The issue of rehabilitation is one that permeates through most, if not all, branches of nursing. From the return to as normal a life as possible of a patient who has had a myocardial infarction (MI), and the multidisciplinary work done with stroke survivors, to helping recovering drug addicts continue the sterling work they have achieved, rehabilitation could be argued to be one of the prime goals of any nurse-patient relationship.

The whole issue of rehabilitation is, therefore, a large one and beyond the scope of a single literature review. But how to narrow the topic down? In order to do this, the author will concentrate on one area of rehabilitation, briefly and generally discuss the chosen problem, look at the rehabilitation associated with it, and then focus in on one aspect of research within the chosen topic.

The author has decided to look at rehabilitation following traumatic brain injury, as it is a subject in which he has a personal interest. In particular, he will discuss patient motivation and some of the research associated with this.

Traumatic head injury accounted for 300 deaths in Scotland and 213 deaths in the male population of Scotland in 1998. The previous year, the figures were 301 and 222 respectively (General Register Office (Scotland) 1999). They also accounted for 2-3% of all long-standing disabilities in the 16-44 age group in 1997. (StatBase, 1999).

A traumatic brain injury [the terms "brain injury" and "head injury" may be considered synonymous] can be thought of as a series of events, beginning with the direct effects of the accident, be it Road Traffic Accident (RTA), fall or whatever. This occurs in the first second or two following the accident and may be followed by any injury from a secondary cause such as hypoxia or hypovolaemic shock following blood loss. A tertiary injury may be considered as an injury that occurs hours, days or even months after the accident. These can include bruising and swelling of the brain, leading to hydrocephalus (an accumulation of cerebrospinal fluid where its circulation is blocked) and raised intra-cranial pressure; and blood clots and haematomas, which can, again, lead to raised intra-cranial pressure or even blockage of the blood vessels (Gronwell, et al, 1990).

Brain injury may also include cerebro-vascular accidents (CVA, commonly called a "stroke"). Stroke can occur in the younger age groups as well as, admittedly more commonly, in older age groups (MacWalter, et al, 1999).

The effects of brain injury can be many and varied, depending on the precise site of injury, and may include sensory, motor and cognitive impairments. Effects can be minor and temporary, or severe and permanent. Each patient will present with a different history and different symptoms. This is one reason why using a holistic, biopsychosocial, approach is so important in the initial treatment, and ongoing rehabilitation, of a patient with a brain injury.

The initial treatment is obviously important, but even the acute neurosurgery areas recognise the essential role that rehabilitation units play in the recovery of patients with a head injury "There is no doubt that departments of rehabilitation and agencies such as Headway have much to offer [head injury] patients and their families" (Waldmann & Thyveetil, 1998).

It is, therefore, also important that the family of a brain-injured person are kept informed about, and involved in, the care that their loved one is receiving. There are, fortunately, many anecdotal cases where the ideal situation is achieved, both in hospital, and after the patient has returned home (Barry, 1998). Unfortunately, this is not always the case and divorce rates among couples where one partner, or a child, has had a brain injury are distressingly high (Chamberlain, et al, 1995; Faulkner, 1989).

To the families of brain injured patients, the term rehabilitation often conjures up ideas of magic cures (Gronwall, et al, 1990). However, the reality is that, because of several factors, not least of which includes the motivation of the patient (which will be discussed later) and the actual resources available, the reality may fall somewhat short of what the family expects.

The basis of rehabilitation of brain injured patients relies on the theory that, even if some neural pathways are completely lost following injury, new pathways can be instituted through practice and repetition of the lost action (Gronwall, et al, 1990, Chamberlain, et al, 1995). Examples of this include repetitive passive exercise and regular tasks with the occupational therapist.

The emphasis in all of the literature is on multidisciplinary teamwork. Some areas seem to have grasped a better idea of what this involves than others. For example, Gronwall, et al (1990) lists the following members of the rehabilitation team.

• Physiotherapists
• Occupational therapists
• Speech therapists
• Neuropsychologists
• Cognitive retraining therapists
• Social workers
• Clinical psychologists
• Rehabilitation officers

However, it will be noted that this list has left out the one person, or rather profession, who is with the patient twenty-four hours a day and, therefore, arguably the most important! The nurse has a huge role to play in rehabilitation, as it is he who will be ensuring that the patient complies with, for example, the physiotherapist’s directions outwith the short period of the day when the patient is undergoing his therapy. Fortunately, most other literature recognises the fundamental role of the nurse in the rehabilitation team, both in the rehabilitation unit (Chamberlain, et al, 1995) and in the community (Hemingway & McAndrew, 1997).

This basis of teamwork means that any models or tools which are used in the rehabilitation setting also have to be multidisciplinary. A specifically nursing model, such as the Activities of Living model (Roper, et al, 1996), while it may be useful and is used in some areas, may fall short of offering a truly holistic view, when the needs of the physiotherapist, occupational therapist and clinical psychologist are also taken into account.

Therefore, any tool created must be as a result of the whole team getting together and producing a tool that can be used by everyone. It necessarily follows that not all individual members of the team will need the whole tool, but everyone as a team will.

As an example, the Brain Injuries Unit at Royal Victoria Hospital, Dundee uses two tools. One is a simple dependency score (Turner-Stokes, 1997), primarily used by nurses and occupational therapists. The other is a comprehensive Functional Assessment Measure which quantifies the level of disability of a patient by considering dependence in thirty categories and involves input from all members of the team.

In the USA, the Functional Independence Measure (FIM) is widely used (Vanetzian, 1997) and is similar to the aforementioned Functional Assessment Measure (FAM). However, the FIM also introduces an equation that relates a patient’s tendency to succeed to his motivation and incentive to succeed.

It can be inferred that motivation on the part of the patient plays a large role in all of the models described, although it is only specifically mentioned in the FIM. As it states motivation will figure heavily in the patient’s success in his or her rehabilitation. With, say, a patient undergoing cardiac rehabilitation, this motivation is likely to be high, especially if the patient is young. Older patients, such as those who have had a stroke, though their motivation may be lessened by the fact of their age, will still have a degree of motivation to return to a level of independence, even if such a goal is unrealistic (Hafsteindottir & Grypdonck, 1997).

However, patients who have had a stroke that has affected some cognitive ability, and the majority of patients with a head injury, may well have lost some memory and other cognitive functions, leading to a lack of insight. This may manifest as a denial that he has problems requiring rehabilitation, or even putting others or himself in danger by inappropriate actions (Gronwell, et al, 1990). The patient may see as different, problems seen by the nurse or another member of the multidisciplinary team, or may put a different emphasis on a particular aspect of his rehabilitation. This is where perception of need comes in. An example may be where the nurse and physiotherapist realise the importance of the patient learning to walk again, to prevent a sedentary lifestyle which can lead to many problems, not least of which is pressure sores, whereas the patient who has little insight may prefer to just sit and watch the television (Resnick, 1999).

In order to overcome this, the nurse, and indeed the rest of the multidisciplinary team, must understand the basic concepts of patient motivation and compliance, and also of the patient’s insight.

The classic, and yet still widely regarded as the most helpful (Wilkinson, 1997), model for understanding motivation is that of Abraham Maslow (Maslow, 1987). Here, Maslow presents a "hierarchy of needs", which streams human needs into categories and has the most important needs (physiological) such as air and water at the bottom of a pyramid forming the foundation for other needs such as safety, love and belonging, self-esteem and self-actualisation. Wilkinson (1997) acknowledges that this has limitations, but that it is helpful in planning care. Having established his "needs hierarchy", Maslow continues with a discussion on patient motivation and expands his hierarchy by introducing concepts such as instinct and personality. However, he fails to fully appreciate the impact that a lack of patient insight, such as that caused by traumatic brain injury, may have on their motivation to succeed.

Gross (1996) covers the idea of insight in depth, and Gronwell, et al (1990) also includes a section on this important part of gaining an understanding into the motivation of a patient to succeed in their rehabilitation. In this context, "insight" is the knowledge of "how well you are able to do things" (Gronwell, et al, 1990, p56) or the "urge that... prompts a person to action" (Resnick, 1998, p23). However, following head injury, particularly to the front parts of the brain, a patient may really feel that there is nothing wrong with him, and therefore does not need to focus on his rehabilitation, or, as previously discussed, may focus on a less important consequence of the accident (Gronwell, et al, 1990). In other words their perception of need has been altered. (Wilkinson, 1997). If Maslow’s hierarchy of needs (Maslow, 1987) can be pictured, the patient will have, unwittingly, changed the order of need, and may, for example, feel that a sense of belonging is actually more important than the physiological need for food. Without insight, or with an impaired insight, he may not understand that he is actually putting his life at risk.

Insight is only one aspect of this. One other thing which a nurse must understand is the grieving process which can have a profound effect on the motivation of a patient. While Elisabeth Kubler-Ross’s work ‘On Death and Dying’ (Kubler-Ross, 1970) was intended as a study on death and terminal illness, her "stages of grief" are, as well as still being recognised as significant even nearly thirty years on, also understood to cover grief from any loss, such as an amputation, or loss of mobility. Any person who loses something significant, such as the loss of independence felt by many brain-injured patients, will undergo a form of grieving process. The model proposed by Kubler-Ross, as mentioned, remains the most-widely used in trying to understand the grief process. These stages are:-

• Denial
• Anger
• Bargaining
• Depression
• Acceptance

As with any model representing a process, there is bound to be some overlap between "stages" and not every person will experience all of them. However, once the nurse, or other member of the rehabilitation team, understands that a patient may well be undergoing a form of grieving, some of that patient’s more unacceptable, inappropriate behaviour may be explained, if not excused.

Some significant losses which may be felt by a brain-injured patient include:-

• Loss of independence
• Loss of use of limbs, body function (breathing, eating, elimination)
• Loss of communication skills
• Altered body image
• Alteration in family and sexual relationships

(derived from Chamberlain, et al, 1995)

As can be seen, the problems cover the whole spectrum of the Activities of Living (Roper, Logan & Tierney, 1996). As examples, the latter two can be particularly interesting. A specific problem that a brain-injured person may face is the loss of gut motility, which will probably result in the siting of a stoma. This will have a profound effect on the patient’s body image and the nurse must boost his understanding of the psychological response to such altered body image (Allison & Stuchfield, 1994).

One of the most taboo subjects, and yet the one which most patients and their partners worry most about, is the resumption of a sexual relationship following brain injury. There is little written in this field (Wilkinson, 1998). Even when studies are undertaken, the factors of embarrassment and sensitivity often lead to poor returns and false accounts when any research is attempted (Glass, 1995).

A few main problems have been identified in the literature regarding the issue of sexuality in brain-injured patients.

• The prejudice of other people towards them. "Society is still struggling with the negative concept that [people with disabilities] are asexual and could not possibly have concerns or problems regarding sexuality in the same way as able-bodied people." (Cole, 1988, in Glass, 1995, p 252).
• Physical problems, including erectile dysfunction, sperm motility. (Glass & Soni, 1999)
• Emotional problem, including altered self-image (Glass & Soni, 1999), change in partner’s role (Wilkinson, 1998).
• Practical problems – how much opportunity is there on the rehabilitation ward for a patient and his partner to have "intimate social and sexual interaction" (Davis & Schneider, 1990)?

The first point of call in trying to counteract these problems is to examine the attitude of the health care professional himself. Whether it is the nurse, occupational therapist (Couldrick, 1998), or any member of the multidisciplinary team, they "must be aware of their own [prejudices and] limitations" (Glass, 1995, p 253). How comfortable would he be "discussing same sex relationships, the issues of HIV, preparation... for fertility programmes" (Glass, 1995, pp253-254)? In cases like these, it is often the nurse, as the person in whom the patient has gained the most respect, that the patient will turn to. He must be prepared to discuss the matter in a sensitive fashion, and be aware of how to contact and utilise other agencies if he feels the matter is beyond his own expertise (Glass, 1995).

The physical problems can be dealt with in a variety of pharmacological and non-pharmacological ways (Glass & Soni, 1999). One of the most topical, and well-known, methods, is the use of Viagra, and studies into the use of the drug in disabled patients are currently being investigated (Maytom, et al, 1999). The use of fertility treatments may also be considered (Glass & Soni, 1999).

Emotional problems can only be overcome through counselling and a lot of help and understanding (Glass, 1995).

And, finally, the practical aspects again lie with the attitudes of the multidisciplinary team on the rehabilitation ward. Maybe it is possible to have a side room on the unit where partners can be alone. Perhaps visits home could be arranged if the patient is able. How would the team, or indeed the other patients, react to same sex partners or even, depending on the age group, unmarried partners using such facilities? Again, all this boils down to the attitudes of society, and whether such issues are still taboo. However, sexuality remains one of the Activities of Living (Roper, et al, 1996) and can also be one of the major issues affecting a person’s motivation to succeed in his rehabilitation (Glass & Soni, 1999).

While the issue of motivation within rehabilitation may be well-documented in, for example, post-MI (myocardial infarction) therapy, the complications implicit in the same subject as regards brain injury rehabilitation mean that the matter is, perhaps, less obvious in the research literature.

However, there is a substantial amount of research conducted in some areas of rehabilitation that relate directly to the motivation of a patient. While this essay focussed in on the, currently fashionable, topic of sexuality, other issues such as body image, loss of independence and difficulties with communication are all very important.

Some areas that call for further, or improved, research include the whole area of motivation in patients who maybe lack the insight to motivate themselves. Within occupational therapy there is a lot of interest in this topic. Perhaps the nursing perspective would offer some, further, valuable understanding. After all, rehabilitation is very much a multidisciplinary venture.

There also exists a definite lack of research into how the lack of motivation, specifically in head-injured patients, relates to the carers and family.

Some thought also needs to be given to the previously mentioned problems (Glass, 1995) with people’s attitudes towards sexuality in brain-injured, or, for that matter any person with a disability. More specifically, it would be interesting to learn how different centres cope with problems encountered in this area.

Also, how do the issues described (sexuality, body image, feelings of loss and so on) actually affect the motivation of rehabilitating patients. Can these effects be quantified?

As with any aspect of research, every new study attempted will open up newer areas of study!

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