Q. What is Acquired Brain Injury (ABI)?
A. ABI is damage to living brain tissue that causes impairment of normal brain function and can be caused by:
- 'internal' events such as a stroke (CVA), brain tumours or neurological disease,
haemorrhage, aneurysm, viruses/infections such as meningitis, hypoxic (oxygen) starvation, events which might be the result of cardiac arrest, drug abuse, near drowning. Some of these events (e.g. stroke, tumour) can cause localised damage, while others (e.g. meningitis, anoxia) can cause
widespread damage.
- 'external' events such as road traffic accidents (RTA) - by far the most common
cause of brain injury, domestic/industrial accidents and falls, sports/recreational
injuries and assaults.
It might be useful to clarify the different terminology used when referring to brain injury since many names are used. For example, Head Injury, Brain Injury, Traumatic Brain Injury (TBI), Acquired Brain Injury (ABI).
In general, ABI is used as an umbrella term that encompasses all brain injuries that have been acquired at some stage in an individual's life. The terms TBI and Head Injury are used interchangeably to refer to damage caused by external events when the damage is a result of
some kind of head trauma that causes sudden physical damage to the brain. Since external events are the most common cause of brain injury, this Handbook will concentrate on ABI.
Although many of the issues discussed will be applicable to other kinds of injury that causes widespread damage, the term 'brain injury' will be used throughout this Handbook.
Q. What does the brain do and how does it work?
A. The brain is the control centre for all the body's functions such as walking, talking, swallowing, breathing, taste, smell, heart-rate and so-on. It also controls all of our 'thinking' functions, our emotions, how we behave and all of our intellectual ('cognitive') activities, such as how we attend
to things, how we perceive and understand our world and physical surroundings, how we learn
and remember and so-on.
Everything in fact!
It follows therefore that damage to the brain for whatever reason can impair some or all of these functions or activities. How much impairment and person will have will depend on the type, location and severity of the injury.
It will help to understand this if we have a look at the structure of the brain and the functions of the different areas within it.
For further information on 'Understanding the Brain' see our research library.
Q. How does the brain get damaged in a 'traumatic brain injury'?
A. A traumatic brain injury is not usually caused by one event but by a series of events. These are usually classified as Primary and Secondary events. The primary event is direct damage to the brain at the point of impact.
The secondary events is are the complications that may arise in the minutes, hours and days following the impact - due to a lack of oxygen and the brain's reaction to the initial insult.
Before you read on it is important to remember that the injuries described cover a range of possibilities - they will not apply to everyone who has sustained a brain injury.
For more information on how the brain gets damaged see our research library.
Q. What are the consequences of brain injury?
A. Depending on the nature and severity of the injury the consequences of a brain injury can range from quite subtle (or temporary impairments in thinking and behaviour), to permanent cognitive impairments and personality changes. These can be devastating for both the injured party and
their family.
In the early weeks following a brain injury there will almost certainly be profound physical
difficulties. Some of these will be overcome in the following months, some will take much longer
and some will be permanent. However, research indicates that around 90% of severely injured people overcome most of their physical difficulties within the first year. Although continuing
physical difficulties can present problems it is the cognitive difficulties and personality changes
that are the most distressing since these have a greater impact on social, work and family life.
Remember, not all of these problems will be experienced by everyone. Just as the nature of brain injury is unique so are the people to whom it happens.
For further information about the consequences of brain injury in our research section.
Q. Will the brain recover?
A. Unlike other cells in o the human body, brain cells do not regenerate when they are destroyed, yet the brain does appear to recover quite spontaneously. The pattern of recovery is usually
one of rapid gains in the first six months, then a plateau, then further but less obvious gains
in the years that follow.
You may have heard that no more progress can be expected beyond two years. Indeed old textbooks make this categorical statement. However, professionals currently working in the field of neuro-psychological rehabilitation hotly dispute this assumption. While most of the progress does appear to be made in the first two years, improvements can continue for very many years.
Families and individuals with direct experience of brain injury will confirm this.
It is not perfectly understood how the brain recovers but research suggests that the brain, particularly the younger brain, is flexible (brain plasticity). Remarkably, it tries to reorganise itself in an attempt to regain lost function.
Well all have millions of 'spare' brain cells. It is thought that the majority of recovery that is witnessed is due to functional areas of the brain taking over the activities of the damaged areas.
It does this by establishing new nerve pathways using these undamaged 'spare' cells.
These new pathways will only be established if the injured person repeatedly practises the skills/actions that have been disrupted. Recovery depends on continuos but targeted stimulation
of the brain to the area needed, whether this is sensory stimulation, exercising muscles and joints
or re-training skills of everyday living. In effect, recovery is a matter of learning and re-educating through a process of continuous rehabilitation.
Before moving on to discuss Rehabilitation, it is important to realise that no promises are made in relation to the amount of recovery that will be achieved. Many families believe that rehabilitation is the 'cure all but no matter how extensive it is, there will always be a limit to its effectiveness. You will hear the phrase that "every brain injury is different"; just as every person who suffers one is different. The degree of recovery will be influenced by many factors including the nature and degree of the brain damage and the age and lifestyle of the injured person.
However, as you will discover in the following pages, amazing gains can be made even after the
most severe brain injury.
Q. Who is involved in the rehabilitation process?
A. The answer is everyone. All 'concerned' parties are involved in combining their efforts to
help the injured person regain as much lost function as is possible so enabling them to achieve
their fullest potential and highest possible quality of life (including of course the injured person themselves).
The process of rehabilitation can be thought of as 'formal' when applied by the rehabilitation team and 'informal' when applied by family members and carers. Formal rehabilitation tends to be for specific periods whereas informal rehabilitation can supplement (and so inform) the formal rehabilitation. For a very long time after the injured person has been discharged from hospital or from a specialist rehabilitation unit.
Research consistently shows the importance of the family in the rehabilitation process. People
who make the best recovery are those whose families actively work with the rehabilitation team
and who continue those processes at home. This applies not only to the early stages of rehabilitation but also to vocational training programmes, such as those offered by Rehab UK later in the rehabilitation process. That is, those family members who actively participate and support the endeavours of the Rehab UK teams at their Brain Injury Centres, are more likely to realise sustained employment for their loved ones. The programmes offered by these Centres will
be discussed in Section 5. For now, we will look at the rehabilitation team that you will first come across in hospital or in a neuro-rehabilitation centre.
Q. Which professionals make up the rehabilitation team?
A. A number of clinicians (as well as doctors and nurses who will have been working as team very closely with the family. Depending upon the nature of the injuries, the injured person may
work with one, two or more of the team. As mentioned in the introduction, practising clinicians have contributed to Section 4.
Firstly, let us look at the make-up of the team.
Q. What factors influence a successful return to work?
A. A number of factors, including the nature and severity of residual difficulties, particularly the degree of self-awareness and how well the person has adjusted to their disability; the nature of the pre-injury occupation; the timing and management of the return to work; the employer and co-worker support.
Success in obtaining and/or sustaining employment depends on the person being able to do the job - that is they must have the cognitive and social skills that the job demands. When considering a return to work it is very important to be realistic about this and to take advice from the rehabilitation team. Unrealistic expectations due to reduced insight can present a formidable barrier to a successful return to work.
There is no doubt that from our own experience and from related research, the degree of self-awareness and adjustment to difficulties is a critical factor in recovery. Those people who have reached a realistic acceptance of their difficulties will take on-board and practise compensatory strategies that will realise effective functioning. They will open their minds to alternative suggestions for employment if a return to their pre-injury occupation is not feasible. In short, a person must accept their new difficulties before they can learn to use alternative strategies and realise 'success' again.
It is extremely important to learn social skills to initiate a good working relationship with work colleagues. Research/evidence has consistently shown that poor interpersonal skills are the biggest barrier to a successful return to work. Predictable but cognitive disability can lead to an inability to interact with work colleagues Characteristics in which this is displayed include impulsive behaviour, lowered tolerance, lack of insight and awareness, emotional lability, rigid and inflexible thinking.
Q. Is it possible to go back to work too soon?
A. It is quite natural to want to go back to work as soon as possible. However, people often make the mistake of thinking that because they are feeling physically able to return to work, they will be able to cope with the wider demands of the job. Many jobs are lot because the person returns to work too soon. Typically, they will overestimate their abilities and underestimate the effects of fatigue on performance. Many expect to be able to work a full day straight away and finding out that this is not infact possible for various reasons (already suggested in this Section) can be devastating to confidence and self-belief. It is therefore an essential part of the work of any rehabilitation team to help the person identify both the most suitable type of future job once all variants are taken into account.
Q. How can my employer and co-workers support me?
A. The need for support from both your boss and co-workers cannot be over-stated. It is very important that at the very least your 'line manager' (if applicable) knows a little about the long-term effects of brain injury. With this knowledge they will be able to supply understanding and support when and where necessary. Like many people, employers tend to view disability as a physical condition. When they see no obvious outward signs, such as a wheelchair, they might assume the person fine. Often referred to as a 'hidden disability', subsequent ignorance of brain injury can easily lead to a misinterpretation of events. For example, loss of initiative or fatigue can be interpreted as laziness. The injured person may be asked to stay late to complete additional duties. 'Pride' may lead them to not often refuse such a request, but they required tasks may not be completed to a satisfactory standard.
Because of these examples of potential misunderstanding, a crucial part of the role of the Rehab UK Job Coach is to educate and support the employer as well as the client.
Q. How then can a return to work be 'managed'?
A. A gradual return to work is important, as are easier working conditions and easier work tasks. This will allow the person to build up their stamina and capabilities: a situation that may need to continue for quite an extended time. Ideally, it should start with just a few hours per day initially, gradually building up as stamina improves. However, before a gradual return to work is considered, there should be evidence that the injured person can maintain concentration, having sufficient stamina to work safely and effectively for a specified period in the working day.
Easier working conditions may include a quieter working environment that is free from unnecessary distractions as filtering such distractions is difficult for someone following a brain injury. Consideration will also have to be shown for any physical difficulties; wheelchair access, adapted computers etc. Such 'special aids' can be obtained from your Disability Employment Advisor (DEA) based at the local Job Centre, under the 'Access to Work' scheme.
Having someone to act in a mentoring capacity would be useful if such was required. As an employer/line manager for example, you might not be able to find the time yourself to devote to special requirements. Conscripting somebody to take-on this role might be dually beneficial. None of us are the best judges of how we are 'managing' with new tasks in our work. This is of particular relevance to somebody with brain injury, so the employer just has to use common sense in dealing with the situation.
Our advice to an injured person looking to re-enter the employment market following brain injury, is that it is often better to start-off with some voluntary work or maybe a short college course where strengths and weaknesses can be identified early. If you are still based within a hospital /neuro-centre, your OT will be able to pass you on to the local DEA, and in turn your DEA (depending on locality) could recommend you to Rehab UK. Anyone who works within disability employment will say that a successful return to work depends on:
- A good match between job and current abilities/skills.
- Sufficient stamina to get through the working day.
- Attention and concentration adequate to 'realise' work tasks.
- Acceptable interpersonal/social skills.
- Mentoring/ Job Coaching.
Q. What about those who are unemployed pre-injury?A. Finding work is difficult enough for anyone especially if you are over 40. It is particularly hard for people who have has brain injury. It is a fact that many employers think twice about employing anybody who has been out of work for an extended period, especially when due to illness.
The injured person may be unable to complete an application form pre-interview. If they manage to reach the short-list they may not sufficiently impress and interviewer; they may suffer from a reduced speed of thinking or not have regained sufficient social/interpersonal skills to be able to judge how an interview is going. Make contact with your DEA when the time is right for you. They can be of invaluable help.
To find out more on returning to work after a brain injury see our research section.
Legal IssuesAnyone who suffers brain injury in an accident should seek preliminary advice from a specialist personal injury solicitor about the possibility of compensation as soon as they can. Compensation can only be awarded for injuries received if it can be demonstrated that another party was negligible for the accident, either wholly or partly.
However, even if the injured party appears to be solely responsible it is worth seeking advice in case there can be identified limited negligence on the other party. For example, an employer may have supplied a driver with a vehicle that had defective brakes.
The initial interview is usually free of charge and will take as long as is necessary to establish whether there is a case for claiming compensation. The solicitor will need to get a clear picture of the circumstance surrounding the accident and the nature of the injuries sustained. In the case of severe injury, the first assessment interview may take place in the hospital.
Q. How do I select the right Solicitor?A. This can be a difficult and daunting task since few of us are in a position to judge who has the necessary expertise. There are some every good solicitors, many of whom specialise in personal injury claims but this does not necessarily mean that they have brain injury expertise. It is very important that you select one who specialises in brain injury litigation.
The medical / rehabilitation team at the hospital or brain injury units may be able to recommend some specialist firms. Within this Handbook you will find details of some personal injury lawyers with the necessary experience in brain injury litigation. If none of these companies are in your area, there are a number of professional bodies that can provide you with the names of specialist firms, such as:
- The Law Society
- Association of Personal Injury Lawyers (APIL).
- Victims of Medical Accidents (AVMA) -for alleged negligence cases.
Solicitors can belong to the APIL and AVMA.
Memberships of these organisations suggest an interest in personal injury cases though you still need to confirm that they have brain injury expertise. There are also voluntary organisations such as Headway and The Children's Head Injury Trust that can provide a list of legal firms that are experienced in brain injury litigation.
Q. What happens if the solicitor thinks you have a valid claim?
A. If you are happy with the initial advice received from the solicitor you will need to instruct them to act for you. The solicitor will collect evidence from all concerned parties in order to establish liability (the legal term for 'blame'). This may include interviewing and obtaining evidence from witnesses and in the case of road accidents, getting police reports. (The time that this takes depends on the complexity of the case). Alleged medical negligence claims are particularly complex. (You might like to refer to the Spring 2002 edition of "Re-New" for its legal advice article).
If, after collecting the evidence, your solicitor thinks that liability can be established, he may apply to the court for what is called a 'Summary Judgement'. This enables part of the claim to be dealt with quickly before going to trial. Alternatively the issue of liability may need to go to trial and may take place before the trial for financial compensation. If you are worried about going to court, remember, the vast majority of cases are settled out of court.
The solicitor will also need to collect evidence to establish the effects of the brain injury on all spheres of future life; short-term, long-term, future health and work prospects. This is necessary to calculate financial compensation (called 'Quantum'), and will involve arranging for specialist reports from a variety of professionals. These sources will vary depending on the nature of the injury but could include reports from any one of the following:
Doctor (GP) / Specialist who may have been involved in early care. Physicians, surgeons (possible neuro-surgeon), orthopaedic surgeon, plastic surgeon.
A neuro-psychologist for an assessment of cognitive skills, personality and judgement regarding future prospects.
Consultant. An independent medical report to provide a medical overview.
Case manager - if one is involved.
Reports may also be requested from an OT, Psychiatrist, school or former employer and possibly an employment rehabilitation consultant to advise on occupational potential/ earning capacity.
In the case of severe brain injury this part of the claim can (and should) take a long time, not least because of the recovery time.
Q. How is the financial compensation calculated?
A. Calculating a Personal Injury Claim (PIC) is a highly specialist procedure. Both you and your solicitor will need to ensure that every eventuality is accounted for and that records are kept so that you can claim for every loss and expense.
To give you some idea of what is involved, PIC's have two elements: special damages and general damages. Special damages are awarded to compensate for all direct financial loss incurred as a result of the accident (e.g. cost of equipment, private medical fees, travelling expenses, damage to vehicle and clothing, loss of wages etc).
General damages have three components: firstly, pain, suffering and loss of amenity (amenity refers to loss of capacity due to physical or psychological problems): secondly, loss of earnings (inc. future earnings) or promotion prospects, and thirdly, care needs (e.g. cost of providing specialist care, cost of specialist rehabilitation/therapies, cost of accommodation, special aids and adaptations and transport.
Q. Do I have to wait until the case is settled before I get any money?
A. Not necessarily. Your solicitor can apply for an interim payment and should do if at all possible. This involves applying to the 'other side' (called the defendant) for some of the damages immediately or well before the case is settled. As we have discussed, rehabilitation can make a tremendous difference to the quality of recovery and eventual independence. An interim payment will enable the brain injured person to obtain whatever is needed to aid their recovery when it is needed, as opposed to waiting until the case is settled, which can take up to four years. Applying for an interim payment involves the insurers of the defendant paying some of the damages before the case is finalised.
Q. Is there a time limit on making a claim for compensation?
A. Where the injured person is an adult, the legal time limit for accident claims is normally 3 years. However, there are exceptions:
In serious head (brain) injury cases where the person is so seriously disabled that they are incapable of managing their own affairs, there is no time limit for starting the case. However, certain criteria foe establishing this are very rigid and you need to get advice from a solicitor on this matter. There are, for example, many brain injury victims who cannot readily manage their own affairs and yet still cannot get exemption from the time limit. In some cases, particularly medical negligence cases, the injured person may not be aware that they have been injured as a result of someone else's mistake until 3 years have passed. The solicitor will examine the circumstances surrounding the injury and then advise whether the injured person is still 'in time' for bringing a claim. If the victim is a child at the time of the accident, the 3 year clock doesn't start ticking until they reach the age of 18 years.
