Rehabilitation for chronic neurological disorders including acquired brain injury

Ensure the person is supported to make decisions about their health and social care, especially if they may have complex communication or cognitive needs or 'invisible' symptoms or impairments. This may include involving family, carers or others important to the person as representatives (if the person agrees), or formally appointed advocates.

If a referral for a specific functional needs assessment is received, offer holistic rehabilitation needs assessment unless it is clear that any new rehabilitation needs can be identified through a specific functional needs assessment.

Be aware that a person may have multiple chronic neurological disorders, including a functional neurological disorder alongside another neurological disorder. If this is the case, undertake holistic rehabilitation needs assessment based on the impact of all disorders and agree a single rehabilitation plan.

The person initiating holistic rehabilitation needs assessment (which may be the responsible clinician) should:

• identify and contact the health, mental health and social care practitioners who might be needed and

• agree with the practitioners who is best placed to lead on and coordinate the assessment (the lead practitioner for holistic needs assessment and rehabilitation planning) and

• make onward referrals to other health, mental health and social care practitioners if other needs that are not linked to rehabilitation are identified.

The lead practitioner for holistic needs assessment and rehabilitation planning should seek input from health, mental health and social care practitioners and other practitioners (including teachers, social prescribers and equipment providers) to inform the assessment.

Discuss who is important to the person, and if and how they would like them to be involved in their rehabilitation. Make sure the other people agree to their role in helping to deliver rehabilitation.

Complete holistic rehabilitation needs assessment in partnership with the person and those people important to their rehabilitation (see recommendation 1.8.6.).

Do not delay starting rehabilitation interventions while undertaking holistic needs assessment.

Ask the person about:

• their background, relationships, work, education, meaningful activities, spiritual and religious practices, and hobbies and interests

• their activities of daily living (including self-care skills and domestic and leisure activities) and how these have changed or are changing

• developmental milestones and play, in the case of children

• what would motivate them to engage in rehabilitation and what is most important in their life

• environmental and wider social factors that might encourage or prevent them from taking part in rehabilitation (for example, access to community resources and equipment for rehabilitation and housing).

In addition to their neurological condition or injury, think about how other health conditions, including mental health conditions, may affect the person's rehabilitation.

Think about the possible impact of any existing medication on impairment (for example, cognitive function) and review medication as part of rehabilitation planning.

Encourage the person to talk freely about how their life has been impacted by their neurological condition.

If the person has 'invisible' or less easily recognisable symptoms or impairments or lacks awareness and insight into the effects of their injury or condition, and therefore struggles to articulate their rehabilitation needs, assess using multiple methods, including observation.

Assess the person's need for information, advice and training about how their condition or injury is impacting their functioning and ability to carry out their usual day-to-day activities.

Identify rehabilitation interventions that will help the person, and their family or carers, if appropriate, to prepare psychologically and physically for future changes to impairment and functioning. This is especially important if the person has a rapidly progressing condition.

Assess the person's functioning, symptoms and impairment in the following areas:

• pain (see the section on pain management)

• fatigue (see the section on fatigue)

• physical activity and exercise (see the section on physical activity and exercise)

• stability, mobility and limb function (see the section on stability, mobility and limb function)

• emotional health and mental wellbeing (see the section on emotional health and mental wellbeing)

• cognitive function (see the section on cognitive function)

• speech, language and communication (see the section on speech, language and communication)

• eating, drinking and swallowing (see the section on eating, drinking and swallowing)

• independent living needs, equipment and environmental adaptations (see the section on independent living, equipment and environmental adaptations)

• bladder and bowel function (see NICE's guidelines on urinary incontinence in neurological disease: assessment and management and faecal incontinence in adults: management).

Assess for vision and hearing problems and take into account how these might impact the person's rehabilitation.

As part of holistic needs assessment, find out how the person's functioning, abilities and needs vary, or are likely to vary:

• in different real-life environments, for example, their home, place of education or work, and places they visit such as shops or leisure centres

• at different times of the day and from day to day

• over the longer term.

Assess the need for rehabilitation to enable the person to participate in every aspect of their daily life. See the section on rehabilitation to support education, work, social and leisure activities, relationships and sex.

Do not exclude someone from any aspect of holistic needs assessment based on their communication, memory, learning or other cognitive difficulties.

Make reasonable adjustments and adaptations to enable a person with communication, memory, learning or other cognitive difficulties to engage in rehabilitation.

Use the NHS continuing healthcare guidance to determine if someone is eligible for continuing NHS healthcare at home.

Discuss with the person, and their family or carers, if appropriate, whether they have social care needs and whether a social care needs assessment is required. For more information, see NICE's guideline on social work with adults experiencing complex needs.

For children and young people with severe complex needs, assess their rehabilitation needs as part of an education, health and care plan (EHCP), which should cover special educational needs, social care and healthcare, including rehabilitation. For more information, see NICE's guideline on disabled children and young people up to 25 with severe complex needs.

Be aware that people who have experienced trauma as a direct result of their injury or condition, or prior life experiences, or both, may need adaptations to assessment, rehabilitation and support plans.

Ask the person about their aspirations and goals in relation to staying in, returning to, or leaving work, education or training.

Use information from discussions with the person (see recommendation 1.9.9), together with the person's likely developmental trajectory in the case of a child or young person, when setting education and work goals with them.

Work with the person to identify their strengths, motivations and rehabilitation needs in relation to work, education or training provision.

Review the person's goals connected to work, education or training whenever their rehabilitation needs are being reassessed.