Long-term employment outcomes following rehabilitation for significant neurological impairment in UK military personnel: a 3-year study.

BACKGROUND: Returning to employment is a major modifiable factor affecting long-term health in brain injury which neurological and vocational rehabilitation attempts to address. In military patients, little is known about long-term employability, whether employment is sustained and how they fare in civilian roles. METHODS: A telephone review was undertaken of every military patient having undergone inpatient neurorehabilitation between 2012 and 2014. This was compared to their employment outcomes one to three years post discharge. We further evaluated whether this employment was sustained over successive years in the same patients. Finally, we identify those rehabilitation interventions deemed most influential in improving employment outcomes in brain injury. RESULTS: During this period, an average of 57 (51-61) such patients were discharged each year. A review conducted by telephone successfully contacted 46% (43%-49% across cohorts) of all possible patients; 71.4% (64-81) returned to work increasing to 80.7% (76-85) including those training/actively seeking-work. Overall, 31.7% (24-40) returned to full-time military-in those leaving, 89.6% (85.4-90.9) were discharged for medical reasons. Severity of brain injury was unrelated to successful employment; 63.6%/78.6% had the same vocational outcome over two consecutive years while 36.3%/21.4% showed improved outcomes. DISCUSSION: Despite significant brain/neurological injury (graded by severity/Mayo Portland Adaptability Inventory 4), 80.7% (76-85) were working/training 2/3 years postdischarge from neurorehabilitation with 31.7% returning to full-time military role. Inability to continue within the military was not synonymous with inability to work. Return to work was independent of severity of brain/neurological injury and follow-up over consecutive years demonstrated sustained employment. The argument against inpatient neurorehabilitation has always been cost> This 3-year analysis reinforces that patients can and most likely will return to employment with all the benefits this brings to person/family/society. Vocational rehabilitation is therefore recommended for all brain/neurological injury.

Antiepileptic prophylaxis following severe traumatic brain injury within a military cohort.

INTRODUCTION: Traumatic brain injury increases the risk of both early and late seizures. Antiepileptic prophylaxis reduces early seizures, but their use beyond 1 week does not prevent the development of post-traumatic epilepsy. Furthermore, prolonged prophylaxis exposes patients to side effects of the drugs and has occupational implications. The American Academy of Neurology recommends that antiepileptic prophylaxis should be started for patients with severe traumatic brain injury and discontinued after 1 week. An audit is presented here that investigates the use of prophylaxis in a cohort of military patients admitted to the UK Defence Medical Rehabilitation Centre (DMRC). METHODS: Data were collected and analysed retrospectively from electronic and paper records between February 2009 and August 2012. The timing and duration of antiepileptic drug use and the incidence of seizures were recorded. RESULTS: During the study period, 52 patients with severe traumatic brain injury were admitted to the rehabilitation centre: 25 patients (48%) were commenced on prophylaxis during the first week following injury while 27 (52%) did not receive prophylaxis. Only one patient (2%) received prophylaxis for the recommended period of 1 week, 22 patients (42%) received prophylaxis for longer than 1 week with a mean duration of 6.2 months. Two patients (4%) had post-traumatic epilepsy and started on treatment at DMRC. CONCLUSIONS: The use of antiepileptic prophylaxis varies widely and is generally inconsistent with evidence-based guidance. This exposes some patients to a higher risk of early seizures and others to unnecessary use of antiepileptics. Better implementation of prophylaxis is required.

Injury severity at presentation is not associated with long-term vocational outcome in British Military brain injury.

INTRODUCTION: Injury Severity Score (ISS) and GCS can be retrospective markers of injury severity, but if used by clinicians to decide on the treatment of acutely brain-injured casualties at the point of injury may potentially limit interventions on people who may ultimately survive with good functional outcomes. METHODS: ISS/GCS and long-term outcomes were reviewed by assessing all UK military neurorehabilitation patients with an operational/combat brain injury treated over 4 years (February 2008-July 2012) at Defence Medical Rehabilitation Centre (Headley Court). RESULTS: 34 participants from 9 operational tours of Iraq and Afghanistan were analysed. Overall, 44% of injuries were due to improvised explosive devices (IEDs) and 41% from gunshot wounds; 70.9% of injuries were penetrating wounds with the remainder due to blast/blunt trauma or combined injury. The primary injury was head/neck in 76.5%, although eight patients (23.4%) requiring neurorehabilitation were initially 'non-head injury'. Eight patients (26.5%) sustained more than 10 injuries, and 18 had between three and nine injuries. Eleven patients (32%) had an initial GCS of 3, and 16 (47%) had ISS of 75 (deemed 'unsurvivable'). All patients with ISS of 75 were long-term survivors. At 4 months after discharge, 47% (16) were fully independent, and a further 41% (14) were independent in own homes, but needed assistance with some activities, such as paying bills. Over three-quarters (27 patients, 79%) returned to full/part-time work, 11 of whom returned to military duties; 93% of 'unsurvivable' ISS, and 91% of patients with GCS of 3 were capable of returning/returned to work. In total, 7/11 casualties returning to military duties had major trauma ISS, and two were 'unsurvivable'. All seven casualties with both GCS 3 and ISS 75 survived and returned to independence (help with some activities). CONCLUSIONS: ISS/GCS at the point of injury does not reflect eventual outcome. IEDs/gunshots cause the greatest number of injuries and the highest incidence of brain injury. Brain injury should be considered in every battlefield casualty, irrespective of whether the head/neck/spinal cord was avoided. ISS should not be considered indicative or predictive of long-term prognosis/quality of life/employability as brain injury in this small cohort is both survivable and recoverable. It should not be used as a retrospective guide to alter treatment pathways, as there is poor correlation with long-term outcome. Subsequent neurorehabilitation should always be considered because survival, return to independence and full employment are very likely.

Getting soldiers with brain injury back to work: the defence medical rehabilitation centre neurological vocational pathway.

The Neuro-Rehabilitation Group at the Defence Medical Rehabilitation Centre (DMRC) has developed an integrated vocational pathway to transition service personnel back into employment. This article describes how vocational rehabilitation at DMRC fits with the wider UK military, in comparison with civilian rehabilitation. It also describes the ongoing development of the vocational pathway, which contributes to improved outcomes from neurological disorders, including traumatic brain injury. We present two cases to highlight how the programme integrates with and influences patient care.