Traumatic Brain Injury: Rehabilitative Treatment and Case Management
Authors: Jeremy Gibson
Journal: Journal of the Royal Society of Medicine (2004)

Because traumatic brain injury causes an almost limitless range of troubles, Mark Garrison and his contributors, all from North America, concentrate on disorders that are common and persistent. Their target readership includes physicians, allied therapists and case managers, and the book is divided accordingly.

The medical section has ten chapters, of which the most fascinating (to me) is that on vestibular dysfunction—a frequent but often overlooked post-traumatic disorder. An easy-to-follow account of the anatomy, physiology and pathophysiology of the vestibular system is followed by technical descriptions of vestibular investigations that will provide a valuable resource to non-specialists. The chapter concludes with a plain breakdown of the various components integral to vestibular rehabilitation. The authors make clear that, especially in patients with other deficits, the best hope in vestibular rehabilitation will often be symptom control rather than symptom elimination. I also liked the brief chapter on heterotopic ossification, with its account of diagnostic methods and its flow chart to guide treatment. Less high marks go to the account of post-traumatic epilepsy. There is much information on the side-effect profiles of antiepileptic drugs (AEDs) and we are counselled on the importance of distinguishing seizures from behavioural spells (so as to avoid unnecessary AED prescription and resultant side-effects). The authors discuss when to start an AED and the controversy on this question but offer no clear guidance on the more difficult issue of whether and when to stop—a matter addressed in the UK national guideline, 'Rehabilitation following Acquired Head Injury', published in 2003. I did not enjoy the dense account of neurotransmitters and pharmacology, packed with basic science and of little practical use.

The section on allied health themes includes an update on cognition and language that demands a good understanding of language theory. Much less jargon-laden is a contribution on therapeutic recreation, the origins of which can be traced to Socrates and Plato. Unfortunately, little research has been done on the benefits of exercise and activity specifically related to traumatic brain injury, so the authors have to lean heavily on results in other areas such as spinal cord injury and spina bifida. From these sources they extrapolate possible benefits including improved physical and mental health, higher cognitive functioning, enhanced social integration and better quality of life. The chapter ends by honestly acknowledging that the medical and insurance communities have yet to be convinced. A chapter entitled 'Children and Adolescents: Practical Strategies for School Participation and Transition' is full of valuable insights. It presents examples of cognitive difficulties and resultant classroom behaviours following traumatic brain injury together with specific strategies for dealing with them. To illustrate the principles the progress of 'John', who was injured as a child, is charted to the age of 19.

In part three the best written chapter is an overview on external case management. The fact that it is geared to an American readership does not detract from its value to UK readers in summarizing the roles and responsibilities of a case manager—in particular, the importance of knowing the patient's family dynamics, premorbid personality and interests, the vocational rehabilitation services available, and the possible benefits and sources of funding. The emotional stresses faced by a case manager are not overlooked.

The book is attractively produced and contains some excellent material. As I have indicated, the quality and pertinence vary.