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Response to: Management of traumatic brain injury: practical development of a recent proposal

Lucia M Li, Michael D Dilley, Alan Carson, Jaq Twelftree, Peter J Hutchinson, Antonio Belli, Shai Betteridge, Paul N Cooper, Colette M Griffin, Peter O Jenkins, Clarence Liu, David J Sharp, Richard Sylvester, Mark H Wilson, Martha S Turner and Richard Greenwood
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DOI: https://doi.org/10.7861/clinmed.resp.22.4
Clin Med July 2022
Lucia M Li
AImperial College London, London, UK and UK DRI Care Research & Technology Centre, London, UK
Roles: NIHR clinical lecturer
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  • For correspondence: richard.greenwood2@nhs.net
Michael D Dilley
BAtkinson Morley Regional Neuroscience Centre, London, UK and Royal College of Psychiatrists, London, UK
Roles: consultant neuropsychiatrist
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Alan Carson
CCentre for Clinical Brain Sciences, Edinburgh, UK
Roles: consultant neuropsychiatrist and honorary professor
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Jaq Twelftree
DHomerton University Hospital NHS Foundation Trust, London, UK
Roles: AHP consultant in neuro-rehabilitation
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Peter J Hutchinson
EUniversity of Cambridge, Cambridge, UK and Royal College of Surgeons, London, UK
Roles: professor of neurosurgery
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Antonio Belli
FNational Institute for Health Research Surgical Reconstruction Research Centre, Birmingham, UK and Institute of Inflammation and Ageing, Birmingham, UK
Roles: professor of trauma neurosurgery
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Shai Betteridge
GSt George's University Hospitals NHS Foundation Trust, London, UK
Roles: consultant clinical neuropsychologist
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Paul N Cooper
HManchester Centre for Clinical Neurosciences, Manchester, UK
Roles: consultant neurologist
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Colette M Griffin
ISt George's University Hospitals NHS Foundation Trust, London, UK
Roles: consultant neurologist
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Peter O Jenkins
JEpsom and St Helier University Hospitals NHS Trust, London, UK, St George's University Hospitals NHS Foundation Trust, London, UK and Imperial College London, London, UK
Roles: consultant neurologist
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Clarence Liu
KHomerton Hospital, London, UK and Barts Health NHS Trust, London, UK
Roles: consultant neurologist
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David J Sharp
LImperial College London, London, UK and UK DRI Care Research & Technology Centre, London, UK
Roles: NIHR professor and consultant neurologist
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Richard Sylvester
MNational Hospital for Neurology and Neurosurgery, London, UK
Roles: consultant neurologist
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Mark H Wilson
NImperial College Healthcare NHS Trust, London, UK and Imperial College London, London, UK
Roles: professor of brain injury
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Martha S Turner
OHomerton University Hospital NHS Foundation Trust, London, UK
Roles: principal clinical psychologist and neuropsychologist
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Richard Greenwood
PNational Hospital for Neurology and Neurosurgery, London, UK and Homerton University Hospital NHS Foundation Trust, London, UK
Roles: neurology consultant
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We thank our rehabilitation medicine colleagues for their comments on our article, which illustrate how strongly all healthcare professionals involved in the care of patients with traumatic brain injury (TBI) feel about the urgent need to improve clinical services.1,2 TBI patients desperately require a pathway that delivers effective, personalised acute and chronic care, and we would like to emphasise that our pathway does not propose replacing rehabilitation physicians and facilities. Rather, we view rehabilitation services as a crucial part of any TBI pathway, and rehabilitation is a highly suitable background form which to recruit leaders of specialist TBI teams.

We entirely agree with Wade that effective rehabilitation is a person-centred process, which depends on an expert multidisciplinary team, working collaboratively within a framework and care pathway derived from the biopsychosocial model of illness towards agreed goals, with treatment appropriate to the individual patient's needs.3 However, any model of rehabilitation must:

  • be underpinned by correct neuroscientifically-based diagnoses

  • be accessible to those that need it.

A robust, structured care pathway does not currently exist for most patients with TBI. This deficit is, in our view, not solely resource-related. It is also down to lack of specific training and, thus, expertise in the neuroscientific diagnostics, clinical management and specialist rehabilitation needed by these patients. Conditions with comparable health and societal impact, such as heart attacks or stroke, all have specialist pathways that are highly effective. In contrast, vast numbers of TBI patients never get to see anyone with specialist knowledge in TBI and miss out on multidisciplinary input that is needed to treat the wide range of complex post-traumatic problems that often arise. This is especially the case for those with milder TBIs who present to smaller hospitals or general practitioners. This is why we proposed a structured pathway to deliver specialist, multidisciplinary care to TBI patients from their presentation to healthcare services through to the management of any long-term conditions. A structured pathway also helps to avoid patients being ‘lost in the system’, promotes service evaluation and supports much-needed research.

We firmly believe that a wide range of specialties should be part of this pathway, in order to best serve the whole spectrum of TBI patients. It surely cannot be controversial to advocate that TBI patients, who have received an injury to the brain, should have increased access to neurologists, neurosurgeons and psychiatrists, as well as rehabilitation teams. One challenge in managing TBI patients is the heterogeneity of clinical presentations and comorbidities. Consider an elderly patient admitted with TBI in the context of pre-existing cognitive problems, a contact sports player with prolonged symptoms after repeated hits to the head, a young person with severe behavioural or addiction issues after TBI, or a patient with refractory epilepsy following severe TBI. All these cases require careful diagnostic engagement from a range of interacting specialties, and the availability of a range of different treatment and rehabilitation strategies. The adoption of our proposed TBI pathway would facilitate early diagnoses of post-traumatic problems and specialist multidisciplinary care, and is complementary to and enhances currently existing services.

Our paper proposes a pathway that unites all healthcare professionals involved in TBI care under a structure that delivers specialist and multidisciplinary care to every single TBI patient. Many therapies and specialties are needed in TBI care and some patients will require more from one area than another. We can only improve TBI care by working together, learning from each other and combining our skills. Perhaps a first step would be a joint meeting, with the aim of designing a training fellowship that would provide the TBI teams of the future?

  • © Royal College of Physicians 2022. All rights reserved.

References

  1. ↵
    1. Wade DT
    , Nayar M, Haider J. Management of traumatic brain injury: practical development of a recent proposal. Clin Med 2022;22:353–7.
    OpenUrlAbstract/FREE Full Text
  2. ↵
    1. Li LM
    , Dilley MD, Carson A, et al. Management of traumatic brain injury (TBI): a clinical neuroscience-led pathway for the NHS. Clin Med 2021;21:e198–205.
    OpenUrlAbstract/FREE Full Text
  3. ↵
    1. Wade DT
    . What is rehabilitation? An empirical investigation leading to an evidence-based description. Clin Rehabil 2020;34:571–83.
    OpenUrlPubMed
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Response to: Management of traumatic brain injury: practical development of a recent proposal
Lucia M Li, Michael D Dilley, Alan Carson, Jaq Twelftree, Peter J Hutchinson, Antonio Belli, Shai Betteridge, Paul N Cooper, Colette M Griffin, Peter O Jenkins, Clarence Liu, David J Sharp, Richard Sylvester, Mark H Wilson, Martha S Turner, Richard Greenwood
Clinical Medicine Jul 2022, 22 (4) 358-359; DOI: 10.7861/clinmed.resp.22.4

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Response to: Management of traumatic brain injury: practical development of a recent proposal
Lucia M Li, Michael D Dilley, Alan Carson, Jaq Twelftree, Peter J Hutchinson, Antonio Belli, Shai Betteridge, Paul N Cooper, Colette M Griffin, Peter O Jenkins, Clarence Liu, David J Sharp, Richard Sylvester, Mark H Wilson, Martha S Turner, Richard Greenwood
Clinical Medicine Jul 2022, 22 (4) 358-359; DOI: 10.7861/clinmed.resp.22.4
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