Some questions answered by Jack Thackeray 1952

Jack Thackeray’s experience in treating head injury patients started in 1952. As well as founding member of the Head Injuries Club he developed an approach and techniques to stimulate recovery that gained him and the hospital national and international recognition. The following is a transcript of a question and answer session between Jack and fellow therapists and patient’s relatives. (for convenience sake the patient in this article is referred to as “he” – this does, of course, also include female patients.)

When do you commence treatment of these patients?
On day one. Care of the chest is of prime importance at this stage, so intensive treatment of the chest is started and continued until the patient is able to cough and breathe normally, and also be free from infections. Anoxia by whatever cause will lead to a poor and/or slow recovery. The patient’s blood gas should be carefully monitored and a respirator used if required to maintain a high blood gas count. The treatment of the patient’s chest cannot be overstressed – it is the rock on which recovery is based particularly as the condition of the chest in the early stages gives many clues as to the kind of recovery the patient is going to make.

When does the actual rehabilitation start?
No actual order is given to start the rehabilitation as this is a natural process – from the nurses and staff of the intensive care unit, who talk to and treat the patient as if conscious using his name and telling him what is about to happen, to the therapist treating the patient’s chest or moving the limbs. When the condition of the patient is stable and he is free of the respirator he is taken to the gymnasium for the stimulation phase to begin.

What should the family be doing at this stage?
a) Make a list of the patient’s likes and dislikes, particularly food and music, giving a copy to the nurses
and the therapist.
b) Make tape recordings of familiar things – at the place of work, a night at the pub, a school lesson,
motorbike racing, meal at home etc.
c) Compile a number of photo albums e.g. weddings, holidays, places visited by the patient in a normal day etc.
d) Make a rota of friends to visit and talk to the patient. They should be advised that it may be some time
before the patient will respond and that they should talk in a normal manner if possible.
e) The immediate family can visit a branch of headway to talk to families of other patients who have had
similar injuries to gain support through shared experience and perhaps gain some insight into the future.

What are your most common findings?
I find that each and every brain damaged patient is totally different from the next one and therefore each one must be treated in an individual way. There is no “routine treatment” for such patients. However, there are certain questions which need answering straight away: –
a) Can the patient see? If the patient is spastic it is reasonable to assume the patient has vision problems
due spasm of the eye muscles. Thus, visual disorders are common and hand to eye co-ordination may
have to be practiced for a long time.

b) Can the patient speak? Again, if the patient is affected by spasm it will also affect the voice hence a clear reply to a question may take a long time. Also, there are many speech disorders where the patient will not be able to use sound to indicate correctly what is required or needed.
c) Can the patient hear? It is rare but not unknown for the patient to be found mentally deaf due to the
changes in pitch or tone or due to the loss of memory for words which for all effective purposes makes
him deaf. Clearly any or all three of these major disabilities will affect your approach to the patient, knowing that with time and patience these problems will be greatly overcome. Then we have the other problems that may also present themselves – loss of muscle tone due to high protein loss and lack of mobility, changes in reflex patterns, incontinence, changes in personality and in some cases impairment of intellect.

Why stimulation?
If the patient is not stimulated as soon as possible after the injury he will vegetate. The longer the gap between the injury and the start of the recovery phase the more likelihood of a slow recovery with perhaps deformity of limbs and with the risk of further chest infects and further brain damage.

With what do you stimulate him?
This is what I call the irritating the patient stage. Mats on the gymnasium or ward floor are usually used. A bed is a poor place for such work.

The following are some of the irritants I use in the early stages: –
1) Ice. Large cubes of ice placed on the body’s tender spots
2) Scratching with a rough pad (nylon type)
3) Pulling body hair
4) Tickling
5) Stroking with feather, silk, sandpaper
6) Placing in uncomfortable positions

There is an excellent kit on the market called the “Comakit” which contains a great many useful aids to this stimulation stage. There is also the constant stimulation of sound either by tape recordings or radio. In this stimulation stage careful note is taken after patient’s reactions. Does ice to the left side of the trunk cause the patient to move where ice to the right does not? Will the patient swallow if the lips are stroked with ice? In what positions does spasticity increase and decrease? Does the patient show any reaction to smells and loud noises? Etc.

Do you use splints?
Yes. In the early stages P.O.P splints are very important to prevent contractions and the shortening of muscles, in the later stages as night splints to maintain the required length. Also, in the later stages I use calipers and splints to assist the ambulation of the patient, knowing that the splint may only be required for a short time to start the patient moving.

Do you use passive movements?
I am going further and further away from the use of passive movements. I have seen and still do see a lot of problems caused by over zealous use of passive movements. All joint however should be put through a range of passive movements if the patients cannot be stimulated to move them. But it is most important that the minimum force is used for these passive movements because of the risk of causing Mysoitis Ossificans and the formation of ectopic bone in muscle.

Do you use relaxation techniques?
I think relaxation is an important part of a treatment session in the early recovery stage, particularly with those with some spasticity. Spasticity can certainly be reduced if not completely overcome in the early stages if the patient is told and shown how to relax a moving limb effected by spasticity. Also, the use of the anti-spasm positioning of the patient should be shown to the nursing staff for use when the patient is on the ward. A drawing of these positions placed above the patient’s bed can be of help

How long is a treatment session?
Usually about one and a half hours. The session is split into working on the mats for spastic exercises i.e. back extension, hip extension or the passive exercises. Work with a beach ball or a gymnasium ball. Standing, if possible or being upright on the Tilting Table. A period of relaxation and a ty and walking. Progression in time and strength as the patient improves. The patient’s day being split into two – mornings in the occupational therapy department and afternoons in the gymnasium.

Do you let the family watch you work?
Always. In fact, I have trained quite a lot of parents into part time therapists. I do not have the time or the staff to treat all the patients fully, so the family quickly learn what is required and are often a great help. This is also a wonderful time to answer the thousands of questions they want to ask. Being part of the treatment team and seeing the progress of their child makes for a very strong bond with the patient and can assist greatly in the early return home.

Do you discharge these patients quickly to be looked after their family?
No. we treat these patients for as long as they require it until they are reasonably independent. This make take many weeks, months or a year or two. Patients will then go home for one or two hours on a Saturday just to remind him what home is about. Progress is then made to one night at home, then to a full Friday night to Monday morning. The family are carefully questioned as to their experiences on these weekends and it is only with their fully co-operation that the patient is finally discharged home. The patient will then attend on a daily basis as an outpatient so that the normal daily routine of family life is disturbed as little as possible, and in order to make certain that the patient continues to improve.

For how long does improvement continue?
For many years, if they have been given a good start right from day one. The progress of even some of our most severely brain damaged patients has been tremendous.

Communication
A great deal of time and effort should be spent on finding a method of communicating with patients – as contact with the patient improves, the frustration and aggression get less and less and the co-operation by the patient will improve.
Whatever method (decided on by the therapist) that is found to work should be written on a large sheet of paper and placed above the patient – therefore, everyone can use a common system so not to confuse the patient. The patient’s physical control and abilities determines the method to be used. The system is taught to the patient until a clear and repeated response takes place.

Example of the treatment of patients – the Jack Thackeray way
The patient is placed over a large gymnasium ball, supine and prone lying, and in both positions is scrubbed with the scrubber or rubber with the nylon pad, and generally shaken about. We then place the patient on the Tolt Table, bringing this up slowly noting the changes in the circulation pattern, but getting the patient upright, so they have no fear of their body height at the walking stage. PLEASE note this is done when the patient is still in, or at the Intensive Unit stage. Yes taken to the gymnasium as soon as the patient is removed from the respirator, for the stimulation programme to start, to delay longer is to allow the patient to become demoralised, fixed in spastic patterns and to try and reserve the loss of muscle tone and body bulk.
[Ice is either placed or stroked over the body’s tender areas. It is placed on the lips to see if the nipple reflex is present, on the soles of the feet to note if the withdrawal reflex is working etc. the scrubbing pad is used on the soles of the feet when the patient is prone lying over the Gymnastic ball, the whole of the back is lightly scrubbed. In this position ice is rubbed over the renal angle.]
This form of irritation stimulation is carried out at each daily treatment session until the patient moves to
command or changes their body position of their own volition. Once the patient is obeying commands, it is up to the therapist to form a bond with the patient, so the patient learns to trust.

Rehabilitation of Head Injuries

• He was famous for strong belief in taking a positive approach to all patients along with the power of early rehabilitation “High quality immediate positive action can and very often does make a tremendous difference to the future of the patient and to their family. The difference can be as great as the vegetative state to returning to sheltered work.” … “It is my opinion, after a lifetime of treating a large number of brain damaged patients, the only view to take is a very positive one. What the patient was like on admission bears no resemblance to the end result a few years later, even if a very small number, after all our best efforts, remain in a vegetative state.” (Jack Thackeray Book 2)
• “I treated a man with most of his left hemisphere lost at the scene of injury, who later became a proud and active father, college librarian, and a first-class chairman of our head injuries club for many years. The worse cases I see are the Vegetative patients who are not produced by primary trauma, but the secondary effect of hypoxia (anoxia).”

Programme of rehabilitation:

• As for any other severe injury, rehabilitation should be initiated; starting from day one, with intensive chest therapy, the use of splints to maintain joints in their mid-positions before the onset of spasm, particularly at the ankle joint.
• The first brief meeting with the family to take place and a team formed who will be responsible as to the future of the patient.
• The patient is now in a stable condition and it is a matter of urgency to bring the patient out of the coma situation. A stimulation programme must be started immediately.
• It is always a great shock for the family and friends to see their loved one being treated this way. So, explanations via verbal communication, video recordings and leaflets are vital.
• At this point family and friends are required to start a diary, a daily record of the patient’s progress.
• Many patients are aware of what is happening to them, and in their area, long before a clear response can be made by the patient. “I very well recall a consultant giving a group of medical students a very graphic, negative description of the patient’s future, and to see tears slowly form in his eyes and run down his face – a year or so later he was back at light work.
• “Pain is a very useful indicator as to depth of the coma and to progress being made. At a later stage we can use irritation to achieve a response – a scrubbing brush on the sole of the feet, inside the thigh or elbow. Ice placed on the pubic area for a few minutes, stroked over the renal angle, plus over the lips to find if the nipple reflex works and of course if cough or swallow reflex are absent or not.”
• “The use of ice packs on spastic limbs can be of great help in reducing spasm before putting the joints through a range of movement. They can also tell the type of spasm – Gamma spasticity is reduced by the effect of ice and Alpha spas, is made worse by ice. “
• “At a later stage, touch as a memory aid is excellent – i.e. using the patient’s own hand to touch parts of the body, saying “Jack, your nose” etc.”
• “Smell can help bring back our childhood days, and we associate smell with pleasures, fears, food, fire, flowers, sex, home and animals.”

Jack Thackeray’s Coma Kit

• Stimulations require a ‘Coma Kit’ – Thackeray’s contained: a bowl to hold the ice blocks, a scrubbing brush, a nylon pan scrubber, a whistle, a pack of Polo mints, and scents and smell for that particular patient, paper towels to soak up the iced water and his right index finger. The ice cubes are plastic drinking cup size – large enough to be effective when placed on the body’s tender areas. The ice is held or stroked on these areas until there is a reaction on the skin becomes insensitive, about 4 to 5 minutes.
• The day they are taken off the respirator is the day they attend the gym (the same day) the therapy staff are experienced with tracheotomy, chest and other problems that may arise.
• A form of irritation stimulation is carried out at each daily treatment session, until the patient moves to command.
• Patient placement was also important. Stimulation by normal activity, the patient must become part of the ward activities – not in a small side room or the at the end of the ward, so all that visit the ward can take an interest in the patient.
• When treating cases of severe brain damage, it is necessary to concentrate on the facilitation of movement, rather than ranges of movement and muscle strength. (head up, sit up, stand up, walk and now sit down – with constant repetition) always leading the patient to a more difficult or demanding effort on their part, with some form of reward for work well done and some loss of expected reward if they have simply not tried hard. Care is taken to ensure the patients doesn’t become dependent on the hospital environment and its members of staff – short stay home visits are part of this routine to maintain close family contact. The final return home of the patient requires careful planning. Being able to spend a few hours at home when all the family are there, enables patients to acquaint themselves with the size and location of rooms and find structural alternations that may need to be fitted in the home.
• Once discharged the patient continues to attend hospital as an outpatient on a daily basis, with the objective of returning to work (be it only sheltered work).

Communication

• A great deal of time and effort should be spent on finding a method of communicating with patients as contact with the patient improves, the frustration and aggression get less and less and the co- operation by the patient will improve.
• Whatever method (decided on by the therapist) that is found to work should be written on a large sheet of paper and placed above the patient – therefore, everyone can use a common system so not to confuse the patient. The patient’s physical control and abilities determines the method to be used. The system is taught to the patient until a clear and repeated response takes place.
• What can family and friends do to help
• Make a list of the patient’s likes and dislikes, particularly food and music
• Make recordings of familiar things (place of work, pub, school, home etc.)
• Compile photo albums
• Make a rota of friends to visit and talk to the patient – they should be advised it may be some time before the patient will respond and that they should talk in a normal manner if possible.

“The Total Damage Package: Sensory, Locomotive and Cerebral”

This injury can be split into 3 phases:

1. Recovery Phase – I call it the stimulation phase
   Where all the hard work is done (on not done in many hospitals).
   In most hospitals starts when the patient is moved from the ICU, but this often means the patient is
   moved to a ward, where they become one of a number, and they are basically left to recover (if they
   do) on their own.
   With a great drop in the standard of care and stimulation, both for the patient and input to the
   family from medical staff. So, it is left to the Nursing/Therapy staff to carry the patient along or
   until the patient becomes so much of a problem something has to be done.
2. The Return Home
   Where a great deal of thought and understanding are given to both the patient and their family, the
   realignments, the frustrations and the skilled counselling as to the future.
3. Start of Treatment
   It was my habit to see the patient as soon as it was possible after entering the hospital. To see for
   myself the extent of the damage and to meet the patient’s family and for them to meet me. To
   exchange a few words and ask a few questions. I tell them to get a few scrap books and make a
   record of each day’s events and what had been told to them, and their own thoughts. So, at later
   stages they can look back and see the progress made.

• I firmly believe that an early start leads to an early finish, with less deformity, less spasm, earlier control of limbs and space. More empathy with the patient and less demoralization of the family.
• But above all, the patient knows that someone is trying for them, and they try to respond and don’t sink into apathy and end up in a vegetative state.
• The patient loses a lot of muscle tone and bulk so the quicker they start to restore this the better, and also to counter the effect of spasm.

The History of Headway

(information gathered from the Headway website)

• In 1979, Sir Neville Butterworth placed an advert in a national newspaper seeking holiday accommodation for his brain-injured son. Dinah and Barry Minton, themselves carers, responded and set out with Sir Neville to find any support networks that already existed.
• Around the same time, two social workers, Philip Lockhart in Birmingham and Reg Talbott in Nottingham, also contacted Sir Neville.
• The five agreed to call a meeting for all those involved in the care of brain-injured people. A total of 23 carers and professionals attended a meeting on 23 October 1979 and Headway was born.
• March 1980: Headway (National Head Injuries Association) was registered as a charity 1981: A management committee was formed

Headway houses

• 1983: The first Headway house was opened in Gloucester, providing a day-centre to assist in long-term rehabilitation, respite care and hospital liaison.
• This was so successful that other Headway houses were soon started in Basingstoke, Colchester, Reading and Bristol, with many more to follow.
• 1985: Headway moved to new premises in Nottingham and Reg Talbott was appointed its first Director.
• 1989: The Hillsborough disaster – spotlighted the chronic shortage of expertise and resources in the field of brain injury and was pivotal in bringing the issues to ministerial attention, following strong representation from Headway.
• April 1991: HRH Diana, Princess of Wales, consented to become Royal Patron, a position which she continued to occupy until 1996.
• During this period, the Princess took a very real interest in the charity’s work and attended a number of Headway functions resulting in extensive media coverage and a much enhanced national profile.
• 1993: HRH announced her decision to withdraw from most of her public duties at the Headway Christmas Lunch but remained a Patron for the next three years.
• 1994: the first Brain Injury Resource Worker was appointed to work in the Scottish Borders region and the initiative was so successful that a policy of greater regional support was adopted by the board
• 1997: the charity’s groups were divided into charities in their own right (groups) and smaller local organisations (branches) operating under the national charity umbrella
• 1999: A new logo was adopted and the charity’s remit was extended to include support for people suffering from other forms of acquired brain injury, such as encephalitis or meningitis
• 2000: Headway’s 21st anniversary, marked by a celebration at Westminster Abbey. As the charity grew in size, it began to play a more active role in shaping brain injury services.
• 2001: Headway was instrumental in the re-formation of the All Party Group for Acquired Brain Injury and the same year made a major contribution to the House of Commons Health Select Committee Inquiry into head injury rehabilitation.
• 2001: The charity’s name changed to; Headway – the brain injury association
• 2003: The national helpline was formally launched and the first Headway charity shop was opened in Ilkeston, Derbyshire
• 2009: The Headway Approved Provider scheme was launched in order to help families identify residential care units that deliver high-quality specialist care and support for brain injury survivors.
• 2011: The Headway Emergency Fund was launched, with support from the Stewarts Foundation, to help families and individuals cope with the practical implications of a sudden catastrophic brain injury. Since that date, grants totalling almost £200,000 have been paid to hundreds of families at a time of crisis.
• 2011: The charity’s first Headway Acute Trauma Support (HATS) nurses were appointed. Based in neurological trauma units, the nurses provide crucial support to families in the acute stage following injury
• 2013: HRH Prince Harry opened Headway’s new home in Nottingham his first ever solo engagement.
• Today, there are more than 125 Headway groups and branches supporting people in their local communities across the UK. The helpline fields more than 8,500 enquiries a year, and there are 28 charity shops generating income and increasing awareness of the support on offer to people affected by brain injury
• Charity ethos on which is was founded: Together, we are stronger and by working together, we can do more to improve life after brain injury.