Open Lecture – Is Rehabilitation Possible in Prolonged Disorders of Consciousness?

After the event

The Royal Hospital for Neurodisability (RHN) receives many referrals requesting rehabilitation for patients who are deemed to be in states consistent with a prolonged disorder of consciousness (PDOC). The RHN is one of a few centres in London accepting referrals for assessment of patients in PDOC.

It is commonly expected that a ‘referral to rehabilitation’ will result in streamlined movement along a pathway – where assessments, interventions, outcome measurement, care plans and discharge planning, will result in a composite endpoint that is desirable, acceptable, justifiable and affordable.

A prolonged disorder of consciousness (PDOC) is a condition where patients remain unconscious for longer than four weeks after a severe, often catastrophic, brain injury. They may be in coma, in a vegetative state (VS) or in a minimally conscious state (MCS), all requiring further time and assessment.

Rehabilitation, like love, is a ‘many splendoured thing’. It means different things to different people, often during the same event but at different times. Defining rehabilitation in the abstract either reduces or elevates it to the status of a concept, a process, a series of activities and, ultimately, a cost. This is the ‘rehabilitation’ expected of pathways, by some commissioners and indeed professionals. This is a relatively simple ‘input-activity-output’ model.

The vast majority of rehabilitation activity may indeed lend itself to such a model that appears simple, driven by demand and is measurable. This is likely to be successful for trivial injury or transient changes in physiological and, usually, physical status. ‘Mild’ traumatic brain injury on the other hand, can be anything but mild to those who have suffered it. Who has suffered this injury becomes far more important than what has happened. The bio-medical model – where the pathology and impairment burden alone are quantified and responded to, begins to crumble.

However, at the moderate-to-severe and profound end of the spectrum, this model does not work. If invoked, it turns out to be inefficient, ineffective, and cost-ineffective, resulting in significant stress to services and distress to all concerned.

Patients in PDOC are at the profound end of this spectrum. A threat to personhood and identity are at the core of this condition. Rehabilitation as a personal, active, participatory activity is impossible. However, rehabilitation is always person centred and family focused. It is proposed that ‘mapping’ persons in PDOC onto the framework of the International Classification of Function (WHO 2001) as a genuine bio-psycho-social undertaking (with further emphasis on the social), goes much further in obtaining the outcomes these patients truly deserve.

Speaker: Dr Andrew Hanrahan, Consultant Physician in Neuro-rehabilitation, Royal Hospital for Neuro-disability