UK: NICE Guideline: Rehabilitation for Chronic Neurological Disorders Including Traumatic Brain Injury

Ebb Tide said:
It is 15 years since I worked in the field so the use of the terminology may have changed, but my understanding of acquired brain injury was an overview term for brain injuries/damage not present from birth or the perinatal period.

Traumatic brain injury results from external direct forces such as road traffic accidents, assaults, gunshot injuries, falls, sporting injuries etc. although will result in additional damage from internal shearing/rotational forces and bruising to the brain and swelling within the cranium.

Some examples for acquired brain injury not involving direct physical trauma, but producing similar problems, would be things like Herpes Simplex Encephalitis, or anoxic brain damage where the oxygen supply to the brain is interrupted.
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There's an acquired brain injury clinic in one of the hospitals here in Belfast and it seemed to have a high proportion of young rugby players. I know of one person, who was told by a Doctor that they may have ME/CFS, who was briefly referred to this clinic.
 
Hopefully they are trying to help and they have the support of other clinicians to try to treat "Chronic Neurological Disorders Including Traumatic Brain Injury". However, the title brings to mind the comment "sorry, I haven't a clue".
 
FMMM1 said:
There's an acquired brain injury clinic in one of the hospitals here in Belfast and it seemed to have a high proportion of young rugby players. I know of one person, who was told by a Doctor that they may have ME/CFS, who was briefly referred to this clinic.
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Apparently, people with Acquired Brain Injury have reported being first misdiagnosed with ME/CFS.
 
Andy said:
What is now included in the scope of this guideline.

"5) Functional neurological disorders

Functional neurological disorders can cause a range of disabling neurological symptoms, which include altered awareness, and motor and sensory changes. However, symptoms are not explained by a physical or neurological disease."
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livinglighter said:
However, the condition is removed from a guideline covering functional neurological disorders.
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It's one thing to remove the condition of ME/CFS from the scope of a guideline covering functional neurological disorders. It's quite another to ensure that the person with ME/CFS is removed from the scope of a guideline covering functional neurological disorders. I'm concerned that many people with ME/CFS will be diagnosed and treated under this new guideline.

I can imagine the BPS people consoling each other - 'never mind that the ME/CFS Guideline was hijacked, let's make a new guideline to capture all but the most assertive of patients with chronic fatigue. In fact, it will probably work out well. We won't have to bother with the difficult ones who insist they have a physical condition and want an ME/CFS label.'
 
livinglighter said:
So far, I've read non-traumatic brain injuries can also impair the functional ability of nerve cells in the brain due to impact on cell structure that can't be viewed using gold standard CT and MRI brain imaging. However, I think that kind of injury is already accepted as part of established neuro and immune conditions such as non and autoimmune Encephalitis.
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@Hutan

Would FND then be considered physical as in the case of the above?
 
Interestingly, in the case of 'FND Acquired Brain Injury', a lot more support, rehabilitation, and medical care are offered.

It seems possible the excluded conditions 'disclaimer' in the scope indirectly implies ME/CFS and LC are the two possible acquired brain injury conditions.

The new NICE Guideline looks like it is being created to align the following existing guides of care.

https://www.headway.org.uk/about-brain-injury/professionals/gps/clinical-guidelines/

Clinical guidelines
This page contains downloads and links to some important clinical guidelines for the management of patients with acquired brain injury. The guidance documents are explained below, and you can download them in the related resources area.

NICE and SIGN guidance for early management of head injury
Guidance developed by the National Institute for Health and Care Excellence (NICE) and the Scottish Intercollegiate Guidelines Network (SIGN) focus on the triage, assessment, investigation and early management of patients with a head injury.

SIGN guidance for brain injury rehabilitation in adults
Detailed guidance covering the longer-term rehabilitation of adults with brain injury following the post-acute stage.

BSRM Standards for Rehabilitation Services
The two documents define a clear set of guidelines and targets, mapped on to the NSF-LTC, for the planning and delivery of rehabilitation services in the United Kingdom. The Rehabilitation following acquired brain injury guidelines address the medium to longer-term needs of people affected by ABI.

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Hutan said:
FND can mean all sorts of things - it usually involves a circle or several circles of factors connected by arrows
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You know, I think this may be the most accurate definition of FND ever. In the end, it really is just all about loopy cycles with labels and arrows, same as how it started. Although when you think of it, it's completely expected that people stuck in circular reasoning would only produce circular arguments.
 
rvallee said:
You know, I think this may be the most accurate definition of FND ever. In the end, it really is just all about loopy cycles with labels and arrows, same as how it started. Although when you think of it, it's completely expected that people stuck in circular reasoning would only produce circular arguments.
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For mentioned reasons, I thought it was just another unproven new age theory. I’m surprised to see it recognised by NICE as part of established neurology.


The lengths these people will go to have no ends.
 
This information on how to ‘tackle’ the rise of FND has been taken from a law firms website. The tone and approach is eerily similar to a well known insurance advisor. Blame is now being placed on doctors and case managers for perpetuating the idea that the patient is ill due to organic causes without visible brain injury imaging. :eek:

https://www.blmlaw.com/news/the-rise-of-functional-neurological-disorder-and-how-to-tackle-it

THE RISE OF FUNCTIONAL NEUROLOGICAL DISORDER AND HOW TO TACKLE IT

06 Apr 2021

In recent months we have seen an increase in medico-legal experts reaching a diagnosis of Functional Neurological Disorder (FND) where a claimant may have sustained a mild traumatic brain injury (mTBI).

This article considers FND in the context of mTBI claims where no organic cause can be given for ongoing debilitating functional symptoms.

WHAT IS FND?
It is important to acknowledge that FND is a genuine disorder. It encompasses all symptoms which are found to be functional.

FND is described in the Diagnostic and Statistical Manual of Mental Disorders (DSM 5) as:

  1. One or more symptoms of altered voluntary motor or sensory function are experienced;
  2. Clinical findings prove no correlation between the symptoms and a recognised neurological or medical condition;
  3. The symptom or deficit cannot be better explained by another medical or mental disorder; and
  4. The symptom or deficit causes clinically significant distress or impairment in social or occupational areas.
FND IN THE CONTEXT OF MILD TRAUMATIC BRAIN INJURY
There are several definitions of mTBI including post-concussion syndrome (PCS). PCS is a term used to describe a variety of symptoms that can occur after a suspected mTBI such as poor memory, pain, headache, fatigue, dizziness, persistent vertigo and psychiatric symptoms post trauma.

In these cases it is important to consider the findings from paramedics and hospital records rather than relying solely on the claimant’s retrospective recall. The reporting of ”loss of consciousness”, for example, may be due to the stress and anxiety of the accident.

Whilst it is possible that an isolated mTBI can produce temporary damage to the brain, cognitive (and other) symptoms that persist beyond the expected weeks to months are likely to have a functional basis.

Claimants who have been diagnosed with an mTBI where there is no organic cause for persistent ongoing symptoms, will usually have an extensive history of physical, cognitive and psychological symptoms in their pre-accident presentation.

Furthermore, they often have a significant history of functional illness independent of the index accident.

The “memory problems” described after mTBI are often deficits of attention and concentration, which are affected by anxiety, depression, fatigue, sleep deprivation, medication, pain etc., all common after mTBI.

Often patients with mTBI have normal structural imaging. In these cases it is important that the claimant is advised that their ongoing symptoms have a functional basis rather than being as a consequence of persistent brain damage.

There are however arguments that abnormalities in Diffusion Tensor Imaging (DTI) reflect axonal damage.

Abnormalities in DTI found in claimants following an mTBI do not necessarily provide evidence that there has been an axonal injury. DTI changes have been found in patients with depression, borderline personality disorder, ageing, opiate addition and even in healthy volunteers.

MANAGEMENT OF FND
FND is treatable and the prognosis can be good.

Unfortunately, the diagnosis of FND is often not made early enough and the claimant is often treated under the mistaken belief that they have sustained a brain injury. This is often perpetuated by a Case Manager and the claimant’s treating consultants.

Insurers should seek to get involved in the rehabilitation process very early on in these claims to ensure that the correct rehabilitation is provided to the claimant.

FND is often misunderstood because movements may be controlled when distracted. This is not to say that claimants with FND do not have some degree of wilful symptom control. This may be produced to convince others of their suffering.

At the other end of the spectrum however, is where claimants are consciously malingering and fabricating their symptoms for financial gain. It is not always possible to be sure if a claimant is fabricating or not and in this situation it is important that all the available records relating to the claimant’s past are forensically examined.

THE MULTI-DISCIPLINARY APPROACH
The aim of FND treatment is to “retrain the brain” by unlearning abnormal and dysfunctional behaviour and relearning normal movement.

A multi-disciplinary treatment approach has been found to be the most effective for FND because of the variety of symptoms the disorder encompasses. A range of medical specialities may be involved although, ultimately, the best approach allows treatment to be tailored to the individual.

Neurological, neuropsychiatric/psychiatric and neuropsychological assessments will be key in terms of maximising the claimant’s recovery. They are crucial to make a judgment as to whether such symptoms would likely have occurred despite the accident, to recommend the appropriate treatment and to undertake an objective review of the claimant’s previous medical history.

EARLY REHABILITATION AND EXPERIENCE IS KEY
FND is a complex and poorly understood condition but we are certainly seeing it as a more prevalent diagnosis within personal injury claims, particularly those involving mTBI.

Early rehabilitation is recommended to implement the multi-disciplinary approach.

All potential records should be identified and forensically reviewed to ensure that the correct treatment is implemented.

Medico-legal experts who are experienced in identifying and diagnosing a claim involving FND should, where possible, be instructed to avoid the attribution of any persistent ongoing symptoms to brain damage.

Incorrect treatment or diagnosis could prove costly for insurers as if the claimant does not recover they may seek substantial awards for lost earnings, care, case management, aids and equipment and possibly accommodation.



Claire Collins is the lead Partner in the CAT/Large Loss Team in London and is a member of the Special Interest Brain Injury Group at BLM.



Disclaimer: This document does not present a complete or comprehensive statement of the law, nor does it constitute legal advice. It is intended only to highlight issues that may be of interest to clients of BLM. Specialist legal advice should always be sought in any particular case.
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Some information on Claire Collins expertise.

https://www.blmlaw.com/people/claire-collins

CLAIRE COLLINS
Partner
London


EXPERIENCE
  • I am a partner in BLM's London catastrophic injury team.

  • I deal with a wide range of defendant personal injury claims and have over 20 years' experience dealing with large and complex claims, to include spinal, brain injury and amputation cases. I have a specific interest in subtle brain injury claims. I have a strong technical background with many years’ experience dealing with high value, high profile personal injury claims for many leading insurers who advocate my appointment with their policyholders.

  • I successfully highlight risks to opponents through my close attention to the finer details and cases include obtaining knowledge of a proposed and unwanted arranged marriage, investigations of medical records into undeclared pre-accident psychological histories and events breaking causation, all of which resulted in substantial savings for clients. I am acknowledged for my confidence in negotiations and in RMH v SWA (2018) I successfully achieved a 55% deduction on damages in a matter involving a claimant crossing at a road crossing and persuaded the claimant to accept an award for loss of chance in respect of a substantial claim for future loss of earnings.

  • I acted in the widely reported decision of Mustard v Flower (2019) in which the claimant’s conduct in covertly recording medico-legal examinations, whilst not unlawful, was deemed reprehensible and I was successful in applying to have the disproportionate Part 35 Questions to the defendant’s experts disallowed.

  • I also acted in the follow-up case of MacDonald v Burton (2020) dealing with the importance of a level playing field for medico-legal recordings and the refusal of permission for a neuropsychological examination to be recorded.

  • I have mentored individual claims controllers at various insurers in their personal, technical and professional development.

  • I have been named as a “Leading Individual” in Legal 500 2018, 2019 and 2020 and a “Next Generation Lawyer” in Legal 500 2017.
SIGNIFICANT REPORTED CASES
A successful trial where the defence of ex turpi causa was upheld (D v H - 2017)

A successfully contested liability trial (D v N - 2018)

Involvement in the first hybrid trial in the RCJ during the pandemic, where I successfully secured a trial win in a claim pleaded in excess of £2million (S v M - 2020)


MEMBERSHIP/APPOINTMENTS
  • Member of the London Catastrophic Injury Group and FOIL.
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The piece mentions nothing about the fact that law firms now contact people with minor head injuries unsolicited and try to encourage them to make claims.
The whole thing is of the legal industry's making it seems.
The good thing about the quoted article is that it is so garbled and incompetent that most doctors will see through it. That is not to say that the professional rehabilitationists will not lap it up.
 
chrisb said:
I was struck by the similarities of some of the ideas to those of Arthur Cott of McMaster from circa 1985. We know that he worked with major insurance companies in drawing treatment guidelines on behalf of the Canadian Insurance Bureau in circa 2000.
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I agree, and you honestly also can't miss the similarities between ME/CFS and ABI. From my reading of various sources, it feels like ME/CFS has been syphoned off Acquired Brain Injury due to it not being recognised by neurology, and NTBI can't be viewed using brain imaging.

I made a second call to Headway today to discuss my inability to wake up, a clear symptom of brain injury I have yet to see defined in any ME/CFS resources. A different operative this time agreed it is very different from general fatigue. She recommended requesting a referral to a neuropsychologist specialising in brain injury as post-viral syndromes can also involve injuries that aren't visible in scans, so neuropsychological assessments are used to determine its presence.
 
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I should also add non-Traumatic Brain Injury (nTBI) is more often referred to as Traumatic Brain Injury (TBI) or Acquired Brain Injury (ABI) without the distinction, so it appears to be covered less extensively. A bit like NICE’s omission of mentioning indirect head injury within the current head injury guidelines, which a Coroner raised issues with. ;)

Management of indirect brain injuries (not caused by direct trauma in the head)

NICE received a Coroner's letter in June 2019 which raised concerns about the NICE guideline not adequately considering the management of indirect brain injuries (not caused by direct trauma in the head) in elderly patients. The Coroner's report highlights that this type of injury mechanism (which is more likely to occur in older people) is not well considered in the NICE guideline, and actions need to be taken to prevent further incidents.

Head injuries caused by direct or indirect trauma of the head are both considered in the NICE guideline. However, the guideline could be more explicit that brain injuries caused by indirect trauma is also included in the guidance. The update needs to clarify that the guideline applies to indirect head injuries (for example, making the definition clearer and easier for users to understand).

https://www.nice.org.uk/guidance/cg...gement-nice-guideline-cg176-pdf-8944653877477
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Up-to-date NICE acknowledge sometimes the guidelines do not make clear what life changing conditions are covered. I wonder how many other conditions are in the same boat that need a coroners letter to rectify. :dead:
 
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Latest update.

Dear Colleague,


RE: NICE committee to develop a Rehabilitation for Chronic Neurological Disorders Including Acquired Brain Injury guideline

The National Guideline Alliance (NGA), on behalf of the National Institute for Health and Care Excellence (NICE), is looking to recruit committee members to develop a clinical guideline on Rehabilitation for Chronic Neurological Disorders Including Acquired Brain Injury.

We are looking for experts in Rehabilitation for Chronic Neurological Disorders to join our clinical guideline committee. We need people with a professional or practitioner background in the topic.

Chronic neurological disorders include:

1. acquired brain injury (causes including trauma, tumours, infections, metabolic insults and disorders of the blood supply)

2. acquired spinal cord injury resulting in neurological impairment

3. acquired peripheral nerve disorders

4. progressive neurological diseases (including Parkinson’s disease, multiple sclerosis, motor neurone disease and Duchenne’s muscular dystrophy)

5. functional neurological disorders

See the scope of this guideline for further information about what will be covered.

The committee membership has been produced based on the topic areas that will be covered in the guideline. We are recruiting for the following areas:

Core members of the committee (who would be expected to attend all meetings):

· General practitioner

· Dietician

· Commissioners of services which may impact on people with CND. 1-2 committee members e.g. health, social care, education.

Co-opted members (who would attend 1 or 2 meetings):

· Individuals who support people with CND in access/return to education or work and leisure. 1-2 committee members e.g. special educational needs advisors, vocational rehabilitation advisors.

· People in social care roles who are involved with assessing/interventions for people with CND. 1-2 committee members e.g. social worker, care worker


If you or any of your colleagues would like to apply, there are more details on the NICE website.

Applications must be sent to NGAApplications@RCOG.ORG.UK for the attention of Hayley Shaw by 12pm on Monday 14th March 2022.

We would appreciate it if you could circulate this information widely in your organisation and to any other people or organisations who may be interested in this topic.

If you have any queries about Committee membership or the recruitment process, please contact Lisa Boardman at LBoardman@RCOG.ORG.UK.

Kind regards,

Hayley



Hayley Shaw | Project Manager
 
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