Recovery of impairment disability and handicap

Psychological symptoms far outstrip neurophysical symptoms (e.g. hemiparesis or dysarthria) as determinants of chronic disability and suffering, both of the patient and their carer, following brain injury.

The ideas encapsulated in the International Classification of Impairments, Disabilities and Handicaps ( ICID^1,9» are important for understanding recovery from brain injury.

• Impairments are abnormalities of structure, or physiological or psychological function. Thus poor performance on a test of memory or on a test of co-ordination is an impairment.

• Disability refers to the behaviour of the person and their ability to perform activities. Several impairments may contribute to a single disability.

• Handicap reflects the limitations on fulfilling the person's normal social role and participation in society. External factors (e.g. personal support systems or the availability of appropriate transport) play a large part in determining handicap. Handicap depends partly on the expectations of the individual patient.

The term 'disability' will probably be replaced by 'activity', and 'handicap' by 'participation', in the next version of ICIDH.

Recovery of impairment is usually complete by 1 year, with improvement in neurophysical impairments tending to stop before neuropsychological impairments.

However, the level of disability may continue to fall long after the recovery of the underlying impairment has stopped. This reduction in disability largely reflects improved coping strategies and these will be the focus of inpatient cognitive and behavioural rehabilitation. Once the person is back to living in the community then the rehabilitation team can focus on minimizing handicap, for example by improving access to local shops.

Psychiatric symptoms and quality-of-life measures do not fit easily into the ICIDH model. Psychiatric symptoms, with their multifactorial aetiology, show no simple pattern of recovery.

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