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How to be a better medical expert

Ten tips from Paul Sankey, partner at Enable Law and a trainer at Inspire MediLaw, which runs courses on medicolegal topics.

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There is more to being a good medico-legal expert than being a good doctor. It is rare to win a clinical negligence case (and this is my field) without good experts. But sometimes cases go wrong because the expert lets a client down.

With the right expert evidence, people who should get damages win their cases but those who should not, do not pursue claims (and hopefully understand why). Costs are incurred on the right cases. My goal is for the right people to get damages and for the health service not to spend the minimum on costs in the process.

So after many years of running clinical negligence claims, here are 10 top tips on how to be a good medical expert.

1. Make sure you have the right expertise 

Many years ago, an expert reported for me that a surgeon caused harm because used the wrong technique in carrying out an unusual procedure. (If you want to know it was a Lue procedure for Peyronie’s Disease.) The claim was strongly defended. My expert produced weighty reports and explained his view convincingly in conference with counsel. But at a late stage, when the pressure was on, he confessed that he had never actually done the procedure. He thought he knew how to do it – but he was wrong. He led my client wrongly to believe he had a good claim. The result was not just disappointment but a lot of wasted money. I should never have instructed him and he should never have accepted instructions. I learned a lesson and now always check an expert’s experience.

Judges, being wiser than I was then, will probably look carefully at an expert’s cv at trial. See for instance how Mr Justice Foskett in a 2011 case worked his way through an impressive cv and commented that she was ’eminently well qualified to offer an opinion on relevant issues in this case’. In case you are daunted by the impressive cv I have quoted it him more widely but only in a footnote[1].

Don’t allow yourself to be trumped by someone who knows more than you do. If you are not the right expert, don’t put yourself forward.

But it is not always the most impressive cv that impresses the judge. Sometimes the court will prefer a less experienced expert if they spend more time at the coal-face. In one case the court preferred the evidence of 2 less experienced experts (although to be fair, they were still both professors). As the judge said, ‘…they had the advantage of being more in the front line of medical practice and did not spend an undue amount of time in medico-legal work'[2] – which suggests a degree of suspicion of the ‘professional expert’.

There are occasions when an expert is too specialist. If the court is judging the standard of knee surgery by a general orthopaedic surgeon in district hospital, it is unlikely to want to hear from a specialist knee surgeon in a tertiary referral centre. There may be a suspicion that the specialist’s standards are too high.

2. Try to be objective

The Civil Procedure Rules require an expert to be impartial. Your overriding duty is to the court. It may sound naïve to think that an expert will be totally impartial and it probably is. But that should be the aim. We all know of ‘claimant experts’ and ‘defendant experts’. I do not want to instruct either. I want experts who give an honest and impartial view – not ones who tell me what I want to hear or undermine a legitimate claim. Experts who display obvious bias will undermine their own evidence.

In plenty of cases biased experts have been recognised for what they are.

Consider a recent commercial case where the judge said this about the defendant’s expert: ‘I formed the impression that he has…developed what might be regarded as an expertise in giving evidence. [He] was extremely careful in giving answers. I increasingly took the view that this was because his first priority was to avoid saying anything that might damage [the defendant’s] case'[3]. Ouch. Needless to say the judge was persuaded by the claimant’s expert who ‘gave clear and direct answers’.

In another very recent case, the judge said of one expert, ‘I have to say that I found [his] evidence to be absurd…Had he made proper enquiries of his client…he would have been in a much informed position. But he did not do so’.[4] Comments like this from a judge are likely to form an epitaph to a forensic career.

3. Avoid the temptation to be an advocate

One medical expert I instructed used to take over conferences with counsel with advice on the law and likely award at trial. Some have even re-qualified in law. In one recent case, although the judge accepted the expert’s evidence he expressed concern that the (otherwise excellent) expert used words like ‘submit’ and referred to his ‘argument'[5]. I do not think this expert is anything other than highly professional and independent in his evidence. But the choice of his language was unfortunate. So avoid the temptation to plead a case. Stick to giving evidence.

4. Avoid prejudging the facts

What do you do when there is a conflict of evidence? The answer is that you give opinions based on both scenarios. You leave deciding which is correct to the judge. You do not base your view only on what the party who instructs you says.

If you do not follow this advice you risk:

Annoying the judge – who will not like you usurping his or her role;

Appearing biased – because you have worked on the basis of only one party’s case; and Failing to engage with the other side’s case.

It is a constant frustration to be served with expert reports from experts who assume their client’s account of the facts is correct and do not engage with the other possibility.

5. Put the work in and get it right first time

It is much better to consider your evidence carefully and carry out research before you set pen to paper (or finger to keyboard). There is nothing more annoying that a case collapsing at a late stage when an expert is forced into a change of view. I would not encourage experts to stick with a view in the face of clear evidence that they are wrong. The expert’s whose evidence was criticised as ‘absurd’ was also criticised for failing to make reasonable concessions. In the judge’s words, ‘His evidence on a number of points was unsatisfactory and showed an unwillingness to concede anything'[6]. But it is better to do your homework and get it right first time.

I am unlikely to instruct an expert again once they have let me down.

6. Address the Bolam test correctly

Can you spot the 3 medico-legal errors in what follows? ‘His care was substandard (a responsible body would not have done the same) and breached his duty’. I have seen countless variations of that sentence. It does not satisfy the legal test of breach of duty and will irritate the judge.

First, ‘substandard’ is meaningless from a legal point of view. The test of breach of duty is whether a doctor has acted in accordance with a practice rightly accepted as proper by a responsible body skilled in that particular art. So what we need to know is not whether treatment was gold standard, bog standard or substandard but whether it there is a responsible body who would (with good reason) have done the same.

Secondly, experts sometimes turn the Bolam test upside down and say that a responsible body would not have done the same. But the test is whether there is a responsible body who would have done the same. That is quite a different thing.

Finally – and at risk of pedantry – it is not for the expert to say whether there was a breach of duty but for the judge. It is for the expert to define the standard of care and then leave the judge to draw the conclusion as to whether there was a breach of duty. Saying that care failed to meet the Bolam test implies a breach of duty. So if the judge accepts that evidence, a finding of breach of duty is not a great leap of logic. But it is still the judge’s leap and not yours.

7. Address causation correctly

Establishing liability of course entails not just a breach of duty but causation. In most cases the test is whether Outcome X would have happened ‘but for’ the breach of duty. (There are other causation tests applicable to other situations but I cannot cover them here – and the ‘but for’ test covers the vast majority of cases.)

In relation to past events, all we need here is to establish what would ‘probably’ have happened. 51% is a probability. 50% is not. This may not seem very sophisticated to the medical mind. But it is as simple as that. It may be a matter of life and death – whether the claimant would have survived but for the breach of duty. 51% likelihood of survival may lead to an award damages, whereas 50% leaves her with nothing. But simple probabilities are what we need even if they seem a rather blunt instrument. So please avoid telling us too much about what possibly would have happened – past possibilities do not take us anywhere. And please also avoid if possible saying that the outcome was 50/50 (unless it really was exactly 50/50). Better to come off the fence as say 49/51 or 51/49. It makes all the difference.

When it comes to future events – what might or might not happen – different principles apply. Here quantifying possibilities is important. If, for instance, there is a risk of amputation, we need to know the degree of risk – say 30% or 60%. The claimant may need to claim 30% or 60% of the loss arising in the event of amputation. So without a figure we do not know the percentage to claim. So the rule is: past events – address the balance of probabilities; future events – address possibilities and give percentages.

8. Provide evidence for your views

The best reports cite literature. Persuasive opinion rests on evidence. Without support the judge has little to go on in determining whose evidence to accept. So where possible cite literature and show its relevance to the issues. So please undertake database searches and cite peer-reviewed literature, international, national or local guidelines or, in establishing current practice, refer to textbooks. Make sure the textbooks are up to date.

Beware attracting the sort of criticism a judge made of an expert in one case, ‘Although there was a good deal of literature on the subject…Mr M did not rely on any of that…He only referred to it to dismiss the literature altogether…Instead he sought to rely on his own experience which, because it was both contradictory and undocumented, could not be the subject of meaningful research or comment by the defendant’s experts’.[7]

Or consider this comment by another judge, ‘Mr C’s valuation approach effectively involved putting the available information into a black box from which a figure emerged based entirely on his gut feel. The problem with a valuation being pronounced ex cathedra in this way is that it is not capable of being tested or subjected to any rational scrutiny. It amounts to saying, ‘Trust me, I am an expert valuer…Experts’ opinions, if they are to be accorded any weight, need to be supported by a transparent process of reasoning’. [8]

9. But Be Prepared to Hazard a Guess Where Necessary

At risk of undermining the last tip, there are occasions when there simply is no research or textbook evidence to cover the point. Rather than say, ‘I don’t know’, you should give a view if you can. After all, the court needs to make a finding one way or the other. It is looking to you for assistance. You can base your view on your own clinical experience. Give your reasoning. Say that you know of no research on the point but you are doing your best to give an answer despite an absence of data to support it. Doing so does not align you with Mr M above – who simply dismissed the literature. Nor does it amount to Mr C’s ex cathedra pronouncements. You are simply doing your best to assist the court in addressing an issue on which it needs evidence.

10. Be Thorough at Every Stage

My final tip is to be thorough and careful at every stage of the claim. Prepare for conferences and particularly for experts’ meetings as if for trial. Take care over responses to questions from the other side. Careless talk costs cases. An ill-thought-out response to a question can undermine the work of several years. Once a comment is made in writing, it is very difficult to backtrack. Even if you explain later that it was not really your view, no one will be persuaded and you can expect some tough cross-examining at trial.

The most frustrating experiences I have had with experts have been when the joint statement of experts arrives and an expert – who clearly had not prepared properly for the meeting – has lost sight of the issues and strayed from a carefully considered opinion. Explaining to a client why their case, which had looked so promising over the last 3 years, is unlikely to succeed is not a pleasant experience for the lawyer. It is devastating for the client. Sometimes we have to do it because that is simply how the evidence turns out. But we should not have to do it because an expert has been ill-prepared.

Final Comments

Working with experts who think things through carefully from the outset, understand the legal tests, support their views with evidence, listen to reasonable points but are able to be consistent from beginning to end, is a pleasure. They make the legal system work as it should. They provide the specialist opinion the courts need to decide difficult cases. They enable people who should be compensated to obtain damages. And they protect our health service from incurring costs where they should not. I hope these tips help you to be that sort of expert.

Paul Sankey is a partner at Enable Law and also a trainer at Inspire MediLaw, which runs courses on medicolegal topics, including becoming an expert witness. See more here

Footnotes

[1] The expert was Professor Kirkham. ‘Her CV demonstrates that she is a highly qualified and highly distinguished paediatric neurologist who has been a Consultant for about 20 years with clinical experience at Great Ormond Street Hospital and Southampton General Hospital. She was a senior lecturer in Paediatric Neurology at the Institute of Child Health for approximately 16 years prior to her appointment as Professor of Paediatric Neurology at the Institute in October 2006. Her written contribution to medical literature, both in textbook form and article form, is very extensive and her particular research interest has been in the detection and prevention of brain damage in acutely sick children. Her recent Doctor of Medicine thesis at the University of Cambridge was entitled ‘Cerebral Haemodynamics in Normal Subjects and Children in Coma’. She was eminently well-qualified to offer an opinion on relevant issues in this case.’ Morwenna Ganz v Dr Amanda Jillian Childs and others, [2011] EWHC 13 (QB).
[2] Melhuish v Mid Glamorgan Health Authority [1999] MLC 145
[3] Edward Lifesciences v Boston Scientific [2017] EWHC 755 (Pat)
[4] BHL v Leumi ALB Limited [20170 EHWC 1871 (QB).
[5] Muller v Kings College Healthcare Foundation Trust [2017] EWHC 128 (QB)
[6] BHL v Leumi ALB Limited [20170 EHWC 1871 (QB).
[7] Nasir Hussein v Bradford Teaching Hospitals NHS Foundation Trust 2011
[8] Hirtenstein and another v Hill Dickinson LLP 2014

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Update:concussion in sport

A run through the latest developments in concussion in sport research and protocols.

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A study published in the May 27 in the medical journal of the American Academy of Neurology, looked at a biomarker called neurofilament light chain, a nerve protein that can be detected in the blood when nerve cells are injured or die.

Levels of the protein in the blood were measured and it was found that those with three or more concussions had an average blood levels of neurofilament light 33 per cent higher than those who had never had a concussion.

“The main finding in the study is that people with multiple concussions have more of these proteins in their blood, even years after the last injury,” said study author Kimbra L. Kenney, M.D of the National Intrepid Center of Excellence.

“Additionally, these proteins may help predict who will experience more severe symptoms such as PTSD and depression. That’s exciting because we may be able to intervene earlier to help lessen the overall effects of concussions over time.”

Following on from our article on the game changing tests into concussion in children it has been found that concussions sustained by high school athletes continues to increase.

Injury data collected from 100 high schools for sports including football, volleyball and wrestling found that, between the academic years 2015 and 2017, the average amount of concussions annually increased 1.012-fold compared to the previous four academic years.

Approximately 300,000 teens suffer concussions or mild traumatic brain injuries each year while playing high school sports.

Wellington Hsu, M.D, professor of orthopedics at Northwestern University’s Feinberg School of Medicine said: “It’s understandable to think that with increased awareness among practitioners who diagnose concussions, the incidence would naturally rise; however because we’ve studied and reported on concussions for a number of years now, I feel that enough time has passed and I would have expected to see the numbers start to level out.

“What we found was that the overall average proportion of concussions reported annually in all sports increased significantly, as did the overall rate of concussions.”

The data also revealed that in gender-matched sports, girls seemingly sustain concussions at a higher rate than boys.

The effects of concussion in young people continues to be a key concern, with links between concussion and football, specifically when heading the ball leading to some big changes when it comes to training guidelines.

Coaches have been advised to update their rules connected to heading the ball in training, with no heading at all in the foundation phase for primary school children and a “graduated approach” to introduce heading training at under-12 to under-16 level. This guidance is expected to be issued across the continent later this year.

These new guidelines were recommended following a FIELD study, joint-funded by the English FA and the Professional Footballers’ Association, published in October last year, finding that professional footballers were three-and-a-half times more likely to die of a neurodegenerative disease than members of the general population of the same age.

The study did not identify a cause for this increased risk, but repeated heading of a ball and other head injuries have been identified as possible factors.

Dr Carol Routledge, director of research at Alzheimer’s Research UK, said: “Limiting unnecessary heading in children’s football is a practical step that minimises possible risks, ensuring that football remains as safe as possible in all forms.

“As such, measures to reduce exposure to unnecessary head impacts and risk of head injury in sport are a logical step. I would, however, like to see these proposals introduced as mandatory, rather than voluntary as present, and a similar approach to reduce heading burden adopted in the wider game of football, not just in youth football.”

A similar stance, that also includes restrictions during matches, has been in place in the US since 2015 after a number of coaches and parents took legal action against the US Soccer Federation.

There is clearly a need to educate coaches and athletes about the concussion recovery process while equipping physicians with quick diagnostic tools.

A partnership between Neurotechnology and brain health analytics player SyncThink and concussion education technology specialist TeachAids aims to offer the latest concussion education combined with mobile, objective measurement technology.

EYE-SYNC, which allows a clinician to use analysis to decipher between brain systems to determine whether a patient may be performing poorly or impaired, will create a brain health education and evaluation system based on the implementation of CrashCourse, an interactive educational module that teaches athletes, parents and coaches about concussions.

This implementation will be available to all SyncThink partners which include top athletic organisations and clinical partners providing medical care and education for over 10,000 high school and college athletes.

This implementation could make tracking those who receive concussion education easier while complying with sport governing bodies educational requirements.

SyncThink founder and medical advisor to TeachAids, Jamshid Ghajar said: “Using the SyncThink platform to feature the CrashCourse educational technology for athletes and coaches is brilliant.

“Now clinicians can use the Eye-Sync tests and metrics alongside CrashCourse’s latest evidence-based information on concussion.”

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Stepping up the fight against alcohol-related brain injury

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Alcohol-related brain injury (ARBI) is becoming more widely recognised, but specific rehab services for the condition are surprisingly rare.

With few dedicated units for patients with ARBI, many patients in need of specialist care instead find themselves in a hospital or even an elderly care home.

ARBI is characterised by prolonged cognitive impairment and changes in the brain due to chronic alcohol consumption.

The average age of diagnosis in men is 55, and only 45 for women – following at least five years of excessive alcohol consumption, of around 50 units per week in men and 35 for women.

ARBI is not a degenerative condition, with up to 75 per cent of patients recovering to some degree with the correct support; and the first three months following diagnosis are recognised as key in a person’s recovery. Access to appropriate provision, therefore, is even more crucial at this time.

In February, UK-wide charity Leonard Cheshire opened a residential unit in Northern Ireland to help some of the many patients in need in the country. It is the first facility of its kind on the island of Ireland. 

The 14-bed unit, near Belfast, opened inconveniently – after years of planning – just as the COVID-19 crisis was emerging.

Its work goes on, however, with the centre taking patients from across the country, though initially from the capital and surrounding areas.

The residential centre aims to support residents over a two to three-year period, although that can be shorter for some patients. It helps them to live independently, by building the life skills and confidence to do so. 

Naomi Brown, clinical lead at the centre, joined Leonard Cheshire late last year to oversee the opening of the facility, following an extensive career in brain injury work and in being part of multidisciplinary teams.  

She says: “The background here in Northern Ireland is that the acquired brain injury (ABI) service is really well structured and established but for ARBI, often the person wouldn’t meet the criteria for addiction services, but their needs would not be such that they needed to be admitted to hospital, or even fulfil the criteria for ABI services, so they would fall through the cracks.

“The provision they receive would often come from the care sector, but to end up in a care home at what could be a very young age is not appropriate either.

“There is a real lack of options. Their care managers recognise they aren’t in the appropriate setting for them, but through a lack of alternatives, it is very difficult.

“A lot of symptoms are very similar to those under the influence of alcohol, difficulty with balance and memory for example, which can make ARBI difficult to diagnose.

“Often it can be something like liver failure that gets them into hospital, but then it becomes obvious there are cognitive issues there too.

“Our centre only has 14 beds, which we don’t pretend is going to answer the scale of the problem, but the decision to restrict it to that number is that we don’t want quantity over quality. To try and accommodate huge numbers would risk the patient-centred approach that we are really proud of, so we wanted to keep it on a small scale.

“But there are 14 places here at any one time for people to get access to the specialist rehabilitation they need, so we are really pleased to be able to offer this.”

With the centre’s goal being the independent living of its patients, a resident-led rehab plan is created for each individual, based around their individual goals and aspirations.

It is delivered by Leonard Cheshire’s team of rehab assistants, supported by clinicians, occupational therapists, physiotherapists, speech and language therapists and neuropsychologists who come in to hold sessions with the residents, and overseen by Naomi. 

“From the minute someone is admitted to us, we are already planning for their discharge, even though that may be a long time and a lot of work away.

“From the very start, it’s about the individual, it’s absolutely not a generic approach, even though the ultimate outcome for everyone may be the same. Most people who move in do want to live independently, so if that’s their goal and we will do all we can to help them achieve that, with a plan individualised for them. 

“Some people will come to us and we realise they won’t be here very long as they do very well very quickly, but for others, they are going to be with us for two or three years.

“Some people arrive and love it here and say they don’t want to leave, which is a great reflection on the work we do and the centre we’ve created, but the ambition is that the point will come where they realise they don’t need us anymore.

“Through the work we do and our interventions, we can make very good progress. We’ve had some people here already who have been in quite an acute state but the progress they make brings joy into my heart.”

One such patient is David* who, despite only being with the centre for a matter of weeks, has made significant progress in his recovery.

Prior to moving to Leonard Cheshire, he lived in a nursing home for two years.

Before his arrival, Naomi remembers he had low mood, minimal spontaneous conversation and spent long periods of time in his bed sleeping.

He had no clear weekly routine and lacked any scheduled therapeutic or recreational activities.

Naomi says: “David initially required a significant amount of support to initiate activities, engage with others or even leave his room. He has slowly adjusted to the active therapeutic programme in the unit and his mood has improved significantly.

“His mobility and exercise tolerance has greatly increased, he participates in group activities, is now more spontaneous in conversation and has developed facial expressions. David has been able to self-identify rehabilitation goals and discovered a new love for playing the drums and guitar. 

“He is in the very early stages of his rehabilitation but having spent three months in the ARBI unit, the change is his quality of life is already dramatic.

“He engages in an individual, weekly timetable which includes activities of daily living, physical, cognitive and social activities, and is reportedly very happy in his current placement. Once the COVID-19 restrictions are lifted, we very much hope to begin reintegrating David to the local community and making future plans for his discharge.”

David’s experience is one which the unit is keen to replicate, by engaging patients from the earliest stages of their arrival at Leonard Cheshire in building a new and healthier daily routine.

“We are always keen to introduce routine, as that is so important in the longer-term. Where some people have maybe traditionally watched TV all night then get up into the afternoon, we try to create a new routine with lots of support services available in the morning. A healthy routine is what we want them to have when they go back home,” says Naomi.  

“We encourage people to do things for themselves – to get up, make yourself breakfast, maybe do some gardening or help with the cleaning, all things which promote the ability to do things independently.

“If they put the washer on, they’ll need to go back to it when it’s finished. We have rehab assistants on-hand to support them, but we do actively encourage independence.”

Everyone has an individual timetable for the week based on their own interests, combined with their clinical requirements, which centres on promoting reintegration into the community.

“It’s very individualised, so if someone wants to do an online course or learn how to cook for themselves, or learn a musical instrument, we’ll focus on that. We have a fantastic team here who will turn their hand to anything for the benefit of our residents,” says Naomi.

“As well as activities in the centre, we do a lot in the community, or rather we did before COVID-19, but that will resume when it’s safe to do so. We did sports activities, yoga classes, bowling, it’s not just your classic physio. We want people to be engaged and comfortable with the world outside. 

“We will always ensure residents have support once they leave us, and are setting that up long before they go.

“If there was someone who was with us who wasn’t from Belfast, we would use resources we knew were transferable to where they lived, so they didn’t leave us and not know how to access support.

“We build up these links with community services in the relevant discharge areas, so ideally the person will already be confident at being independent and will have the added assurance of knowing they continue to be supported.”

The Leonard Cheshire centre’s launch came amid changes to Northern Ireland’s legislative backdrop with the implementation of the Mental Capacity Act (NI) 2016. This has new deprivation of liberty regulations, a significant new introduction for the country and its approach to capacity and consent.

Naomi says: “When planning for the opening of a new centre, a global pandemic wasn’t on the radar, and for it also to coincide with the new mental capacity legislation meant it was a really busy time for us in the early stages, the COVID-19 aspect of which we could not have foreseen. 

“The pandemic did present challenges for our residents, many have a certain level of confusion so it’s difficult for them to always remember that they can’t be close to someone else, they have to regularly wash their hands. There is a lot of prompting which leads to a certain amount of frustration. While they are watching these things on TV about how COVID is affecting the world, it’s hard to relate that to everyday life.”

New referrals continue to arrive during the pandemic, from both hospital discharge and moving from a care home environment, although happily the Leonard Cheshire unit has remained COVID-19 free.

“We were keen to admit new residents and take referrals from hospitals and care homes, subject to extra measures being in place to protect ourselves and our residents.

“We wanted to continue to support hospitals and free up beds, but also to offer the appropriate care to people whose specific needs through their ARBI diagnosis meant they would be better in our centre than a hospital environment or care home.

“This has certainly been a challenging period in which to start our ARBI unit, but we have come through it well together so far and we look forward to continuing to develop ourselves as we come out of the pandemic and go into the future.”

*Name changed for anonymity.

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Neurobehavioural rehab in aggression management after TBI

Changes in personality following TBIs are often more problematic than neurocognitive, functional deficits or even physical disabilities. Dr Grzegorz Grzegorzak, consultant neuropsychiatrist at St Peter’s Hospital, South Wales, explains why taking a neurobehavioural approach to treating TBI can be highly effective.

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Personality changes are sometimes referred to as neurobehavioural disability (ND), especially when associated with social difficulties.

The concept of ND involves impairments of numerous aspects of functioning including the abilities to self- monitor and self-regulate, to control frustration, anger and aggression, to tolerate delay in gratification, and to self-motivate.

These impairments can lead to a sense of being overwhelmed when facing situations requiring control and management of internal impulses or coping with social situations or tasks.

Impulsivity, disinhibition and aggression all have significant potential to interfere with rehabilitation efforts, jeopardize recovery and become a major obstacle to successful functioning in social roles.

Research estimates the prevalence of aggression in survivors of TBI as being as high as 33.7 per cent.

Addressing aggression as soon as it arises is critical to the individual’s recovery.

Sometimes aggressive behaviour is so intense and frequent that its management takes priority over all other aspects of care and rehabilitation.

Neurobehavioural rehabilitation (NR) was introduced in the late 1970‘s as an attempt to improve functional abilities of TBI patients.

NR stems from recognising that people who survive TBI can still learn new skills to self-regulate and to modify their behaviour.

The basis of NR is embedded in learning theory and thus the success of NR is reliant on the patient’s ability to make use of new information and experiences.

Therefore, NR is only suitable for the post-acute phase of recovery from TBI, and in fact is intended as a medium to long term rehabilitation programme.

​NR interventions are composed of comprehensive and multidisciplinary efforts to create a user-friendly, supportive and encouraging social environment which facilitates therapeutic interactions and activities.

Specific goals and detailed routines are constructed for each patient individually, based on structured collection of data informed by behavioural analysis.

The process of designing and implementing the interventions puts emphasis on personal autonomy.

Clinical formulation is preferred over medical diagnosis. The attitude of the MDT should always be positive, embracing a strong belief in the patient’s ability to achieve their goals, improve and recover.

Carefully managed feedback and positive reinforcement are an essential part of NR.

Consistent interactions with every member of the team are of utmost importance, given that neurobehavioural intervention should not be limited to scheduled activities but in fact incorporated in every interaction.

Over the last forty years the model has been implemented by many neurorehabilitation services worldwide.

Several case studies describing recovery pathways through NR paint a very positive picture, and our own experience at St Peter’s of adopting a neurobehavioural approach has demonstrated it can produce real and measurable outcomes for both our patients andtheir families.

Case Study: Mehmet

On admission to St Peter’s Hospital, Mehmet presented with extreme challenging behaviours including serious assaults on staff, destruction of environment, verbal abuse and shouting.

Mehmet has frontal lobe dysfunction as a result of a head injury he sustained. For the previous 18 months he had been in a general hospital.

At St Peter’s a bespoke positive behaviour support plan and activity plan were developed with Mehmet’s input and reflecting his cultural needs which, under the supervision of his MDT, promoted positive changes to his social interactions, routines and activities.

Over nine months Mehmet’s challenging behaviours reduced significantly and he now enjoys a wide range of activities including regular community visits and has strengthened his relationship with his family.

Dr Grzegorz Grzegorzak is one of the consultant neuropsychiatrists at St Peter’s Hospital a specialist 39-bed Neuropsychiatric facility in Newport, South Wales run by the Ludlow Street Healthcare Group. www.saintpetershospital.co.uk

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