute illness

Conclusion

Rehabilitation after acute neurological illness demands all knowledge and skills and additionally requires awareness of the personal and philosophical aspects of the patient’s illness. Because rehabilitation services tend to accumulate patients with more severe and unusual problems, you can learn about many exciting phenomena rarely seen by neurological services. Some may be previously unreported. Your great advantage is a long-term relationship with the person, giving you insight into prognosis that is not captured in formal research studies.