Rehabilitation: Headley Court
IN A MEDICAL CONTEXT, rehabilitation means restoring a human being to effectiveness by training after injury, disease or surgery. Rehabilitation is a specialised form of healthcare, focusing on the achievement of the highest levels of function and independence and quality of life. For the patients of the military ward at Birmingham, the unexpected survivors of the Afghan cohort, including Mark Ormrod, this specialised form of healthcare was done at Headley Court. Headley Court, in Surrey, has been the centre of military rehabilitation services since the Second World War. But the roots of rehabilitation, wherever it is done in Britain today, lie in the First World War, with all those orthopaedic specialists who took their understanding of locomotor systems out to the casualties of the Western Front and restored their lives. How we understand physical rehabilitation today comes from them, word for word, across a century.
In the last months of the First World War, Sir Robert Jones reflected on the work that he and his orthopaedic colleagues had done, and what it meant for medicine as a whole. He emphasised how what they did was never just about repair. They all had ‘an orthopaedic mind which thinks in terms of function, and has to deal with a pre-operative and post-operative stage as well as an operative stage, which although it may be essential, has only a proportional value’.1 Surgery was just one part of the process. Surgery alone would not be sufficient to restore a human being to effectiveness. Of equal importance was ‘the treatment by manipulation, operation and re-education of disabilities of the locomotor system’.2
Jones had built his network of orthopaedic centres on these principles, creating rehabilitation centres ‘with operative, technical and re-educational departments’.3 Inside these departments specialist therapists trained their patients in movements that made everything in the system stronger: not just bones but muscles and nerves and joints too. The careful rebuilding of muscle power within a smashed and reconstructed locomotor system, using exercises, repetitive stretches, massages. Jones included a range of different skills within these departments: physiotherapists, massage therapists, the electro-therapists, the hydrotherapists, gymnasium therapists (therapists who designed rehabilitation around gymnastic equipment such as ropes and wall bars and got kit specially made if it didn’t do exactly what they needed it to).4 Everyone working together to create a new locomotor system, with the wreckage of the old one. For the majority of the patients who passed through his centres the ultimate aim was to support the fitting of the often delicate and complicated artificial limbs produced in the prosthetics workshop by instrument makers (we don’t call them that today, and I rather wish we did), to restore the wearer ‘to the highest possible grade of health and earning power’. Or function and independence – however you like to put it. As I like to put it, one hundred years later, welcome to Headley Court.
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Rehabilitation: it’s not surgery, it’s exercises. Everything’s slower. There’s none of the urgency of the cabin of a helicopter swerving through hostile fire, rushing back to Bastion, or the brilliance amid the chaos of the trauma bays. By the time rehab began, everyone’s lives were saved, blood back where it should be, point zero way off in the distance. Negotiations over, the deal was done. There was no blood on the floor or life measured in pulse beats on a monitor. The patient didn’t die. Nobody dies at Headley Court. But rehab doesn’t mean that the hard part is over. It’s all the same hard part, from point of wounding to rehabilitation. What happens at Headley is a continuation of what was started in the desert, with a tourniquet or a field dressing or a chest drain. No point in having one without the other.
Like Bastion, everything was transformed at Headley after 2009. Before then, Headley ran along quietly, managing military rehabilitation that mostly meant sports injuries – soldiers running, playing rugby, climbing – pushing themselves too far and wanting to get back to doing it in double-quick time. There was capacity to spare, so it also treated locals, referred by the NHS (Robert Lawrence did his head injury rehab at Headley and met a girlfriend there with a sports injury). But once the IEDs began to infest the landscape of Afghanistan there were no more spare beds for civilians or the lightly injured as, for the first time in almost fifty years, Headley found itself overmatched. Injuries, particularly blast injuries, required an immediate response. So all the physios they could fit in were hired, from inside and outside the military. A new residential unit was built because there wasn’t enough room in the old house, and the existing buildings grew: the gym, the prosthetics workshop, the car park, scattered about the grounds, wherever space, time and the planning system allowed.
And although we aren’t really allowed to say this sort of thing as historians, it was as if everything at Headley had been waiting, gathering together exactly what was needed just in time. All those sports physios and rehab specialists, all their work oriented to getting young, determined soldiers back running, playing rugby, skiing. They had little experience of anything else, so that’s what they brought into the treatment rooms and the gym every day. Get back to where their patients were before they were injured, somehow, despite what has been lost. This is not how it works outside the military. NHS rehab tends to focus on what has been left, rather than what can be regained, which isn’t wrong necessarily; it’s just the way it is. Things have evolved differently in a system that has to treat everything from car crashes to diabetic complications to bad backs. By 2010 the difference was officially enshrined at Headley, where ‘the outcome goals for service personnel after injury are considerably higher than those set within civilian practice.’5
Headley is not a hospital. At Headley the patients are dressed, and they’ve been home, and so to them it feels like the next stage, where everything will be different. Perhaps they aren’t even patients any more, not entirely, even if they still have IVs for antibiotic drips and analgesia some of the time. The good part of its being different is that Headley is the place where they start to take on responsibility for their recovery, in partnership with physios and prosthetists. There’s a hard part of being different as well. Coming to Headley makes them realise that, despite the weeks and months at Birmingham, there are problems that are not yet fixed, and that fixing them completely may not be one of the available options.
Headley is where all the difficult, serious, hard questions are asked for the first time. What is happening to me? What is going to happen to me? Where do I fit in from now on? Who am I now? And Headley is where the pain really rolls in when they thought it was gone, and the phantoms catch up with them, and their brain doesn’t normalise and the last bits of their old sense of self slip away. There are mirrors everywhere at Headley. Huge walls full of them, in which people with new lives to comprehend stare at their reflection, at the price of the deal; there is no getting away from it.
Coming to Headley could feel strange right from the start. The entrance is via a courtyard surrounded by the walls and high, darkened windows of the Jacobean house, and some people find it spooky, which is fair enough because in one of the windows there hangs a skeleton, slowly twisting on a hook. The window belongs to the office of one of the rehab specialists, who needs the skeleton because obviously it’s the best way to demonstrate the interconnectivity of bones, but when people walked or wheeled into this whole new world, strange trumped obvious every time. Their family came with them into their new room, and put their stuff in drawers or in wardrobes, sponge bags in the small bathroom with the disabled fittings, and went to whatever meetings they were allowed to, but soon they went home, leaving them behind.
Then came their first real meeting with them at its centre. They sat in a group, one part of what was introduced as a multi-disciplinary team – nurses, pain consultants, rehab consultants, physios, prosthetists (sounded good), a mental health specialist (couldn’t see why they were there). The meeting resulted in two things. A problem list. And then, based on that, and quickly, because otherwise the mental health specialist knew where that went, a series of goals. The only ones they really remembered to tell the historian about were the ones they set for themselves, and it was usually roughly the same one for all, no matter how long the problem list – I want to run again. Scott Meenagh had two: he wanted to be on his big legs by July, and running by Halloween. Personal goals, big goals, and so they were noted, at the top of the page on their file, but so were other smaller goals (like ‘do stairs’) because in the weeks to come they would need to see small targets met on the way to bigger ones. As it says in the textbook: patients may need encouragement and support to improve their performance, but the more difficult cases to manage require a limitation to be placed on their activity – a common phenomenon in high-achieving military or sporting personnel. Sometimes doing too much is as dangerous as doing too little: both do damage. Acceptance, understanding, ‘concordance’ – a medical term which means agreement, but which sounds bigger than that because in this context it is.6
They’d seen themselves in mirrors before – they had them in bathrooms at Birmingham and when they got home – but the mirrors at Headley are huge, covering whole walls, and the lighting is bright and hard and real. The mirrors at home were something they looked in alone, at pieces of themselves, trying to put things together. Their first sight of themselves full length – not full-length – was hard, but at Headley there was someone else there with them, usually a physio, also looking, pointing out something interesting on their new selves – postural re-education, gait re-education – and before long they could see it themselves, could keep tabs on how they were doing, precisely, competitively, like they did before. Mirrors – they think about them on burns wards because that first sight of the new self has to be carefully managed, so nothing in the bathrooms, nothing reflective or shiny at all, but patients still try to see themselves in the back of spoons, in reflections on metal teapots, on glass door panels. Not at Headley. There was their new self, right there, all along the walls of the gym and the treatment rooms, every step they took reflected back at them. Using this method to accept a new self wasn’t an initiative from the mental health end of their team. It was, as any physio will tell you (and one told me), very important to adjust, to see the wound and see what was left of them. Since the age of two, their brain and body had worked in sync – sensory feedback and a learned movement pattern. Twenty-something years later, and deployment to Afghanistan, and it was all gone, and so they needed to learn a new one, and to learn, they needed to see.7 It got so they looked forward to seeing it, because at the same time they could see their own progress, right there in the mirror.
Not everything was unfamiliar and had to be relearned from the brain up. This was medical treatment, but it was also a new posting. Back in the military, back at work, back on duty, tasked with something. Almost everyone at Headley is in military uniform, and there was saluting, and hats to be worn at the right time and in the right place. They showed their ID cards when entering and leaving the grounds to duty sergeants in guardhouses. This wasn’t the annoying RAF nit-picking; this was proper medical reckoning. Their recovery was now their military service, so they should act like it. They were becoming a soldier again, even though in the long weeks at Birmingham it never really felt like they would be. At Headley they were a soldier again, so they should try to look like one, cut their hair really short again, clean regimental T-shirt, try to feel like one. Back in the army, with regulations they recognised and had come to rely on, and were relying on again. Even if they couldn’t quite find their new self yet, there was structure left over from the old one to fall back on in the meantime.