Rehabilitation after traumatic injury

Context

Traumatic injury is a significant cause of early death and morbidity – particularly in the working population. Major trauma is the biggest cause of death in children and adults under the age of 40.

This guideline defines traumatic injury as any injury that requires admission to hospital at the time of injury. This could include musculoskeletal injuries, visceral injuries, nerve injuries, soft tissue damage, spinal injury, limb reconstruction and limb loss. Minor injuries can also lead to a hospital admission.

This guideline does not cover the management of traumatic brain injury, except in relation to early screening for onward referral and the coordination of services for people with multiple injuries, one of which may be traumatic brain injury. The specialist assessment and delivery of rehabilitation services for traumatic brain injury will be covered in a new NICE guideline on rehabilitation for chronic neurological disorders including traumatic brain injury.

In England, 45,000 people are affected by very severe or major trauma every year. A further 500,000 people (included in the population for this guideline) experience less severe trauma, and a proportion of those will need hospital admission because of pre-existing conditions, disability, frailty, or because the functional impact of injuries and environmental factors means that they will not be able to manage in their own home.

Trauma affects all age groups, but there are 2 peaks: younger age and older age. People may have different rehabilitation needs that reflect different functional expectations and priorities. Trauma can negatively affect quality of life, both physically and mentally. It can lead to problems with mobility, pain, breathing, swallowing, eating, drinking, toileting, cognitive function, speech, language and communication, sensory problems, and can lead to depression, anxiety and other psychological difficulties. These issues can similarly have a social and financial impact on the person, as well as on their family and carers. The impact of these problems may be influenced by pre-existing conditions.

After a traumatic injury, people need rehabilitation assessment and interventions that take account of any pre-existing conditions and focus on helping them regain optimum function and independence as quickly as possible.

This guideline focuses on people with complex rehabilitation needs after a traumatic injury. The defined population in this guideline has not been based on the severity of the injury (sometimes measured using an injury severity score) but on the complexity of the rehabilitation need, taking into account existing conditions and circumstances that will impact rehabilitation. Complex needs cover multiple needs, and will involve coordinated multidisciplinary input from at least 2 allied health professional disciplines, which may include rehabilitation medicine, and could also include:

Currently, people who meet 'major trauma' criteria should have a rehabilitation assessment and prescription carried out during the hospital admission. Further assessments are performed over time to capture changing needs. For people who do not meet major trauma criteria (currently those with an injury severity score of less than 9), the pathway for rehabilitation is less clear.

There are limitations in access to the appropriate rehabilitation services for people after trauma, which may be related to geography, age, injury type or rehabilitation need. There is significant variation in practice, with no national network of services.

Improvement in survival rates resulting from the introduction of major trauma networks in 2012 has led to an increased need for rehabilitation.

Military experience has shown better outcomes with improved rehabilitation, where early and intensive rehabilitation has been shown to improve function, pain, quality of life and mental health outcomes. It can also improve outcomes for carers of those affected by traumatic injury.

Costs of treatment after a traumatic injury are high in the acute phase, and there are also long-term care costs to the NHS through ongoing treatment. Social care costs may be high for people who need ongoing care and support in the community. There are wider costs to the community if people are unable to return to work or education. Rehabilitation may be able to reduce these costs through improving overall function. Interventions may improve outcomes at a number of stages.

There are several NICE guidelines about the assessment, treatment and management of specific injuries for adults and children. There is guidance about service delivery, assessment and management of major trauma, and rehabilitation after critical illness and stroke. There are also guidelines about the transition between hospital and home, from children's to adults' services, and about home care services.