In February 2010, the UK National Audit Office published its report on Major Trauma Care in England, finding no efficient, effective, coordinated care. Two years later, the first of 27 centres in England was opened; Scotland, Wales, and Northern Ireland now also have them. Rehabilitation was always intended to be fully integrated into trauma service. Unfortunately, the rhetoric was not resourced, as a National Clinical Audit of Specialist Rehabilitation for Patients with Complex Needs Following Major Injury demonstrated. Nevertheless, the situation is hugely improved compared to the position in 2010, and the British Society of Physical and Rehabilitation Medicine has a flourishing Trauma Rehabilitation Special Interest Group open to anyone interested. Competency in trauma rehabilitation covers almost all organ-specific subspecialties. In the UK, at least, it includes managing acutely ill patients in hyperacute rehabilitation wards. Trauma rehabilitation is potentially life-changing; giving the person an explicit patient-centred rehabilitation curriculum may set them off on the correct path. There is, fortunately, a well-designed and validated tool, the Post-ICU Presentation Screen (PICUPS), which, with the Rehabilitation Prescription, will identify rehabilitation needs and guide its provision. It is available as a download. This page introduces the competency.
F-30 Trauma rehabilitation
Table of Contents
The competency: trauma rehabilitation
The rehabilitation expert is “able to assess rehabilitation needs, give rehabilitation advice, and take rehabilitation responsibility for any patient in the early days and weeks after trauma.” I must stress that the acute trauma medical or surgical teams should still be responsible for patients’ medical and surgical care; responsibility must be shared. A document outlining the behaviours, knowledge, and skills associated with this competency and giving some references can be downloaded.
Introduction
The primary meaning of trauma is “a deeply distressing or disturbing experience”, with physical injury being the second associated meaning. [Oxford English Dictionary]. This is relevant because it highlights the crucial psychological consequences of being wounded and thus emphasises the central role of psychological input in trauma rehabilitation services.
The physical injuries caused by accidents vary enormously. In severity, from trivial minor skin wounds to damage to many different organs threatening survival. Consequently, it is impossible to categorise trauma rehabilitation because each patient’s needs will be determined by the number of other organ systems damaged and the relative severity of each.
This leads to a great challenge and, at the same time, an excellent opportunity for rehabilitation.
The challenges follow from the scope of the problems seen in a trauma population. This makes it almost impossible to design and run studies researching the effectiveness of “trauma rehabilitation services” Even if one selected the relatively more severely injured patients, the range would still be too extensive.
At the same time, it is impossible to design trauma services that specialise in a specific group of patients. One may select people with a particular injury class, but the range of associated injuries will be too extensive to allow a single rehabilitation approach. Conversely, if patients with other injuries are excluded, the trial can only be generalised to some people with that restricted injury and associated injuries.
This problem is universal in rehabilitation; each patient has a unique combination of the many influencing factors identified in the biopsychosocial model of illness. Rehabilitation’s insight is that we can analyse and manage the patient’s situation. Rehabilitation is necessarily patient-centred, and some common treatments are tailored to the patient’s needs.
This approach is made explicit in the General Theory of Rehabilitation. All (!) you need to do is become an expert in rehabilitation while also developing a good understanding of the relevant physiological aspects of the person's damage (or disease).
Evidence
In 2011, Fary Khan and colleagues published a systematic review of multidisciplinary rehabilitation in patients with multiple trauma. No randomised or controlled clinical trials were found. In 2020, Hanne Naess and colleagues published a systematic review of early interdisciplinary rehabilitation for trauma patients, with or without brain injury. The only two trials found concerned patients with brain injury and other trauma. Four studies on 409 patients gave weak evidence of benefit.
I have already pointed out the impossibility of undertaking trial on all trauma rehabilitation in a single trial.
Comparing across trials would also be challenging because outcome measures vary so much; this is also a problem afflicting the audit of trauma services. Karen Hoffman and colleagues reviewed measures used in studies on outcomes after major trauma. In 34 studies, they found 38 measures, of which 21 were only used once. One five were used in more than three studies. They concluded, “Outcome measures used in major trauma capture only a small proportion of health impacts.”
Wail Ahmed, Rupali Alwe, and I audited the Oxford Major Trauma Centre's outcomes in 2016. Our results suggested that the 12-item version of the World Health Organisation’s Disability Assessment Schedule (WHO DAS) might be a practical tool for measuring outcomes across all conditions and injury severities.
The evidence supporting specific treatments for specific traumatic injuries is considerable. Daniel You and colleagues reviewed treatments for many orthopaedic injuries, suggesting early mobilisation was likely to be better. A Cochrane review suggested multidisciplinary rehabilitation benefitted people after hip fracture. A randomised comparison of rehabilitation interventions in nonoperatively treated distal radius fractures found advice was equivalent to a course of face-to-face therapy. Another Cochrane review found insufficient evidence to determine the relative effectiveness of rehabilitation strategies after a distal radius fracture.
Some common well-defined injuries will likely have some evidence to guide rehabilitation, but most injuries will not, and patients who have complex and multiple injuries in the context of pre-existing conditions will have no evidence. Most trauma rehabilitation will be based on first principles arising from the General Theory of Rehabilitation and evidence on the characteristics of effective rehabilitation interventions.
Special expertise needed for trauma rehabilitation
Most rehabilitation after trauma will be undertaken by services that see people with many conditions other than trauma. For example, a person with a traumatic brain injury will usually be transferred to a neurological rehabilitation service and then to community services. Thus, most of the competencies needed are covered in the other 39 competencies within the syllabus.
There are a few skills which are crucial to trauma rehabilitation and much less used in other areas of rehabilitation.
Not every patient needs significant rehabilitation input after trauma. More importantly, it is easy to overlook an essential area of need in someone with multiple injuries and needs. The rehabilitation expert must be able to identify all injuries and the resultant needs, record these briefly, and prioritise those needing the most attention initially.
After trauma, many patients will pass through the intensive care unit, and a screening tool initially developed for intensive care unit staff, the Post-ICU Presentation Screen and Rehabilitation Prescription referred to as the PICUPS and RP, can help. The PICUPS tool has good evidence supporting it. A team including rehabilitation and intensive care specialists developed it and then tested its feasibility and validity. The rehabilitation prescription (RP) was developed within major trauma services to ensure that needs were recorded and to assist in transferring crucial information to other services.
Rating the severity of trauma is complex. Several systems exist, and they are typically validated by their ability to predict mortality or long-term morbidity. Hideo Tohira and colleagues undertook a systematic review of scoring systems in 2012. Four were identified, but the data were too weak to enable a rational choice. Thomas Paffrath and colleagues have suggested that severity measures must add physiological to anatomical data to improve measurement.
The psychological needs of people involved in trauma are easily overlooked, not least because the need is only loosely associated with the severity of trauma as measured by the Injury Severity Score (ISS), which is based on the damaged body parts. A review in 2020 considers how best to identify people who need psychological input. Various screen tools exist, but the best way may be to ask the person how significant the psychological or emotional impact of the accident has been and whether they want help.
At the other end of severity, rehabilitation experts may be involved in determining whether life-lengthening treatments are appropriate in people with catastrophic injuries. This requires complex judgments and estimating the best plausible outcome. Usually, one will be considering people with brain injury, and a recent review may offer some ways of determining prognosis; unfortunately, the review omitted one vital prognostic indicator, the rate of change observed in the patient’s state.
One way to manage such challenging situations is to suggest a Time-limited trial of intensive care treatment; these should use agreed timescales and outcome measures. The rehabilitation expert should help select feasible, helpful measures to determine whether sufficient progress is occurring to warrant the hope of enough recovery to continue treatment.
Last, although the evidence may still be limited, early mobilisation is likely beneficial, especially in reducing the risk of muscle wasting, psychological demotivation, loss of confidence, and loss of existing skills in activities such as walking or interacting socially. A review by Daniel You and colleagues outlines some of the evidence.
Conclusion
In every field of rehabilitation, some patients will have trauma as the original cause of their difficulties. The needs of these patients will be like those of all other patients. However, in the very early phase after trauma, rehabilitation has a vital and different role. A person starts adapting immediately, and it is easy to overlook or ignore ‘hidden’ consequences, such as the event's emotional impact or a minor injury that may eventually have significant persisting effects. The rehabilitation expert will be able to identify these problems, whereas the patient, their family, and their acute-phase healthcare advisors may all fail to recognise them and plan accordingly. The expert will also advise on early mobilisation to reduce the risk of adverse secondary consequences. Third, in people with severe life-threatening injuries where crucial decisions must be made about the appropriateness of some treatments, the rehabilitation may advise on likely prognosis and measures to use when evaluating change over time.
