Rehabilitation for chronic neurological disorders including acquired brain injury

Acquired brain injury

Injury to the brain that results in neurological impairment. Causes include trauma, tumours, infections, metabolic insults and disorders of the blood supply.

Acquired peripheral nerve disorders

This includes acute-onset disorders of the peripheral nervous system that result in neurological impairment. Causes may be inflammatory, autoimmune or paraneoplastic causes.

Acquired spinal cord injury

Injury to the spine that results in neurological impairment. Causes include trauma, tumours, infections, metabolic insults and disorders of the blood supply.

Clinical pathway

Setting out a process of best practice and evidenced rehabilitation options for a person and mapping out the care journey they can expect. A tool to inform decision making and prompts for the involvement (and disinvolvement) of different people and services along the way. Also referred to as care pathways, integrated care pathways, integrated care systems, clinical care pathways, pathways of care or care maps.

Community rehabilitation services

All rehabilitation interventions and services delivered by rehabilitation practitioners in settings outside of hospital, including the person's home. These are often non-specialist services and may not have expertise in working with people with chronic neurological disorders.

Compensatory aids

Tools or devices designed to help people perform tasks more effectively when they face difficulties due to impairments. These can include things like smart phone apps, paper diaries, electronic calendars, video games, virtual reality and other computer-based exercises.

Complex case manager

A named health, mental health or social care practitioner (for example, a social worker) with specialist knowledge in inpatient and community-based rehabilitation and support, including education or training support for children and young people, if needed. They must be able to engage and commission services, monitor them, and integrate input from various different services and professions.

A complex case manager works with people who have severe, complex and long-term rehabilitation needs and impaired cognitive or executive function, are unable to advocate for themselves, have serious comorbidities, learning disability, complex mental health needs, misuse drugs or alcohol or neurobehavioural symptoms that place them at risk of harm to themselves or others.

They provide advice, proactive support and signposting, coordinating rehabilitation across multiple services provided by therapists, support workers and other health, mental health and social care practitioners, as well as liaising with community services such as transport and housing services. They assess rehabilitation needs, consider multiple clinical assessments, identify priorities, and create tailored rehabilitation plans, acting as advocates and promoting inclusion. Complex case managers review rehabilitation plans as needed and offer ongoing support as circumstances change.

Where assigned, a complex case manager would also cover any responsibilities of a key contact or key worker that are not covered here.

Errorless and error-based learning

Errorless learning is an instructional method aimed at preventing mistakes during the learning process. It involves giving clear, step-by-step guidance and prompts to ensure successful completion of tasks without errors.

Error-based learning, for example trial and error, allows mistakes to be made as part of the learning process. These errors help people identify and correct misunderstandings, fostering deeper understanding and long-term retention of learning.

Executive function

A set of cognitive processes that help direct and coordinate other cognitive functions. These processes help a person to plan, meet their goals, display self-control, follow multiple-step directions even when interrupted, and stay focused despite distractions. Executive function also includes the ability to draw conclusions from known or assumed facts (reasoning ability), initiate purposeful behaviour, and demonstrate insight into one's own actions and limitations. These abilities are primarily associated with the frontal lobes of the brain and are essential for adaptive, goal-directed behaviour.

Impairments in executive function are common in people with acquired brain injury and may not be immediately apparent, especially in structured or familiar environments. Failure to recognise deficits in initiation and insight can result in unmet needs and increased vulnerability, as these impairments may not be self-reported or observable without specialist assessment.

Functional activity

Tasks performed as part of a person's daily life that require physical or cognitive effort, such as walking, eating, dressing, and engaging in school, work or hobbies. These are important in rehabilitation as they help the person to live independently.

Functional assessment

The evaluation of a person's ability to perform a specific activity in their daily life. Functional assessments may cover activities of daily living in the home; activities involving memory or cognition skills; psychosocial and behaviour issues, and communication.

Functional neurological disorders

Functional neurological disorders can cause a range of disabling neurological symptoms, which include altered awareness, and motor and sensory changes. However, symptoms are not explained by a physical or neurological disease.

Health or disability passport

Allows a person with a long-term health condition or disability to record information about themselves and the support they need, so that this can be shared with others. It is carried by the person and can be used in the workplace, in education and when accessing any other service. It helps to explain the necessary adjustments and accommodations required by the person in order to access services or participate.

Holistic rehabilitation needs assessment

Focuses on the person as a whole and not just their condition or injury. Made up of a number of functional assessments and discussions with the person about their priorities and goals.

Initial contact for rehabilitation

The initial contact for rehabilitation is a named practitioner assigned by the responsible clinician following diagnosis or initial treatment for a chronic neurological disorder where potential rehabilitation needs are identified.

They may be temporary and may also be assigned at hospital discharge.

This role is distinct from the lead practitioner for holistic needs assessment and rehabilitation planning. It is also distinct from the single point of contact, who is assigned after holistic needs assessment and on the agreement of a rehabilitation plan.

The role of the initial contact for rehabilitation may be undertaken by a wide range of practitioners, for example:

The role can be hospital- or community-based (for example, in a community neurorehabilitation team) and provides a link to rehabilitation services, early service delivery and early assessment coordination before a lead practitioner for holistic needs assessment and rehabilitation planning is agreed.

Internal and external compensatory strategies

Internal compensatory strategies involve using cognitive techniques or skills to adapt to, or overcome, cognitive difficulties. For example, using memory aids like visualisation or creating associations to help recall information.

External compensatory strategies involve using tools or external devices to assist with tasks or challenges. Examples include using calendars, alarms, or speech-to-text software to assist with memory or physical limitations.

Key contact

A named unit, team or person involved in the person's rehabilitation care. This contact can be community or hospital based. The key contact primarily signposts, provides relevant information, and facilitates entry into rehabilitation services as needs emerge. They seek information and input from others if they cannot offer advice directly. This contact should remain in place even when the person is not receiving active rehabilitation.

Key worker

A key worker is a named health, mental health or social care practitioner. This role may change along the rehabilitation care pathway, such as after hospital discharge. A key worker can be community- or hospital-based, working across professional and health and social care boundaries.

Key workers support people with impaired cognitive or executive function affecting their ability to self-manage or navigate rehabilitation services, unpredictable or rapidly changing neurological conditions, multiple rehabilitation needs, potential new care access needs, and associated family support needs.

They provide signposting, relevant information, and facilitate re-entry into services. They also manage care, coordinate rehabilitation and liaise with other services, such as social care. There are mainly qualified NHS staff currently undertaking this role, but practice varies in whether people are assigned key workers.

Where assigned, a key worker would also cover any responsibilities of a key contact that are not covered here.

Lead practitioner for holistic needs assessment and rehabilitation planning

The lead practitioner is the person who leads on and coordinates the holistic needs assessment, goal setting, the agreement of a personalised rehabilitation plan and the appointment of a key contact, key worker or complex case manager. They may also be the initial contact for rehabilitation or responsible clinician or key clinical contact (as referenced in the recommendations) and they would usually require knowledge or experience of working with people with the same or related disease, disorder or injury.

This role is distinct from the single point of contact, which is assigned after holistic needs assessment and on the agreement of a rehabilitation plan.

The role of the lead practitioner may be undertaken by a wide range of practitioners, for example:

The role can be hospital- or community-based (for example, in a community neurorehabilitation team) and provides a link to services, early service delivery and assessment coordination before a rehabilitation plan is finalised and before the most appropriate single point of contact is agreed.

Neurodevelopmental stages

Physical, cognitive, communication, social or behavioural signs of development for infants or children. A set of functional skills or age-specific tasks that most children can do at a certain age range. These stages or milestones provide important information regarding the child's early development.

Progressive neurological disease

Disorders that involve a gradual progression of neurological difficulties over time.

Rehabilitation

Rehabilitation is defined by the World Health Organisation as 'a set of interventions designed to optimise functioning and reduce disability in individuals with health conditions in interaction with their environment'. Rehabilitation helps a person to be as independent as possible in everyday activities and enables participation in education, work, recreation and meaningful life roles such as taking care of family. It does so by working with the person and their family to address underlying health conditions and their symptoms, modifying their environment to better suit their needs, using assistive products, educating to strengthen self-management, and adapting tasks so that they can be performed more safely and independently. Together, these strategies can help an individual overcome difficulties with thinking, seeing, hearing, communicating, eating or moving around.

Rehabilitation is defined by the British Society of Rehabilitation Medicine as 'a process of assessment, treatment and management with ongoing evaluation by which the individual and their family/carers are supported to achieve their maximum potential for physical, cognitive, social and psychological function, participation in society and quality of living'.

Rehabilitation plan

An agreement about the rehabilitation treatments and approaches that will help the person maintain, improve or support function, live as fully and independently as possible, and to achieve their rehabilitation goals.

This may be in the form of a rehabilitation prescription. It may also come in different versions such as the rehabilitation passport, which is a patient-held document, and may be a simplified version of the plan. It is carried with the person and also communicated between rehabilitation teams and updated accordingly and used to document information about the condition and rehabilitation treatments in an accessible format.

Rehabilitation practitioners

Any registered health, mental health or social care practitioner contributing to the rehabilitation of a person with a chronic neurological disorder at any stage of referral, assessment, delivery, review, follow-up or re-referral.

Rehabilitation practitioners include but are not restricted to:

Together these practitioners may also form hospital- or community-based multi-disciplinary teams to deliver holistic rehabilitation needs assessments and rehabilitation plans.

Responsible clinician

The doctor or healthcare professional responsible for the person's treatment and care in relation to their neurological disease, disorder or injury either in hospital or in the community. For the purposes of this guideline, they are responsible for making sure the person has an initial contact for rehabilitation even if rehabilitation needs have not yet emerged.

Single point of contact

This may be a link to a unit, team or person in health or social care involved in the person's rehabilitation (a key contact) or it may be a key worker or a complex case manager. This single point of contact can be community- or hospital-based.

The decision about the most appropriate single point of contact is made following the completion of the holistic rehabilitation needs assessment and incorporated into the rehabilitation plan.

The type of single point of contact needed will vary dependent on the person, their circumstances, whether they are at home, in a residential or inpatient (hospital) setting and the intensity of other medical or social care they may be receiving.

Decisions should be based on the complexity of needs, service organisation and abilities of the person to coordinate their own care as identified at holistic needs assessment (see also the definitions for key contact, key worker and complex case manager and the criteria for decision making in the recommendations in section 1.11).

A single point of contact must remain even when the person is not receiving rehabilitation, to ensure access to services as needs emerge.

Skills-based learning

Emphasises the development of specific skills required to perform certain tasks. This type of learning is often hands-on and practical and involves directly applying and practising the skills needed for a particular job or activity, such as technical skills, communication, or problem-solving.

Social cognition

Describes a variety of disparate cognitive, affective, and behavioural abilities that interact and contribute to a person's interactions with other people. It includes how people understand and make sense of social interactions, such as the recognition of emotions, intentions, beliefs, and behaviours in themselves and others. Social cognition plays a key role in effective communication, empathy, and social functioning, and is particularly relevant in the assessment and support of people with neurodevelopmental or cognitive conditions.

Specialist neurorehabilitation services

Any rehabilitation service that is tailored to treat and care for people with a chronic neurological disorder, including services for any disease, disorder or injury that can result in neurological impairment or disabling neurological symptoms (for example, any rehabilitation service based within a neuroscience centre). This includes specialised rehabilitation services that support people with a complex disability whose rehabilitation needs cannot be fully met by general community rehabilitation services. It would also cover specialist advice and expertise on care or equipment.

Standard cognitive tests

Standardised assessments that evaluate specific mental functions (also known as cognitive processes), such as memory, attention, language, executive function and problem-solving. These tests aim to measure how well a person's brain processes information, rather than how they perform everyday tasks. Cognitive tests assess internal cognitive processes and are used to evaluate how cognitive abilities translate into real-world activities and daily living skills.

Task-based training

A teaching approach where people engage in activities that replicate real-world tasks that are part of their daily life. The focus is on applying skills to complete specific, realistic tasks rather than focusing on abstract concepts or theoretical knowledge, with the intention of acquiring or reacquiring a skill.

Trusted assessment

Where a trusted assessor – someone acting on behalf of, and with the permission of, multiple organisations – carries out an assessment of a person's health, mental health or social care needs, or all of these.

Vestibular problems

Dizziness or problems with balance caused by damage to parts of the inner ear or the brain that process the sensory information involved with controlling balance and eye movements.

Vocational rehabilitation

Focuses on the rehabilitation interventions needed to help people with long-term health conditions or disabilities return to or stay in work, education or training. This may involve adapting working conditions or job roles, retraining or providing support in leaving a role and finding alternative occupations.

Working memory

The cognitive system responsible for temporarily storing and manipulating information needed for complex tasks such as reasoning, comprehension, and learning. It helps people hold and process information in the short term while performing cognitive tasks, like solving maths problems or following multi-step instructions.