Recent NHS data suggest that 50,000 people in the UK alone are living with a Spinal Cord Injury (SCI) [1]. These conditions can be life changing for the person directly involved, as well as having a ripple effect on loved ones around them, and wider economic impacts on society [2]. Although traditionally investigated separately [3, 4], one of the most commonly co-occurring conditions when someone suffers an SCI is Traumatic Brain Injury (TBI). Some research indicates that between 20–60% of people with a SCI will also have at least a mild TBI, particularly in those who acquire a traumatic SCI through motor collisions and falls [5, 6, 7].
Research suggests that having both an SCI and TBI poses unique rehabilitation challenges compared to having either condition alone. Firstly, individuals with both conditions may require additional adjustments during SCI rehabilitation, such as a longer stay in inpatient settings [8]. These individuals may also need early discharge planning and rehabilitation professionals and carers may need additional training to ensure more time and personalised support is provided so that the individual can safely return home [9]. Those with both conditions may also face the potential cognitive difficulties of a TBI. Processing speed, memory, problem solving and language skills may be impaired by a TBI, all of which are key in the learning involved in all aspects of the SCI rehabilitation process [10]. Depending on the severity of the injury, patients may suffer major cognitive impairments impacting their SCI rehabilitation. Some patients, however, may acquire milder cognitive impairments associated with mild TBI, and there is therefore a risk that these difficulties will be missed by rehabilitation professionals, thus limiting the therapeutic gains which can be made through rehabilitation [11]. Moreover, although most with a mild TBI will make a full recovery, a minority will still be recovering at 3–6 months and a smaller minority will have long-term or permanent deficits which can impact on rehabilitation. Suffering a TBI in addition to a SCI may also have a greater emotional and relational impact on the survivor and their families as they adapt to life with both conditions [12].
Due to these difficulties associated with TBI often being ‘hidden’, theories around ‘invisible disabilities’ after TBI provide the theoretical framework for the current study. The theory suggests that people with invisible disabilities may not ‘pass’ as having a disabled identity, as their difficulties are not represented visually. Since their difficulties are not ‘seen’, they are not ‘read’ as disabled, which may lead to other people developing negative beliefs about people with hidden disabilities ‘looking well’, and their additional needs may not be recognised as the external appearance does not match internal reality [13]. Applied to TBI, invisible disability theory may predict that invisible disabilities associated with TBI may not be ‘seen’ by clinicians working in a spinal injury context where disability is typically marked through visual cues. Thus, patients may be labelled rather than invisible disabilities being identified which are attributed to a potential underlying TBI. This may thus mean that TBI may be under-detected, and the additional needs of someone with a TBI in addition to an SCI may not be fully met.
Despite the high concurrence of SCI and TBI and the additional barriers faced by those with a dual diagnosis and their families, TBI in those with a spinal injury remains poorly detected. Previous literature has highlighted many barriers to spinal injury services in detecting and tailoring rehabilitation to patients with a TBI. For example, TBI often is not considered by rehabilitation professionals, is poorly documented, and cognitive screens may not be administered [14, 15]. One recent study by Sharma and colleagues [16] found that more than half of patients referred to acute settings for traumatic SCI rehabilitation had TBIs which had been missed, with more TBIs being missed in falls and assaults compared to motor accidents. Therefore, the researchers suggested rehabilitation professionals may have varying perceptions about how often TBI occurs based on the mechanism of injury. Nonetheless, recent guidelines state that SCI rehabilitation services should be screening for TBIs in this population; the clinical reference group, who set standards for the UK SCI rehabilitation centres has agreed, for the first time, for pre-screening of psychological needs associated with TBI to be part of their core recommendations.
Service Context
This project aims to assess and improve the detection and consideration of TBIs in those undergoing rehabilitation at the National Spinal Injuries Centre (NSIC) in Stoke Mandeville Hospital in Buckinghamshire, a 114 bed rehabilitation unit for people adjusting to life after a SCI. Although the NSIC is specialised in spinal injury rehabilitation rather than brain injury, due to the nature of SCIs, research suggests many individuals admitted to NSIC with SCIs may also experience at least a mild-moderate TBI [17]. Furthermore, despite the clinical reference group’s new guidance, initial discussions with outreach and inpatient staff suggested TBIs are often not detected at NSIC or not recorded prior to referral, and are often not routinely screened for upon admission.
The Current Study
Thus, this service improvement project aims to address the following questions emerging from the existing literature and the service needs at the NSIC: Firstly, is the number of patients reported to have TBI by the NSIC in line with national figures suggested by existing research? Next, what are the barriers to identifying and considering TBI during rehabilitation according to clinicians? The project subsequently aims to improve the NSIC’s detection and response to TBI in patients admitted for SCI rehabilitation.