Rehabilitation after traumatic injury

Why the committee made the recommendations

Rehabilitation can be a long journey, and people will need different interventions and will aim for different endpoints. Because of this, the committee agreed that healthcare professionals should think about each person's individual rehabilitation needs and what is important to them, and take into account their personal strengths, lifestyle and goals, rather than being primarily driven by the nature of the injury.

Psychological and emotional support is important immediately after the injury, to help the person come to terms with their experience and engage with rehabilitation assessment, early interventions and goal-setting discussions.

There was evidence that avoiding delays in acute treatment can improve the effectiveness of early rehabilitation interventions. In the committee's view, early assessments and interventions are also important so that healthcare professionals have up-to-date information and can plan and start rehabilitation promptly. Nutritional assessment (including swallowing safety) is an important factor (particularly in soft tissue healing) but is often overlooked.

The person's longer-term rehabilitation goals should be taken into account when discussing treatment options because these can affect decisions made about the timing and nature of rehabilitation. For example, if a person has upper and lower limb injuries, they might not have surgical treatment of their upper limb injuries because they want to use crutches to help with weight-bearing during rehabilitation for their lower limb injuries.

How the recommendations might affect practice

The recommendations will not involve a major change in practice and are consistent with existing NICE guidelines. Healthcare professionals might need to spend more time assessing how traumatic injuries affect all aspects of a person's life, and explaining the implications of different medical and surgical treatments on rehabilitation. Spending time on initial assessment and early treatment immediately after a traumatic injury will lead to a better tailored rehabilitation plan and goals, which will save time later on. Generally, all professionals involved in the person's care following a traumatic injury will already be equipped to provide psychological and emotional support.

Return to recommendations

Why the committee made the recommendations

There was no evidence in this area, so the committee made recommendations based on their knowledge and experience. They agreed that a comprehensive approach to needs assessment is vital to meet all aspects of the person's care needs, including personal history, usual activities and potential motivations. They also highlighted injuries or conditions that may need to be assessed by specialists who are better equipped to meet complex care needs.

The committee specified the healthcare professionals who should be members of the multidisciplinary team. These members of the multidisciplinary team do not necessarily have to be available all the time, but should be able to contribute when needed.

The committee suggested ways to help people engage in the assessment process because people can have problems with engagement after a traumatic injury. The timing of the needs assessment is also an important aspect of this, because pain, fatigue and confusion can make it difficult for people to understand what is happening. They may need more time than normal to process information and adjust after the trauma. This is particularly important for people with cognitive impairment or brain injuries.

The committee agreed that time was needed for members of the multidisciplinary team to work with clinical teams to fully understand the person's rehabilitation needs and in particular consider the impact of pre-existing conditions so that this could inform a tailored rehabilitation programme. The committee were keen to highlight the importance of validated outcome tools and checklists because these can help identify people who need to be referred to a specialist service early, which can prevent delays in rehabilitation.

How the recommendations might affect services

It is standard practice to have multidisciplinary teams conduct needs assessments. Staff might need additional training on how to use assessment tools, and some extra time might be needed as a result of the recommendations. However, this will be offset by the benefits of appropriate and timely care, increased care coordination, and better outcomes. Overall, the recommendations reinforce current practice and are in line with other guidance.

Return to recommendations

Why the committee made the recommendations

The committee discussed the importance of assessing physical functioning as part of the rehabilitation needs assessment after a traumatic injury. There was no evidence in this area so the committee agreed, based on their knowledge and experience, that the assessment should include both pre-injury and current levels of physical functioning to inform rehabilitation goals. Referrals to specialists may be needed as part of this. The person's current level of physical functioning will serve as a baseline for initial rehabilitation needs and to monitor changes.

How the recommendations might affect services

The recommendations are not expected to have a large resource impact or be difficult to implement, although extra time might be needed to complete the comprehensive assessment. There may also be more referrals to specialist services. However, the involvement of specialist services at the assessment stage will identify needs earlier and reduce unmet care needs.

Return to recommendations

Why the committee made the recommendations

There was no evidence in this area. However, the committee believed that recommendations are needed because problems with cognitive functioning are common after a traumatic injury (even without brain injury). The committee also highlighted some of the cognitive problems the multidisciplinary team should consider as part of the rehabilitation needs assessment, because these may not show up on scans immediately.

How the recommendations might affect services

The recommendations reflect current practice, but where there are regional variations, practice may need to be amended. Some extra time might be needed to complete the comprehensive assessment. There may also be more referrals to specialist services. However, the involvement of specialist services at the assessment stage will identify needs earlier and reduce unmet care needs.

Return to recommendations

Why the committee made the recommendations

There was no evidence in this area, so the committee made recommendations based on their knowledge and experience. They recommended asking about past risk factors to help inform future rehabilitation goals, and current risk factors to help form a baseline for initial rehabilitation needs and monitor changes.

Some people may need additional support because they react to trauma in different ways, have different barriers to rehabilitation, and may have different responses to psychological and psychosocial interventions. Because of this, the committee recommended referral to a practitioner psychologist with trauma and rehabilitation experience when needed.

How the recommendations might affect services

The recommendations reflect current practice, but where there are regional variations, practice might need to be amended. Some extra time might be needed to complete the comprehensive assessment, and there might also be more referrals to specialist services. However, the involvement of specialist services at the assessment stage will identify needs earlier and reduce unmet care needs.

Return to recommendations

Why the committee made the recommendations

Based on qualitative evidence, the committee highlighted the need to agree patient-focused short- and long-term goals with people. They also recommended that these goals are reviewed regularly, to ensure a flexible approach that takes people's concerns into account.

Agreeing small steps as part of long-term rehabilitation goals ensures that efforts are consistently made towards achieving these goals.

The committee highlighted skills and competencies needed by the multidisciplinary team, to ensure that staff have the right training.

How the recommendations might affect services

The recommendations reflect current practice, but where there are regional variations, practice might need to be amended. Some additional professional time might be needed to explore psychological and psychosocial risk factors.

Return to recommendations

Why the committee made the recommendations

There was convincing qualitative evidence on patient education, communication between settings, and follow-up. Combining this with their own knowledge and experience, the committee recommended several key components of a successful and comprehensive rehabilitation plan. This should be a single document that can be shared between people undergoing rehabilitation, families or carers, and healthcare professionals. It should be an evolving document, detailing a person's rehabilitation journey and any changes in goals and needs. The committee reflected that it is not always possible or appropriate for people to have access to all of a rehabilitation plan, and therefore recommended that a separate patient-held document be provided if this is the case.

The committee agreed that preventing recurrence of traumatic injury should form an essential component of the rehabilitation plan. Prevention is covered in several other NICE guidelines, so the committee made recommendations that supplement and refer to these guidelines.

There was strong qualitative evidence from both healthcare professionals and people undergoing rehabilitation that reducing delays leads to better coordination of care and rehabilitation outcomes. Based on this, the committee made a recommendation on referrals for parts of the plan that the multidisciplinary team cannot implement themselves. The committee also used their experience to recommend that older people have access to orthogeriatricians, surgical support or perioperative physicians. This is important because the needs of older people with traumatic injuries are complex, and it will prevent delays further on in rehabilitation.

Limited evidence showed that violence intervention programmes might reduce hospital admissions. There was also convincing economic evidence that such programmes represent value for money. The committee agreed that the effectiveness evidence combined with economic evidence was sufficient to support a recommendation on violence reduction interventions.

How the recommendations might affect services

Practitioners should already be producing these rehabilitation plans, but some extra time might be needed to ensure they fulfil the expectations set out in these recommendations. However, this will be offset by reducing problems with the suitability of the plan further down the line, because the more it is tailored for the person, the more effective it will be at helping the person achieve their goals. The recommendations outline good practice points and should make practice more consistent. Having a clear rehabilitation plan will make the whole process more efficient and potentially reduce the amount of extra support people need (for example, asking the team for more information because they do not understand the rehabilitation plan).

Currently, violence reduction interventions are mainly funded by the voluntary sector, so the recommendation on these may represent a change in practice. However, any cost increase will be offset by a potential reduction in future NHS and personal social service costs (for example, readmissions as a result of violent crime).

Return to recommendations

Why the committee made the recommendations

Evidence showed that rehabilitation programmes should be tailored to a person's needs and rehabilitation goals to maximise their effectiveness. There is no 'one-size-fits-all' programme. Instead, they should be multidisciplinary and developed in conjunction with healthcare professionals and people undergoing rehabilitation, to ensure they are relevant to a person's everyday life. The committee used their knowledge and experience to recommend the content of rehabilitation programmes. There was also evidence on education materials, showing that they can help people learn about their trauma and rehabilitation in their own time, increasing their engagement in the process.

How the recommendations might affect services

The recommendations reinforce current practice and should not be difficult to implement. Education materials on rehabilitation already exist in healthcare settings, but they might need to be changed into a suitable format for people undergoing rehabilitation.

Return to recommendations

Why the committee made the recommendations

There was no evidence on what to include in an intensive rehabilitation programme. Based on their own experience and expert testimony, the committee made a recommendation on general good practice principles.

There was also no evidence relating to the timing or intensity of rehabilitation. The committee were aware, based on their own experience and expert testimony, that delivering rehabilitation at the right time and providing short blocks of intensive rehabilitation might improve patient outcomes, leading to a quicker recovery and return to work. They gave the example of a 3‑week residential rehabilitation programme because economic modelling indicated that this type of programme could be cost effective. However, the committee agreed that an intensive rehabilitation programme would be appropriate only for the most severe injuries and complex needs, when a significant impact on rehabilitation outcomes is likely. Such an approach to rehabilitation may also reduce the health and social care costs associated with longer-term care and rehabilitation.

The expert witness supported the use of education materials before intensive rehabilitation starts, to prepare people for the programme.

The committee made research recommendations on the effectiveness of intensive rehabilitation in adults and the effectiveness of intensive rehabilitation in children and young people.

How the recommendations might affect services

The recommendations are in line with current practice and should have little impact on resources. Intensive rehabilitation is already available for some people (for example, people who have lost a limb). Because rehabilitation services are already being carried out, intensive rehabilitation could be delivered through service redesign and repurposing of existing funds and resources rather than introducing them as completely new resources. Intensive rehabilitation would potentially represent value for money as per the economic model. Also, only a small group of people with the most severe injuries would be eligible for an intensive rehabilitation programme.

On education, existing materials for guided self-management rehabilitation could be used for intensive rehabilitation. This has the potential to reduce the amount of extra support people need, freeing up professionals for other work.

Return to recommendations

Why the committee made the recommendations

Evidence showed that self-management programmes are appreciated because they give people the flexibility to perform exercises at times most suitable for them. The committee used their experience and knowledge to recommend several possible components of a self-management programme.

Guided self-management rehabilitation was identified in the qualitative literature, as well as expert witness testimony and committee experience, but not in the quantitative literature. The committee made a research recommendation on self-management rehabilitation interventions to better inform future guideline development.

How the recommendations might affect services

Guided self-managed rehabilitation is not provided consistently across the country. In areas where it is not currently provided, extra professional time might be needed for planning, particularly for children, young people and vulnerable adults. There may also be costs from adopting self-managed rehabilitation programmes to different settings.

For trusts that do not like sharing their content using external content-sharing services, there may be costs from hosting programme content on their own server. However, much of the content could be standardised for most people using guided self-managed rehabilitation, so the costs for creating the plans would be mostly one‑off. These programmes could be developed at a national level, reducing costs to individual services.

Guided self-managed rehabilitation programmes have the potential to reduce the amount of extra support people need, freeing up professionals for other work.

Return to recommendations

Why the committee made the recommendations

In the committee's experience, rehabilitation plans and goals can only be helpful to people if progress is monitored consistently and accurately. There are many tools that can be used for this; the choice depends on the person's rehabilitation goals and the type of trauma. Because of this variation, the committee did not recommend specific measurement tools.

For some people, family members and carers will need to be involved in monitoring progress (for example, for young children or vulnerable adults). The paediatric professionals on the committee recommended using a measurement tool that includes both children- and parent-reported measures for this population. Another way to monitor progress is to use the person's own views. There was some evidence that supported asking people to record information to assist discussions and shared decision making while describing subjective measurements that are hard to quantify (for example, their motivation to continue rehabilitation).

How the recommendations might affect services

The recommendations reflect current practice, but where there are regional variations, practice might need to be amended. Some additional professional time may be needed to complete tools to monitor progress (for example, patient-reported outcome measures [PROMs]).

Return to recommendations

Why the committee made the recommendations

One theme that appeared throughout the evidence was the importance of giving clear and consistent verbal and written information to people undergoing rehabilitation. Evidence showed that this communication should be tailored to a person's injury, needs and goals. If information was too general, people felt poorly prepared and less supported by healthcare staff and services.

People should be given sufficient time to process information in order for them to adjust after trauma and explore their rehabilitation options thoroughly. This is particularly important for people with cognitive impairment or brain injuries, and they may need professionals to repeat information to them.

Along with good evidence, the committee used their knowledge and experience to highlight the central role that families, carers and friends can have in encouraging and supporting people through rehabilitation.

How the recommendations might affect services

The recommendations reinforce current practice and are in line with current guidance and legislation. Some extra time might be needed to consistently involve people and their families and carers in planning. Services might need to develop multiple templates for different communication formats. However, this will be offset by the benefits of people understanding their options, increased engagement and potentially better outcomes.

Return to recommendations

Why the committee made the recommendations

The committee agreed with the evidence that multidisciplinary teams should be formed early. Evidence showed that delays in rehabilitation can cause poorer outcomes. In order to reduce this, the committee recommended that referrals to specialist rehabilitation services be made as soon as possible. Similarly, the committee recommended follow-up appointments with acute teams when people move to rehabilitation units to further reduce delays.

There was conflicting evidence on how people feel about receiving information from many different specialists. This may be confusing to people, and specialists may have difficulty prioritising different clinical perspectives. The committee believed that named rehabilitation coordinators or key workers are needed to help reduce this confusion. These should be assigned within 72 hours of admission because this is the time limit for starting a trauma prescription for major trauma patients.

There was evidence that providing continuity of staff enhances coordination by building trust and rapport between healthcare staff and the people they are caring for. However, the committee were aware that this is not always possible.

There was good evidence about the importance of prompt and consistent communication when transferring people between inpatient settings. Using their experience and knowledge, the committee agreed recommendations to improve communication between settings, including the use of unique identifiers.

Evidence showed that coordination is improved when a person is educated in their rehabilitation, because they are more engaged. The evidence also showed that coordination is improved when family members and carers receive this information, because they frequently act as a support network for people undergoing rehabilitation. The committee understood the important role that families and friends can fulfil, but were aware of the potential safeguarding concerns around this issue. Therefore, they recommended that this information is only provided to additional people if appropriate, and only with a person's consent.

The committee agreed that families and carers be advised about the support that is available to them at a time that can be confusing and distressing.

How the recommendations might affect services

Multidisciplinary teams are a standard way of working. Having a named rehabilitation coordinator might lead to an increased workload for the coordinator, but this can be limited by daily conversations within the team and delegating responsibilities. Key workers are already routinely assigned to people with complex health and social care needs.

There may be more referrals as a result of involving specialist rehabilitation services earlier in the trauma pathway, but this will ensure timely care with a reduction in disability and will support optimal physical, cognitive and emotional recovery for patients. Most services have established processes and templates for handover. Where this is not the case, services will have to spend time creating them. Additionally, technology might need to be updated to ensure systems are compatible with those used by other services.

Return to recommendations

Why the committee made the recommendations

Discharge home from inpatient settings is often a time of great stress and apprehension for people with a traumatic injury because they are facing a large reduction in monitoring and support from healthcare staff. The recommendations emphasise the importance of making sure that plans are in place, eventualities are covered and people have all the information they need.

There was evidence that early planning for discharge is needed to take into account the person's needs and preferences, contact relevant services to arrange necessary adjustments, and allow enough time to reassess the rehabilitation plan before discharge. For children and young people returning to education, a meeting between healthcare professionals, education staff and parents or carers should be arranged to discuss new education and support needs. This also gives time to address any potential barriers the person might face in using community rehabilitation services.

There was good evidence on the importance of providing adequate information to people and their families or carers before discharge. This should not be limited to immediate medical information, but should be as comprehensive as possible. The committee used the evidence and their own knowledge and experience to identify information that should be provided. Evidence also showed that including family members and carers in discharge planning can lead to a smoother transition back into the community. The committee agreed that it is important to include family and carers, but they should only be involved if all parties consent.

There was good evidence, supported by the committee's knowledge and experience, that people who have help with organising their access to rehabilitation services are more likely to use them. In the committee's experience, complex funding is a barrier to receiving equipment that a person may need once discharged. Similarly, there are many different services that a person may need to work with after a traumatic injury (for example, legal services and welfare advice). In order to prevent delays in discharge, information on these organisations should also be provided as soon as possible, to avoid delays in the application process.

There was evidence that people can find a gradual return home helpful, beginning with overnight or weekend visits home before final discharge. This allows people to adjust to being in their home with their new needs, identifying areas that might need further rehabilitation and multidisciplinary team input before permanently going home. The committee acknowledged that this is not appropriate for everyone, but should be discussed as part of discharge planning. Home visits were also identified as being good practice to highlight any potential risks and allow people to have a fully informed discussion about what would benefit them.

The need for flexibility in rehabilitation appointments after discharge was a key theme in the evidence, because people face certain barriers to access (for example, time constraints, or travel to and from rehabilitation appointments). The committee agreed that arranging rehabilitation sessions at home rather than in a clinic or hospital can help, by decreasing travel and waiting times. Based on the evidence and their experience, the committee also recommended alternative consultation formats (for example, phone or video), to increase the flexibility of rehabilitation appointments.

How the recommendations might affect services

Additional time might be needed to compile information and discuss it with people and their support networks. However, by giving comprehensive information before discharge, there will be a decreased need to contact healthcare professionals with rehabilitation questions, and potentially reduced visits and readmissions to inpatient services.

Additional professional time might be needed to cover early discharge planning, checking access to community rehabilitation services, liaising with education providers and organising home visits. The recommendations imply more coordination between inpatient teams and other health and social care services, which will take more time. However, this additional time spent will result in patients feeling more supported, increasing their confidence in services and improving outcomes. There is a potential resource impact from staggering discharge through overnight or weekend visits home. However, this would only be needed in exceptional cases.

Telephone or video consultations may result in a greater uptake of some services, because people may find remote attendance easier. However, services would have planned to provide in-person consultations for these people anyway, so there should be no overall resource impact.

Return to recommendations

Why the committee made the recommendations

There was good evidence that people benefit from having a single point of contact after discharge from hospital (for example, a discharge coordinator, a phone line or an email contact). Having a team or a professional as a single point of contact can build rapport and trust, increasing the person's confidence in accessing outpatient and community rehabilitation services. It also reduces communication delays or duplication. This contact can also provide injury-specific information and information about local rehabilitation services, help people organise their rehabilitation, and advocate for them. This should be provided for a limited time after discharge in order to provide a secure and safe transition of care. The committee gave an example of 3 months, which was designed to encompass the transition period while still providing a stimulus to ensure healthcare is properly transferred to the appropriate setting.

Based on both the evidence and their own experience, the committee recommended appointing a key contact or key worker for people with continued or complex health and social care needs after discharge. Because of the increased level of support these people might need, a one-to-one relationship will increase trust and rapport, which will benefit patients and healthcare professionals.

How the recommendations might affect practice

Multiple healthcare professionals within the team have access to the relevant patient information and could therefore act as a point of contact, and so this would not need additional resources. Having a single point of contact may reduce the workload of case managers that are routinely assigned to people with complex healthcare and social care needs.

Key worker roles would be filled by existing healthcare or social care professionals. However, there may be more pressure on their time.

Return to recommendations

Why the committee made the recommendations

There was evidence showing that people appreciate psychological and emotional support to adjust to social roles (for example, parenting or other family roles, relationships, intimacy), access meaningful activities for day-to-day living, and return to work, education and training. This is in line with the committee's own knowledge and experience. In the committee's experience, it is difficult to predict the outcome of rehabilitation, and making realistic goals is essential (for example, some people will not be able to return to the same type of work and will need retraining). The committee agreed that it is beneficial for people to continue with their normal activities and hobbies as part of their rehabilitation therapy. Even if adjustments are needed, this improves participation in social activities, counteracts the social isolation people may feel after traumatic injury, and makes rehabilitation goals more tangible. And the longer a person is not undertaking their everyday activities, the more difficult it is for them to return to the same level as before their injury.

There was good evidence on the importance of providing adequate information to people and their families before discharge. Evidence also showed that people often rely on family, carers and friends to help them navigate the multiple appointments and services needed during rehabilitation.

How the recommendations might affect services

More time might be needed to develop a rapport with people, to find out what goals are most important to them and to tailor support needs to them. Additional time may also be needed in order to provide information to employers or education providers.

All team members involved in the care of an individual provide emotional and psychological support, so this would not be an additional cost.

Return to recommendations

Why the committee made the recommendations

The qualitative and quantitative evidence identified aspects of planning, commissioning and coordinating that were important to the successful delivery of rehabilitation services. The committee agreed that rehabilitation services should collaborate and use joined-up commissioning approaches to provide a whole pathway rehabilitation. Based on their knowledge and experience, and limited qualitative evidence, the committee identified general principles that commissioners and providers should consider when planning, commissioning and coordinating rehabilitation services. Because these services will have different commissioners, collaboration and good communication will be needed.

There was no evidence on intensity of rehabilitation, so the committee took expert witness testimony on this. They expanded on the points raised by the expert witness to recommend providing an intensive rehabilitation programme. The committee recommended commissioning this as a tertiary service because it would only be appropriate for some people. This way, the service would be best designed to meet the needs of their local population.

Based on the qualitative evidence and their experience, the committee agreed that it is essential for an identified commissioner to have overall responsibility for local rehabilitation services, to avoid confusion and subsequent commissioning and budget errors.

How the recommendations might affect services

The recommendations are in line with current practice and should have little impact on resources. Where practice differs, there may be some resource implications, because services will need to set up frameworks for more collaborative and integrated commissioning. Intensive rehabilitation is already commissioned for some patient groups (for example, people who have lost a limb).

Return to recommendations

Why the committee made the recommendations

There was qualitative evidence showing that establishing care networks and pathways between different settings encourages conversation, allows services to share advice and support each other, and can help identify gaps in local provision.

There was qualitative evidence on the usefulness of an electronic directory of care pathways, rehabilitation facilities and voluntary sector services. Some trauma units already have these in place, but directories are often out of date or incomplete. Accessing this information is also often difficult.

There was qualitative evidence showing the importance of community and social services for overall rehabilitation and recovery. Non-medical rehabilitative services are wide-ranging and can include social care, housing, home adaptation, transport, and sports and recreational facilities. The committee made a recommendation to make sure that people and their families or carers know these other services exist.

There was qualitative evidence showing that continuity of care increases when various professionals involved are aware of other areas of rehabilitation and can network with each other. There was also qualitative evidence on the importance of professionals in generalised medical settings having access to networking opportunities. This allows greater familiarity between professionals and improves cooperation.

There was qualitative evidence showing that technology and telehealth can be suitable methods of improving flexibility and availability of specialist appointments. This can be particularly useful in rural areas, because qualitative evidence showed that these areas are underserved by specialist rehabilitation services. However, not everyone has the equipment needed for remote consultations, so they cannot completely replace face-to-face consultations.

There was qualitative evidence showing that socialising and interacting with peers can promote rehabilitation uptake and counteract isolation. In the committee's experience, group rehabilitation sessions are a good way for people to get peer support. This was supported by expert witness testimony. However, peer support might not be suitable for everyone (for example, some people may feel discouraged if they are not progressing at the same rate as others).

How the recommendations might affect services

More resources may be needed to establish care networks and pathways. However, there are already examples of this in the NHS. Some trauma units already have electronic directories of care pathways, rehabilitation facilities and voluntary sector services. Services may need to do more to keep these up-to-date.

Most professionals already have opportunities for networking. However, practice may need to change for some services where this is not the case (for example, in rural areas).

Telehealth is becoming more common and does not need any specialist equipment.

Group rehabilitation sessions may represent a change in practice for some services.

Return to recommendations

Why the committee made the recommendations

The evidence identified a disparity in access to specialist rehabilitation services, depending on location (for example, rural areas are underserved) and individual needs (for example, if a person is not able to leave their home). A lack of rehabilitation knowledge within non-specialist healthcare services adversely impacts a person's trust in their rehabilitation services. The committee agreed that training is needed to address this. Community rehabilitation practitioners in general healthcare services should also have access to specialist rehabilitation support. This would not need to be full time, and could be provided remotely. Peer support and networking opportunities are also recommended. These will improve communication between professionals in different areas of healthcare and improve coordination for people undergoing rehabilitation.

How the recommendations might affect services

Specialist rehabilitation professionals might need to spend more time providing peer support to general services. This could be done in low-cost ways, for example, virtual meetings. If non-specialist healthcare professionals are better supported, people's needs are more likely to be met locally and there will be less pressure on specialist services. Time and resources might be needed to provide more training for non-specialists. However, this will also reduce demand on specialist services.

Return to recommendations

Why the committee made the recommendations

There was conflicting evidence on the frequency and intensity of prescribed exercises because of the wide range of possible exercises, wide range of trauma and wide range of populations covered by the evidence. The committee agreed, based on their knowledge and experience, that healthcare professionals should set the frequency and intensity of rehabilitation exercises depending on the person's rehabilitation goals, but that these should be started as soon as possible. Analgesia may be needed to allow people to participate in rehabilitation. The committee also highlighted the importance of minimising the effects of low blood pressure when undergoing physical rehabilitation. This risk is increased because the person would need to change positions to perform certain rehabilitation exercises. Independence in performing everyday tasks should be encouraged, to prevent loss of these skills.

How the recommendations might affect services

The recommendations reflect current practice, but where there are regional variations, practice might need to be amended. There may be more referrals to occupational therapy as a result of encouraging independence with activities of daily living. However, occupational therapists are already available in these settings, and this should not have a significant resource impact or be difficult to implement.

Return to recommendations

Why the committee made the recommendations

The committee agreed with the evidence and current practice that weight-bearing exercises should be started as soon as possible. In their experience, this is important to encourage mobility and maintain postural reflexes, muscle mass, strength and function.

Decisions about weight-bearing should be led by the surgical team because it will be affected by any potential surgeries. However, bed rest can be harmful to muscle function, skin integrity, postural reflexes and respiratory function (especially in older people), and should be avoided as far as possible for most people with traumatic injury. The surgical team should communicate when a person is able to weight-bear as early as possible to keep bed rest to a minimum and so that weight-bearing can start without delay.

Lower limb injuries will affect a person's mobility, which affects their ability to participate in weight-bearing rehabilitation exercises to a greater extent than upper limb injuries, so the committee recommended a targeted weight-bearing programme. This programme should aim to progress the person's function with weight-bearing tasks such as mobility, ability to move from sitting to standing, and ability to lateral step (which is particularly important for people to maintain independence after discharge).

How the recommendations might affect services

The recommendations reflect current practice and are not expected to need additional resources to implement. Some additional time might be needed for communication between medical and surgical teams.

Return to recommendations

Why the committee made the recommendations

There was evidence showing the importance of aerobic and strengthening exercises in rehabilitation after traumatic injury. These exercises lead to better rehabilitation outcomes in several different trauma populations. The committee supplemented this evidence with their own knowledge and experience to recommend several aspects that healthcare professionals should consider when designing aerobic and strengthening rehabilitation programmes. The recommendations cover general components rather than specific exercises because the evidence did not clearly show which exercises were best, and because the recommendations need to be applicable to a wide range of traumatic injuries. The committee also recommended tailoring aerobic and strengthening exercises to each person's interests, to make the exercises more enjoyable and to encourage people to take part.

The committee agreed that the exercise programme should begin as early as possible to limit the loss of muscle tone and physical fitness. Evidence showed that upper body aerobic training can improve rehabilitation outcomes in people with lower limb injuries. The committee discussed how for older people, fitness and strengthening programmes can help to optimise respiratory function, increase endurance when doing rehabilitation exercises, and improve mobility.

Finally, the committee stressed that these exercise rehabilitation programmes should be continued after people are discharged home, to ensure that their physical strength and fitness does not stagnate or decrease. Regular reviews should be carried out during rehabilitation appointments in order to gauge whether the programme components are still appropriate for people's rehabilitation needs, and to change them if not.

How the recommendations might affect services

The recommendations are not expected to have a significant resource impact or be difficult to implement. However, extra time may be needed to tailor exercise programmes to each person's preferences.

Currently, some physiotherapists do not offer aerobic exercise programmes to older people who are frail. For these physiotherapists, there will be a change in practice and there may be a greater uptake of aerobic exercise in older people. Older people would already be working with a physiotherapist, so this will only change the type of exercise used and there will be no additional costs for services.

Return to recommendations

Why the committee made the recommendations

Although there was evidence to show that gait re-education did not improve rehabilitation outcomes, the committee disagreed with these findings. In their knowledge and experience, gait re-education is a very effective rehabilitation tool, particularly for muscle strengthening. In people who are not mobile, gait re-education can still be introduced early but should be focused on reducing the impact of non-weight-bearing. This will maintain the current level of functioning and mobility, so people are ready to undertake weight-bearing gait re-education as soon as possible.

How the recommendations might affect services

At some hospitals, physiotherapists do not get patients into their physiotherapy unit until they can weight-bear fully. These physiotherapists will need to change their practice. Overall, the recommendations are not expected to have a significant resource impact or be challenging to implement.

Return to recommendations

Why the committee made the recommendations

There are a variety of range of movement exercises that can be used for rehabilitation, with different levels of assistance depending on ability. Controlled motion devices should be considered if people are not able to perform exercises independently. The committee agreed that range of movement is particularly important during rehabilitation. Targeted stretching is a good method of preventing loss of movement, particularly after exercises, when muscles tighten as a response to activation.

How the recommendations might affect services

The committee were aware of the potential resource impact of recommending specific controlled motion devices to assist range of motion. Generally, these devices are rarely used (and mostly only in hospitals to help with knee injury). However, once acquired, these devices can be used by multiple people. Overall, the recommendations are not expected to have a large resource impact or be difficult to implement.

Return to recommendations

Why the committee made the recommendations

Evidence showed a benefit from orthoses in rehabilitation after trauma. No evidence was found on splinting. The committee combined the available evidence with their experience and knowledge to recommend several specialised splints and orthoses, and to warn about positions known to cause complications and loss of function later on in recovery.

Because of their complexity, the committee recommended bespoke splints for people with hand injuries, as well as referral to a hand therapy specialist. 'Off-the-rack' splints can be ill-fitting and cause lost range of movement in the hands and fingers.

Regular review of splints is recommended because splinting can have adverse effects if not monitored carefully (for example, pressure sores). This risk is increased in people with reduced skin sensation and recent skin graft or flaps, so splints and orthoses may be contraindicated and specialist advice may be needed. People (and families and carers, if appropriate) should receive education on how to wear splints or orthoses to limit adverse effects and when to seek professional advice.

Evidence showed that spinal orthoses can help improve patient rehabilitation outcomes, and they are used in current practice. However, in the committee's experience, not all trauma populations see a benefit (for example, older people) and spinal orthoses can cause adverse events if improperly fitted. Healthcare professionals should be aware that these devices may be poorly tolerated and know when to discuss problems with the surgical team. Because of these issues with the evidence, the committee made a research recommendation on spinal orthoses for older people.

How the recommendations might affect services

The recommendations reflect current practice. Splints and orthoses are commonly used and are all low cost. Bespoke splints are easily made in a treatment room and would not need any additional resources.

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Why the committee made the recommendations

How the recommendations might affect services

The recommendations reflect current practice, but where there are regional variations, practice might need to be amended.

Return to recommendations

Why the committee made the recommendations

The evidence for nutritional supplementation was of very low quality. However, the committee agreed that there is a lack of awareness about the nutritional risks and needs following traumatic injury. People need more calories after traumatic injury, to help with healing. However, they often have complications that can affect eating habits or nutrient absorption. To address these issues and the lack of awareness around nutritional supplementation, the committee made recommendations based on their own experience.

The committee made a specific recommendation for people with burns in combination with other traumatic injuries because they are at increased risk of losing significant muscle mass, weight and strength for a prolonged period, because of the long-lasting effect of the hypermetabolic response.

How the recommendations might affect services

The recommendations are in line with current practice and will not need additional resources to implement.

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Why the committee made the recommendations

There was no evidence in this area. However, in the committee's experience, trauma-related cognitive functioning problems can be upsetting for people and affect their decision making and participation. Because of this, the committee believed it is important to reassure people that these problems are usually temporary. When problems are not temporary, the committee recommended adapting rehabilitation therapy to take account of this and to help the person participate in therapy and assessments.

As another aspect of helping people with cognitive difficulties to participate, the committee highlighted information needs and formats to use. The committee were also keen to emphasise the need to share this information with the person's family or carers, because they can play an important part in helping the person understand and recall key messages.

The committee agreed on additional steps to follow for children and young people, to ensure that their education providers accommodate their changing needs.

How the recommendations might affect services

The recommendations reflect current practice, but where there are regional variations, practice might need to be amended.

Return to recommendations

Why the committee made the recommendations

The committee used their knowledge and experience to make recommendations on psychological rehabilitation. They highlighted the importance of reassuring people that the acute stress response is common and normally temporary, because it can be very distressing. Outside of the acute stress response, the committee identified several other psychological issues, to raise awareness among professionals and encourage good practice.

Because of low quality evidence, the committee based the recommendations on psychological support on their own experience. They agreed that 'one size does not fit all' within psychological and psychosocial therapies and felt it was important to offer psychological and emotional support that is tailored to a person's rehabilitation goals, needs and preferences.

The committee recommended that any treatment for psychological disorders should form part of a complete rehabilitation package, and not be kept separate. This will allow better communication and coordination of physical and mental healthcare.

No evidence of benefit was found for family support interventions. However, in the committee's experience, involving family can be beneficial.

How the recommendations might affect services

The recommendations reinforce current practice and refer to existing NICE guidelines, so should not need additional resources to implement. Most team members specialising in the management of major trauma are equipped to provide psychological and emotional support. Being more aware of psychological problems may result in more referrals to psychology services.

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Why the committee made the recommendations

There was no evidence in this area. The committee agreed based on their experience who should be involved from the multidisciplinary team and what the discussions needed to cover.

Although no evidence was identified, the committee recommended psychological support before limb amputation because of the life-changing nature of the procedures. Psychological and emotional support can improve outcomes after surgery (such as emotional wellbeing and pain management).

The committee recommended involving limb reconstruction and prosthetic specialists early on, because amputation and limb reconstruction can be life-changing and traumatic.

How the recommendations might affect services

The recommendations reflect current practice, but where there are regional variations, practice might need to be amended.

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Why the committee made the recommendations

There was no evidence identified but, based on their own experience, the committee agreed that rehabilitation should start as early as possible after surgery to reduce the risk of complications that may delay the person's recovery, and to maintain range of movement after limb reconstruction. Because of the complexity of limb reconstruction, the committee did not recommend a specific programme but suggested certain interventions that could be used to accomplish this.

The committee also agreed that psychological support should continue after limb reconstruction surgery, to help the person adjust to their appearance and manage pain.

How the recommendations might affect services

The recommendations reflect current practice, but where there are regional variations, practice might need to be amended.

Return to recommendations

Why the committee made the recommendations

There was no evidence but, based on their own experience, the committee agreed that rehabilitation should start as early as possible after surgery to reduce the risk of complications that may delay the person's recovery. People should usually be referred to the amputee and prosthetic rehabilitation team before their surgery, but the committee acknowledged that sometimes there is not enough time so they would need to be referred afterwards.

The committee also agreed that psychological support should continue after limb loss and amputation to help the person adjust to their appearance and manage pain (for example, mirror therapy).

How the recommendations might affect services

The recommendations reflect current practice, but where there are regional variations, practice might need to be amended. More people being referred to amputee and prosthetic rehabilitation before surgery may cause an initial increase in early referrals, but this will be offset by fewer people being referred later in rehabilitation.

Return to recommendations

Why the committee made the recommendations

The committee agreed that pain management should be discussed before surgery because pain after limb loss or amputation can be difficult to treat, and managing pain effectively after surgery can increase participation in the rehabilitation process. Additionally, people with poor perioperative pain control have an increased risk of phantom limb pain in the long term. There was also evidence that mirror therapy (a type of graded motor imagery therapy) is an effective and inexpensive non-pharmacological treatment for phantom limb pain after limb loss or amputation.

How the recommendations might affect services

The recommendations enforce current practice and are not expected to be difficult to implement. Mirror therapy is relatively cheap and easy to implement. Other forms of graded motor imagery therapy are less commonly used and should be delivered by staff with appropriate skills, potentially resulting in extra training costs where it is currently not available. There may be an increased level of referrals to specialised pain management teams, depending on the complexity of pain management plans. However, this will be offset by increased participation in rehabilitation after surgery and therefore better outcomes.

Return to recommendations

Why the committee made the recommendations

There was no evidence so the committee based the recommendations on their knowledge and experience. They highlighted the benefit of elevation and compression therapy in managing residual limb oedema by reducing swelling and facilitating prosthetics fitting. They also agreed that:

How the recommendations might affect services

The recommendations reflect current practice, but where there are regional variations, practice might need to be amended.

Return to recommendations

Why the committee made the recommendation

The committee used their knowledge and experience to recommend providing range of movement exercises to help prevent complications and optimise functional outcomes.

How the recommendation might affect services

The recommendation reflects current practice, but where there are regional variations, practice might need to be amended.

Return to recommendations

Why the committee made the recommendations

Although there was some evidence identified about waiting until prosthetics had been fitted before starting rehabilitation, this disagreed with the committee's knowledge and experience. They argued that the best way to maintain and improve the person's range of movement after limb loss or amputation is by starting rehabilitation therapy as early as possible. Rehabilitation should not be delayed by waiting for prosthetics to be fitted because the maintenance and improvement of range of movement will help prevent complications and optimise functional outcomes.

The committee also agreed that wheelchairs should be provided early, along with appropriate accessories such as anti-tippers and residual limb (stump) boards. Wheelchairs should be adjusted to accommodate the changes in the person's weight distribution after limb loss or amputation. By providing appropriately fitted and adjusted wheelchairs as early as possible, a person's independence and mobility will be increased and they will be better able to engage in activities of daily living. There was no evidence, so the committee used their knowledge and experience to make the recommendation on wheelchairs.

How the recommendations might affect services

There might be an increased number of referrals to physiotherapists and occupational therapists in order for wheelchairs to be individually fitted and adjusted. However, the committee discussed that the increased mobility and independence will result in an increased engagement with rehabilitation, leading to better rehabilitation outcomes. Overall, the recommendations reflect current practice, but where there are regional variations, practice might need to be amended.

Return to recommendations

Why the committee made the recommendations

Although there was no evidence, the committee used their experience and knowledge to discuss how continuing psychological support after limb reconstruction, loss or amputation can help the person come to terms with their appearance and manage pain.

The committee recommended actively monitoring children and young people for emerging emotional and psychological impact. This is because childhood and young adulthood is a period of change for anyone, and children who have had limb reconstruction, loss or amputation may experience it differently to the general paediatric population (for example, altered body image may become more important during puberty).

How the recommendations might affect services

The recommendations reflect current practice, but where there are regional variations, practice might need to be amended.

Return to recommendations

Why the committee made the recommendations

The rehabilitation plan should be reviewed at key points to ensure it is updated with any changes in the person's goals, circumstance or needs. For children and young people, physical growth may cause complications around the residual limb or prosthetic fitting. The committee recommended referral to specialist assessment when this occurs, in order to prevent any adverse effects.

Based on their experience, the committee recommended psychological and emotional support after trauma to help a person adjust to their altered body image, manage pain and cope with the possibility of further procedures.

How the recommendations might affect services

The recommendations reflect current practice, but where there are regional variations, practice might need to be amended.

Return to recommendations

Why the committee made the recommendations

The committee discussed their experience with early treatment of traumatic spinal cord injury in emergency departments and how this can affect rehabilitation. Studies involving spinal cord injury treatment in the emergency department were not included in the evidence reviews because of an existing NICE guideline on spinal injury: assessment and initial management. However, the committee highlighted several areas of acute treatment that can affect rehabilitation after traumatic injury.

Because of competing clinical interests, certain aspects of spinal cord injury management are often overlooked in emergency healthcare settings. The committee highlighted the importance of timely contact with regional specialist spinal cord injury centres and the national spinal injuries database to establish a partnership of care with specialist healthcare professionals that will continue throughout the rehabilitation journey. An American Spinal Injury Association (ASIA) chart should also be completed early to identify a current reference point for future assessments.

The committee reflected on the additional issues that people encounter after spinal cord injury because of the chronic nature of the injury and resulting disabilities (for example, bowel, bladder and sexual function). External support networks are very important during spinal cord injury rehabilitation, with family members (and carers or friends, if appropriate) being invited into healthcare discussions and rehabilitation goals. Vocational, educational, recreational and home adjustments may be needed after discharge. By starting these conversations and arrangements early in the rehabilitation process, any modifications can be in place and rehabilitation can be better tailored to an individual, creating a smoother transfer back into the community. Ongoing contact with hospital rehabilitation teams should be maintained to ensure a continued progress review to inform outpatient rehabilitation planning.

The committee discussed the additional complications that children and young people might experience after spinal cord injury because they are still growing. Spinal growth patterns, skeletal growth and nutrition need to be closely monitored in children and young people. Complications in any of these areas can cause additional barriers to rehabilitation, and will become more difficult (if not impossible) to treat as the child or young person stops growing.

How the recommendations might affect practice

The recommendations reinforce current practice and are in line with the NICE guideline on spinal injury. The benefits of increased care coordination will offset the extra time that professionals might need to follow the recommendations. ASIA charts can be difficult to administer reliably, and staff with appropriate skills should complete assessments, potentially resulting in some extra training costs.

Return to recommendations

Why the committee made the recommendations

The committee agreed that bladder and bowel management is important because the medical consequences from undetected bladder and bowel malfunction can be severe. Complications include renal tract damage, bowel perforation and respiratory distress. The committee used their knowledge and experience to recommend several measures to monitor and maintain bladder and bowel function. Although keeping people nil by mouth is a common practice while assessing bowel function, the committee highlighted that delays in this assessment should be minimised in order to prevent issues with nutrition and discomfort during rehabilitation.

How the recommendations might affect practice

There is variation in bladder and bowel management, so the recommendations should lead to greater consistency and improve care. Monitoring bladder and bowel function will involve additional time, but should have benefits in reducing complications, avoiding delays in starting and continuing rehabilitation, and improving patient outcomes.

Return to recommendations

Why the committee made the recommendations

Spinal cord injury can cause problems with speech and swallowing, so the committee agreed that people should be nil by mouth until they have been assessed for aspiration risk. They used their expertise to highlight groups of people that are at a particularly high risk, and should be assessed early. Referral to specialists may be needed.

Maintaining respiratory function is essential after a spinal cord injury because the injury may have damaged the chest muscles used in respiration. Without treatment, this could lead to respiratory failure and severe complications. It can also delay rehabilitation until the person is clinically stable enough to start it, and may mean they also need chest physiotherapy to be added to their care plan. Respiratory function should be assessed in line with the NICE guideline on spinal injury to determine baseline function and mark progress. The committee highlighted that children and young people can find it difficult to complete these assessments (particularly forced vital capacity [FVC]), and these should be performed and interpreted in accordance with their age and ability. The committee used their experience to recommend several protective interventions to assist with respiratory function after spinal cord injury.

How the recommendations might affect services

Monitoring respiratory function after a spinal cord injury will involve additional time, but should have benefits in preventing complications caused by compromised respiratory function, avoiding delays in starting and continuing rehabilitation, and improving outcomes. Prophylactic respiratory support will potentially reduce the need for additional chest rehabilitation further down the pathway.

Return to recommendations

Why the committee made the recommendations

The extended periods of bed rest and immobilisation following spinal cord injury can lead to a wide variety of complications, which can delay rehabilitation. There was no evidence so the committee based the recommendations on their knowledge and experience.

Skin management is a particular area of concern because of decreased mobilisation coupled with reduced physical sensation. People can develop deep pressure ulcers very quickly, which need to be treated before rehabilitation can start.

Blood pressure monitoring is important after spinal cord injury because people are at risk of developing autonomic dysreflexia (in high-level spinal cord injury) and orthostatic hypotension. Autonomic dysreflexia has severe consequences (for example, strokes, encephalopathy, brain haemorrhages and heart attacks) and should be managed as a medical emergency. Orthostatic hypotension has less severe complications but, because it is triggered when changing positions, can affect engagement with rehabilitation exercises.

How the recommendations might affect services

The recommendations reinforce current practice and should not need additional resources to implement. Additional education might be needed for healthcare professionals on the best way to inform people with spinal cord injury about skin and pressure management.

Return to recommendations

Why the committee made the recommendations

The committee agreed that it is important to maintain mobility and range of motion after a spinal cord injury. However, they also recognised that the large variety of spinal cord injury disabilities and needs means that this should be considered on a case-by-case basis. Because of this complexity, the committee stressed that specialist advice should be sought when needed (for example, the appropriateness of wrist splints for people with a spinal cord injury involving C6). Spinal orthoses have conflicting results in different people, and can hinder certain rehabilitation programmes. Therefore, the committee recommended referring to surgical teams in these cases, to explore other avenues of treatment.

There was some evidence on the benefit of specialist equipment and rehabilitation techniques to maintain mobility and range of motion. The committee agreed that these should be considered on a case-by-case basis, aligning interventions with rehabilitation needs and goals.

Spasticity is an important area to treat for people with spinal cord injury, to prevent losing range of joint movement and contractures. There was some evidence on baclofen (an oral antispastic medication) and botulinum toxin type A to manage spasticity after a spinal cord injury. Referral to a multidisciplinary team specialised in spasticity management may be needed.

Length of bed rest after spinal cord injury varies throughout different NHS trusts, and is an area that the committee were keen to standardise. However, because of the lack of evidence identified, they were unable to make any strong recommendations and made a research recommendation on the optimal length of bed rest to inform future guideline updates.

How the recommendations might affect services

More people with spinal cord injury might be referred to specialist services. Any additional cost will be offset by more people achieving their long-term rehabilitation goals because of earlier specialist input. There might be some additional costs for training healthcare staff, and some services might need to procure specialist equipment to help with mobility, upper limb function and independent walking. Although some equipment, like robotics, can be expensive, the committee agreed a range of effective interventions. There is flexibility within the recommendations about the use of a range of assistive devices and techniques.

Return to recommendations

Why the committee made the recommendations

There was conflicting quantitative evidence on using psychosocial interventions after spinal cord injury, with some studies reporting beneficial outcomes and some finding no difference. The committee argued that this was low quality evidence, and that their experience and expertise agreed with the beneficial impact of psychological interventions. However, because they have already made recommendations on psychological interventions for rehabilitation after traumatic injury, they used this section of the guideline to make recommendations that are specific to people with spinal cord injury.

People with spinal cord injury have increased rates of low mood and psychological trauma, and this can affect engagement with rehabilitation. Access to a psychologist with experience in traumatic spinal cord injury and rehabilitation is not guaranteed outside of specialised spinal units, so the committee made a recommendation to address this. Active monitoring is recommended for children and young people because childhood and young adulthood is a period of change for anyone, and children and young people with a spinal cord injury could be affected in different ways to the general paediatric population (for example, altered body image becoming more important during puberty).

How the recommendations might affect services

The recommendations reinforce current practice and should not need additional resources to implement. If multidisciplinary teams are more aware of low mood and psychological trauma in people with a spinal injury, they may make more referrals for psychological support.

Return to recommendations

Why the committee made the recommendations

Nerve injuries may be hidden; for instance, when the person has multiple injuries, a cognitive impairment, a head injury, is in critical care or has a pre-existing neurological condition. These obvious injuries could distract clinicians from recognising subtler nerve injury, and neurological deficit caused by nerve injury can be mistakenly assumed to be due to a pre-existing neurological condition. In addition, diagnosis of nerve injury may not be possible if the person is unconscious, and nerve function cannot be assessed on limbs that are splinted. The committee highlighted the need to assess the peripheral nerves of the affected limb to identify the informed nerve and functional deficit.

The committee highlighted the importance of assessing the risks to tissue viability if there is sensory or motor loss secondary to peripheral nerve injury, to manage the risk and not jeopardise the person's functional recovery.

How the recommendations might affect services

The recommendations reflect current practice, but where there are regional variations, practice might need to be amended.

Return to recommendations

Why the committee made the recommendations

Based on the evidence and their experience, the committee emphasised the need to start rehabilitation therapy to maintain range of movement and regain function after nerve injury. This is because nerve injury can cause the joint to rest in an unnatural position and lead to fixed deformity from contracture of the capsule and muscle. Providing vocational therapy while the recovery is ongoing can help the person return to normal activities such as work.

Nerve function should be assessed regularly for symptoms of recovery, which will affect the components and intensity of the nerve rehabilitation programme. It should not be a static programme. For people who have a poor prognosis, a referral to a specialist peripheral nerve injury service should be made because these services are better equipped to deal with the complex needs of peripheral nerve injury.

People recovering from nerve injury may experience low mood, anxiety and lack of motivation, because recovery may be a lengthy process. To ensure that specialist psychological support is available for people who may need it, the rehabilitation team should have access to a psychologist with trauma and rehabilitation experience.

How the recommendations might affect practice

Sensory interventions (including mirror therapy) and hydrotherapy are not widely available and this could have some resource implications. However, hydrotherapy would only be offered if pool facilities were available, and mirror therapy and other sensory interventions are relatively inexpensive and easy to implement. All of the above interventions can play a part in stimulating and aiding functional recovery, and can lead to a quicker recovery, help with pain management, and improve the person's health-related quality of life.

Healthcare professionals may need training to conduct nerve conduction studies reliably, but this will save costs further down the care pathway. There may be more referrals to specialist peripheral nerve injury services.

Return to recommendations

Why the committee made the recommendations

There was no evidence identified. However, the committee discussed the importance of starting rehabilitation as soon as possible to avoid further complications. They also discussed the need for regular assessment of pain and highlighted pain management options. This is because pain is a contributing factor for much of the morbidity associated with chest injury, and the appropriateness of pain management options may vary between people with chest injury.

For people with chest trauma, the committee highlighted the need for movement in order to optimise their respiratory function and prevent deconditioning. They further highlighted a range of rehabilitation therapies to use in preventing respiratory difficulties because this is a key component of chest trauma rehabilitation. The committee are aware that the availability of these therapies may differ between services, and different therapies may be preferred by different people.

Because of the concerns over possible injury causes and underlying pathologies, the committee highlighted the need to assess people with rib fractures, in order to inform future treatment and prevent recurrence. The committee recognise stiffness of the upper limbs as a common complication and discussed measures to prevent compromised function.

The committee recommended referring people with complex chest injuries that affect communication and swallowing skills to speech and language therapy to prevent speech decline and swallowing difficulties.

The committee also recommended providing information that will help people to return to normal life and explain how to seek help for different problems that may arise because rehabilitation for chest injuries can take a long time, causing stress and worry.

How the recommendations might affect services

The recommendations reflect current practice, but where there are regional variations, practice will need to be amended.

Return to recommendations