Rehabilitation after traumatic injury

As part of the rehabilitation needs assessment after a traumatic injury, the multidisciplinary team should assess the person's pre-injury and current physical functioning, which should include:

• assessing pain management to enable physical rehabilitation activities to begin

• a comprehensive neuromusculoskeletal assessment to identify physical impairments such as nerve injury, muscle imbalance and proprioception problems

• assessing upper and lower limb function and the impact of the injury on the person's ability to move and use walking aids (if needed)

• assessing and recording the range of movement for each joint affected

• asking about any problems with balance or dizziness and other vestibular symptoms (either pre-existing or new), and considering assessment for benign paroxysmal positional vertigo (BPPV) and for head injury

• if the traumatic injury has been caused by a fall, asking about previous falls and considering a falls risk assessment in line with the section on multifactorial risk assessment in the NICE guideline on falls

• assessing pre-existing or newly acquired vision or hearing problems

• assessing whether there are any new difficulties with communication, speech and language

• assessing ability to do transfers, for example, to move from lying to sitting, and sitting to standing

• assessing trunk control and core stability (if relevant)

• assessing ability to move and level of aerobic fitness and/or exercise tolerance

• assessing skin care, wound care and pressure area management

• for children and young people, asking about previous developmental attainment and functioning.

Refer the person for a specialist assessment if the multidisciplinary team does not have appropriate skills or expertise to perform the assessment needed. Examples are:

• to determine when and how splints and orthoses should be used, taking into account that people with complex traumatic injuries may need bespoke splints or orthoses

• if they have external fixation for lower limb fractures

• if they have sensory loss or nerve injury (see the section on rehabilitation after nerve injury).

Assess the person for factors that may affect their ability to engage in rehabilitation. These may include balance and coordination issues (neurovestibular disorders), and newly acquired vision or hearing loss. Refer for specialist assessment and management as needed. Also see the section on sudden or rapid onset of hearing loss in the NICE guideline on hearing loss in adults.

Be aware that even if there has been no brain injury, problems with cognitive functioning are common after a traumatic injury because of the psychological shock and trauma.

As part of the rehabilitation needs assessment after a traumatic injury, the multidisciplinary team should ask about any cognitive problems, for example:

• confusion

• disorientation

• slowed thinking and/or slowed processing of information

• withdrawal

• memory problems

• agitation

• communication, speech or language changes (for example, withdrawal or selective mutism).

If a person has problems with cognitive functioning after a traumatic injury, investigate for other causes such as:

• pre-existing cognitive impairment or dementia (see the NICE guideline on dementia)

• delirium (for example, alcohol or drug misuse, drug toxicity or opiate-related confusion, infection or sepsis, or hypoxia; see the NICE guideline on delirium)

• behavioural problems or learning disabilities (see the NICE guideline on challenging behaviour and learning disabilities)

• traumatic brain injury (this may not show up on scans immediately and further investigations will be needed if it is suspected; see also recommendation 1.2.3).

If a person has problems with cognitive functioning after a traumatic injury and the potential causes in recommendation 1.2.18 have been ruled out, assess the person's:

• orientation to time, place, person and situation

• ability to follow simple instructions

• ability to recall information and communicate it correctly after a short period of time.

If the assessment in recommendation 1.2.19 confirms difficulties with cognitive functioning, refer the person to an occupational therapist, practitioner psychologist (ideally a neuropsychologist) or a speech and language therapist (as appropriate) for a specialist cognitive assessment.

As part of the rehabilitation needs assessment after a traumatic injury, the multidisciplinary team should ask about psychological and psychosocial risk factors, for example:

• past or present mental health problems, such as anxiety or depression

• past or present mental illness or psychiatric treatment

• history of traumatic brain injury

• history of self-harm or suicide attempts

• any experience of domestic violence or abuse

• any safeguarding concerns (if the person is a child or a vulnerable adult)

• excessive alcohol consumption or recreational drug use

• the circumstances of the injury, for example, self-harm or a violent crime

• social factors that mean the person may need additional support, for example, if the person is socially isolated, homeless, a refugee or recent migrant, if they have difficulty reading or speaking English, or if they have learning disabilities or other needs.

As part of the rehabilitation needs assessment after a traumatic injury, look for indicators of psychological problems (including lack of engagement with rehabilitation) beyond that of an acute stress response (see recommendation 1.13.1). Take into account any psychological and psychosocial risk factors (see recommendation 1.2.21) and, if needed, refer the person for a psychological assessment with a practitioner psychologist (with relevant expertise in physical trauma and rehabilitation) or a member of the liaison psychiatry team to inform their rehabilitation plan and goals.

Rehabilitation programmes of therapies and treatments should:

• form part of the person's rehabilitation plan, and be tailored to their individual needs (see the section on developing a rehabilitation plan and making referrals)

• focus on outcomes (for example, return to work, school or leisure activities) and be based on the person's short-term and long-term rehabilitation goals (see the section on setting rehabilitation goals)

• include educational material to help people understand the nature of their injuries, to promote self-care and to prepare them for any long-term or intensive periods of rehabilitation (for example, sleep, pacing activities and pain management)

• include (as appropriate) physical, cognitive and psychological therapies and treatments such as physiotherapy, exercise, occupational therapy, psychology and orthotics, as well as injury-specific therapies and treatments; see the sections on:

  • physical rehabilitation

  • cognitive rehabilitation

  • psychological rehabilitation

  • rehabilitation after limb reconstruction, limb loss or amputation

  • rehabilitation after spinal cord injury

  • rehabilitation after nerve injury

  • rehabilitation after chest injury

• include access to specialist services to address complex issues such as fertility and endocrine concerns

• include (as appropriate) a combination of group and individual sessions as well as the development of a self-management rehabilitation programme (see the section on supporting access and participation in education, work and community [adjustment and goal setting])

• include and document regular progress reviews and a final assessment to review outcomes, update the rehabilitation plan and detail any ongoing rehabilitation needs for onward referrals to GP, outpatient and/or community services

• include post-programme follow-up, in person or virtually.

Tailor the start time, frequency, intensity and duration of the rehabilitation programme to have the most beneficial effect on the person's recovery (for example, a short period of intensive rehabilitation at an important time point might be better than weekly sessions over a long period).

In the post-acute period, consider an intensive (for example, 3 weeks) inpatient or outpatient (including residential) rehabilitation programme for adults, young people and children with complex injuries and rehabilitation needs if such an intervention is likely to have a significant impact on change in function (for example, it could result in return to work or education and living independently).

When providing intensive rehabilitation programmes:

• offer education and learning materials (see the section on guided self-managed rehabilitation) to prepare people for intensive rehabilitation, for example, 1 week of remote learning followed by a (for example, 3‑week) residential or outpatient programme

• answer questions, such as those relating to the person's injuries and rehabilitation

• consider delivering rehabilitation therapies with regular breaks (for example, only during weekdays to allow for rest periods at weekends and time to review progress)

• communicate any changes to the rehabilitation plan with the local team following the intensive period of rehabilitation.

Start an intensive rehabilitation programme at the appropriate time for the person, taking into account:

• that the timing and nature of rehabilitation therapies and treatments will depend on issues such as bone and soft tissue healing, weight-bearing, and removal of weight-bearing restrictions

• the person's psychological and emotional wellbeing, levels of adjustment and engagement with the rehabilitation process.

Consider guided self-managed rehabilitation to allow the person to engage in rehabilitation in their own time and by their own schedule, working with rehabilitation healthcare professionals and practitioners, with regular reviews to check on progress, provide ongoing reassurance and answer queries.

As part of a self-management rehabilitation programme, consider providing a tailored package of online education and learning materials for people after a traumatic injury, which could include information on:

• movement and physical activity

• energy conservation and pacing

• sleep

• activities of daily living

• work, social activities and hobbies

• nutrition and diet

• pain management and medicines

• wound healing

• mental health

• local and national sources of information

• peer support services, including local and national groups.
  
  For people who cannot access the internet, explore alternative ways to provide these materials.

If people are following a self-management rehabilitation programme, consider arranging follow-up appointments and regular reviews with rehabilitation healthcare professionals and practitioners to check on self-managed progress, provide ongoing reassurance and answer new queries.

For children, young people and vulnerable adults, offer additional support to develop and deliver a self-management programme that takes into account their communication needs, their own views and priorities and (for children) their developmental stage.

Monitor the person's progress after starting rehabilitation. Use tools such as patient-reported outcome measures (PROMs) and clinician-reported outcome measures (CROMs) for adults; parent- and child-reported measures for children and young people; and consider using tools that involve family members and carers. Additional specific clinical assessments may be used as appropriate.

Encourage people to record information about their injuries, treatments and rehabilitation therapy options (for example, using a diary as part of their rehabilitation plan) to assist discussions and shared decision making.

Where possible, provide continuity of staff throughout the person's rehabilitation pathway.

Assign a named rehabilitation coordinator or key worker to oversee the person's care as soon as possible and within 72 hours of admission. Ensure that the person knows who their rehabilitation coordinator or key worker is, how they will coordinate care, and how they can be contacted.

The trauma team should agree the core members of the rehabilitation multidisciplinary team who will establish an injury management plan and start developing a rehabilitation plan and goals. See recommendation 1.2.4 for details of the multidisciplinary team after hospital admission.

A member of the rehabilitation multidisciplinary team should discuss the person's rehabilitation at daily trauma meetings or ward rounds.

Where assessment identifies the need for specialist rehabilitation (see the section on multidisciplinary team rehabilitation needs assessment), complete the referral to specialist rehabilitation units as soon as possible.

Use a unique identifier, preferably the NHS number if this is known, when exchanging clinical information about the person's assessment, rehabilitation plan, onward referral, transition between services, discharge to community services, and all aspects of their care pathway.

Make follow-up appointments with acute teams (if needed) for people moving from an acute unit to rehabilitation services, and ensure that the person is informed before they are transferred.

When people transfer between service providers or settings (for example, wards, hospitals and inpatient rehabilitation facilities), share information (with the person's consent) by providing a detailed verbal and written or online handover (for example, the rehabilitation plan and the person's progress against it) and let the person know this has been done. Ensure information is promptly communicated:

• to those coordinating and delivering rehabilitation in the new setting or service

• to the person, and family members and carers (as appropriate)

• to any other service providers involved in the person's care and support.

The detailed handover and report should include oral and online or printed information about:

• all of the person's injuries

• different treatment options and their benefits and risks

• the person's current rehabilitation plan and goals

• the person's cultural, language and communication needs

• psychological approaches to managing pain and fatigue, if relevant

• beneficial activities, and activities to avoid

• how to manage activities of daily living, including self-care and re-engaging with everyday life

• plans for returning to work or school, housing and benefits, and driving, if relevant

• how to recognise possible problems or complications, and what to do

• local support groups, opportunities to access peer support, online forums and national charities, and how to get in touch with them

• services that provide independent legal, financial, employment and welfare advice

• advice for the family or carers about:

  • what to expect and how to support the person at home

  • the impact of the traumatic injury on family members and carers, and how they can get support.

When people transfer between service providers or settings, discuss with them:

• their expected recovery pathway

• what might happen if recovery is slower than expected

• the emotional impact of living with possible long-term symptoms and treatments.

Consider early, multidisciplinary discharge planning to ensure appropriate and smooth discharge and transition to outpatient and community services.

Reassess the person's needs and review the rehabilitation plan before discharge to ensure that their needs are addressed alongside any long-term, existing health conditions or disabilities.

Be aware that family members and carers can play a key role in the smooth transition to outpatient and community services. If the person consents and their family members or carers agree, actively involve them in the transition process.

Give people information and support at the earliest opportunity if they need to apply for funded equipment for use after discharge from hospital (for example, wheelchairs) because applications can take time to process and may delay the person's discharge.

For children and young people, arrange a meeting between the school or education setting, 1 or more members of the multidisciplinary team, and their parents or carers, to inform the education provider about the changes to the environment and education plan that the child or young person may need to meet their education and support needs. This should take into account transport needs.

Advise people that further help with funding for equipment, assistive technology, environmental adaptations and other forms of support with rehabilitation might be available for their home, education and workplace settings (for example, through local authorities, the education, health and care plan, Access to Work grants, voluntary sector grants and the Department for Work and Pensions).

Give people, and their family members or carers (as appropriate), information about services that provide independent legal, financial, employment and welfare advice (for example, Citizens Advice).

If a person has significant ongoing and complex medical and therapy needs, offer a gradual and incremental return into the community, for example, transfer to a local hospital, a stepdown bed or a pre-discharge visit to home, to reduce the distress of the sudden loss of support as an inpatient.

Ensure that ongoing advice about pain management, including a plan to reduce analgesia, is discussed with the person and passed onto the person's GP or another lead clinician. See also the NICE guideline on medicines optimisation.

Where possible, arrange joint inpatient and community team home visits with the person before discharge, especially for people with significant ongoing needs.

If there are any concerns about how the person will manage at home after they are discharged, consider overnight or weekend visits home before discharge, depending on their needs, preferences and home circumstances.

When arranging overnight or weekend visits home, involve the person in discussing the possible risks and how to manage them, especially if they live alone.

If a person is likely to have continuing health and social care needs after discharge to home:

• inform relevant healthcare professionals, social care practitioners and education practitioners (as appropriate)

• establish the person's eligibility for funded social care support, including for families and carers

• use the NHS continuing healthcare checklist, to establish the person's eligibility for a full continuing healthcare assessment before discharge

• for children and young people, establish their eligibility for emergency education funding for short-term support at school and for funded support through an education, health and social care plan (if appropriate).
  
  Also see the NICE guideline on transition between inpatient hospital settings and community or care home settings for adults with social care needs.

Offer a multidisciplinary approach to meet the person's rehabilitation and social care needs that is coordinated, consistent and as integrated as possible, to support the person, and their family or carer (as appropriate), through transfer from inpatient to outpatient rehabilitation services.

Document in the rehabilitation plan and handover report how rehabilitation after discharge will be delivered (see recommendations 1.7.7 to 1.7.9 for what should be included). When transferring the person to outpatient and community settings (including home), also include:

• whether ongoing support and follow-up after discharge is needed, for example, community rehabilitation, referrals and review appointments

• when community rehabilitation appointments will be likely to take place.

For people who will have significant ongoing needs after discharge:

• arrange a pre-discharge planning meeting with community practitioners who will be involved in the person's rehabilitation, care and support (for example, therapists, social workers and care coordinators)

• encourage pre-discharge visits by community practitioners to meet the person, and their family or carer (as appropriate)

• consider organising a joint 'handover' appointment between the inpatient multidisciplinary team and community practitioners at the point of discharge.

Liaise with community teams (such as community and voluntary sector providers, physiotherapists and occupational therapists, education support, and special educational needs coordinators in schools and nurseries for children and young people) to agree a staged return to the workplace or education. (See also the NICE guideline on transition between inpatient hospital settings and community or care home settings for adults with social care needs.)

When planning discharge, address potential barriers that may prevent the person accessing rehabilitation in the community. For example, ensure that they can travel to and access the location of treatments, and ensure that the timing and length of appointments will be manageable for them.

If a person cannot travel to rehabilitation appointments, offer telephone or video consultations, or rehabilitation in the person's home.

Consider arranging telephone or video consultations or rehabilitation in the person's home, rather than in a clinic or hospital setting (for example, if the person needs help to learn to live independently in their own home).

At discharge from hospital, provide people and their family or carers (as appropriate) with a single point of contact at the hospital for information, help and advice for a limited time period (for example, 3 months).

If people need ongoing rehabilitation and other health and social care support after discharge, the inpatient multidisciplinary team and community practitioners should agree who will be the key contact after discharge when contact with the hospital is no longer appropriate (see recommendation 1.8.23). This person may be a GP, rehabilitation physician, special educational needs coordinator, allied health professional, family support worker, social worker, case manager, disability paediatrician or speciality-specific coordinator, for example, a neuro navigator.

If people have complex or long-term conditions or social care needs, consider appointing a key worker as a direct source of advice, support and signposting. This should be a healthcare or social care professional with knowledge and expertise about inpatient or community-based rehabilitation and support, including education or training support for children and young people.

For young people who are transitioning between children's and adults' services, see recommendations about the role of the named worker in the NICE guideline on transition from children's to adults' services for young people using health or social care services.

When planning, commissioning and coordinating the delivery of rehabilitation and related services (for example, social care and the voluntary sector), commissioners and providers should design services with whole care pathways in mind, from acute treatment and inpatient rehabilitation through to community provision, including specialised and non-specialised elements.

Ensure collaboration between commissioners from different commissioning bodies to ensure seamless provision, for example, to include specialist community, vocational and educational rehabilitation provision for people after a traumatic injury, including those transferring between children's and adults' services.

Ensure that it is clear locally who has overall designated commissioning responsibility for rehabilitation services.

Commissioners and providers should ensure that rehabilitation services for people after a traumatic injury:

• meet the needs of people of all ages and at all stages of rehabilitation

• are developed and co‑designed in collaboration with the people who use rehabilitation services and the healthcare professionals who work within them

• are outcome-focused and relevant for the people who use them.

Consider commissioning intensive (for example, 3‑week) residential or outpatient rehabilitation programmes for people of all ages in addition to existing rehabilitation pathways, for example, as a tertiary service for trauma rehabilitation within the trauma network.

Establish care networks (for example, trauma networks) and clear guidance on coordination and communication between rehabilitation settings and services to meet the needs of the local population across different aspects of rehabilitation service commissioning.

Rehabilitation units should maintain an online directory of care pathways, rehabilitation facilities and voluntary sector services (including recreational facilities) so that practitioners have access to up-to-date information and contact details to pass on to people with complex rehabilitation needs.

If community treatments and services remain uncertain at the point of discharge, give people and their families and carers (as appropriate) information about rehabilitation community and social services available in their local area and from national support networks, and how they can access these.

Offer networking opportunities between different rehabilitation, social care and related services to enhance inter-service awareness and working relationships.

Consider technology-enabled follow-up, support and rehabilitation sessions if people request more local, accessible therapy or if rehabilitation practitioners are not available in their area, for example, in rural areas.

Consider group rehabilitation sessions to allow people to interact with peers, share experiences and to provide valuable support.

Ensure that staff working with people with complex rehabilitation needs have specialist skills, knowledge and expertise in the person's injuries, the complexity of their rehabilitation needs and goals, and the stages of their recovery journey.

Ensure that hospital staff have access to supervision and training to develop their specialist knowledge in the management and rehabilitation of traumatic injuries.

Ensure that community rehabilitation practitioners have access to training expertise, advice or peer support from specialist services, especially where specific rehabilitation interventions or services are not widely available. For example, healthcare professionals such as speech and language therapists, practitioner psychologists and consultants with specialist knowledge of specific injuries and complex rehabilitation could work together with general rehabilitation staff working in community-based rehabilitation services.

Provide personalised exercises as soon as possible after a traumatic injury to maintain and improve muscle function, strength and range of movement.

Proactively support people in managing their pain, and ensure that they have adequate analgesia so that rehabilitation can go ahead.

Choose a pain scale appropriate for the person, taking into account a range of factors such as their developmental age, cognitive ability, any communication difficulties and their first language.

If needed, provide aids, splints or orthotics to maintain range of movement or protect the injury (for example, an ankle-foot orthosis, knee brace or spinal orthosis).

Use clinical judgement and expertise to determine the frequency and dose of the prescribed exercises because this is vital to the success of the interventions, and will differ depending on the individual needs and goals.

Before starting weight-bearing exercises, be aware of the effects of low blood pressure (for example, postural hypotension or vasovagal syncope [fainting]) and monitor the person for hypotensive symptoms when starting therapy.

Minimise adverse effects of low blood pressure and loss of postural reflexes by:

• optimising the person's bed position and using strategies such as thromboembolic stockings

• ensuring adequate hydration

• carrying out a medication review

• using abdominal binders and tilt tables.

Be aware that traumatic injury that requires intubation, or causes facial trauma, oedema or loss of dentition may lead to a voice disorder, decreased speech intelligibility and/or swallowing difficulties. Consider early referral to appropriate professionals as needed; this may include maxillofacial specialists, dental services, ear, nose and throat services, or speech and language therapy.

Promote independence with activities of daily living, in particular personal activities of daily living, and consider referral to occupational therapy if needed.

The surgical team should define and document the person's weight-bearing status at the earliest opportunity after a traumatic injury, and inform the rehabilitation multidisciplinary team, explaining the reasons for restricted weight-bearing, what limits should be put in place and for how long.

Start a programme of weight-bearing exercises, including exercises through play for children and young people, as soon as possible after a traumatic injury to encourage mobility and maintain postural reflexes, muscle mass, strength and function.

For people with lower limb injuries, start a programme of targeted weight-bearing exercises, including exercises through play for children and young people, to improve range of movement of the affected joint(s), improve muscle activation, and improve strength and balance. 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.

As soon as possible after a traumatic injury, start a tailored exercise programme to help with reconditioning, fitness, strengthening, balance, proprioception and vestibular function, irrespective of the person's age, stage of rehabilitation or combination of injuries. The exercise programme:

• could be self-directed and/or delivered as one-to-one sessions or in a group

• should include resistance training, core strengthening exercises and general aerobic fitness

• should include task-specific balance training if needed

• should be incorporated into the usual play activities for children

• should be tailored to the person's needs and goals (for example, the frequency of the sessions and the exercises involved).

Consider a continued programme of aerobic exercise when agreeing a rehabilitation plan and at appropriate points along the rehabilitation pathway.

For people with limited lower limb mobility or immobility after a traumatic injury, consider a programme of upper body aerobic training or seated exercises.

Tailor the aerobic exercise programme to the person's interests to help with personal commitment and adherence, and depending on the nature of their traumatic injuries.

Do not withhold aerobic exercise programmes from older people after a traumatic injury.

After discharge from hospital after a traumatic injury, offer people a home exercise programme that includes aerobic and strengthening exercises, and review their progress at outpatient clinics or key worker appointments.

For people who are unable to weight-bear (because of clinical restrictions or pre-existing conditions), start an exercise programme as soon as possible after the traumatic injury to reduce the impact of non-weight-bearing and to optimise the transition to gait training when possible.

As soon as possible after a traumatic injury and once weight-bearing can begin, start a gait re-education programme that:

• aims to restore gait patterns

• includes passive stretches and range of movement exercises

• reduces the impact of non-weight-bearing on joints and muscles.

For people who need a non-weight-bearing period after a traumatic injury:

• assess muscle weakness and joint range of movement as soon as possible after the non-weight-bearing period ends and

• start an exercise programme aimed at muscle strengthening and gait progression.

Provide a programme of passive, active assisted or active range of movement exercises for all affected joints.

Consider a programme of targeted stretching techniques in addition to the standard range of movement exercise programme in recommendation 1.11.22.

If the person is unable to engage in range of movement exercises independently, consider using controlled motion devices to help with range of movement at the knee and ankle joints.

Regularly review the use of splints (as part of donning [putting on] and doffing [taking off]), cautiously increasing the length of time the splint is in use to ensure that it is still appropriate and that there are not complications such as nerve injury or pressure sores.

Ensure that the person, and their families and carers (as appropriate), know how to put on and take off their orthoses and splints, when to wear them and when to seek advice.

For people with lower limb fractures or nerve injuries, consider an orthosis (for example, a dorsi-wedge in a moon boot or an ankle-foot orthosis) if there is a risk of loss of ankle range of movement.

For people with external fixation for lower limb fractures, carry out specialised splinting to maintain ankle range of movement.

Monitor the pressure effects on skin by orthoses or splints, particularly in people with reduced cutaneous sensation and/or recent skin graft or flaps. Seek advice from tissue viability services and/or plastic surgery specialists as needed.

Be aware that spinal orthoses, such as cervical collars and thoraco-lumbar spinal orthoses, may be poorly tolerated by some people, particularly older people or those with delirium, cognitive impairment or dementia.

If spinal orthoses are causing problems (such as pain, pressure sores, or swallowing or breathing difficulties) or are significantly affecting the person's ability to engage with rehabilitation, inform the relevant surgical team.

If splints or braces are used to immobilise and protect joints, avoid positions that may result in loss of function or complications in the future.

For people with upper limb injuries that affect range of movement in their hands and fingers, offer bespoke (thermoplastic) splints as early as clinically possible to maintain range of movement. Refer people with complex hand injuries to a hand therapy specialist, as appropriate.

Monitor the person's intake of adequate food and drink to maintain weight, taking into account the effects of post-surgical anorexia, pain medications, constipation and nausea, and the increased calorific needs of healing.

Regularly and proactively review the person's nutritional needs and the dietary plan for effective rehabilitation. See recommendations in the NICE guideline on nutrition support for adults.

Following assessment by a dietitian specialising in trauma care, consider supplementation of dietary protein for people who are frail, have gastrointestinal health issues or have multiple injuries.

Involve specialist dietitians when considering dietary protein requirements for people with severe kidney impairment.

For people with a fragility fracture, measure vitamin D levels and consider a supplement. Also see the recommendations in the NICE guideline on osteoporosis: assessing the risk of fragility fracture and the NICE guideline on vitamin D: supplement use in specific population groups.

For people with burns in combination with other traumatic injuries, regularly monitor their weight and involve a dietitian with experience of burns, for example, if the person's weight fluctuates or they are at risk of losing muscle mass and strength.

If there are concerns about safe swallowing and risk of aspiration (see recommendation 1.1.10), keep the person nil by mouth and carry out a swallowing assessment by an appropriately trained healthcare professional as soon as possible. If immediate assessment is not available, maintain hydration and nutrition by non-oral means. Also see the NICE guideline on nutrition support for adults.

Involve a dietitian and nutrition team for treatments to maintain nutritional supply, for example, a nasogastric tube, percutaneous endoscopic gastrostomy (PEG), radiologically inserted percutaneous gastrostomy (RIG) or parenteral nutrition (PN).

Discuss limb reconstruction and/or amputation with the person, and their family members or carers (as appropriate), when making decisions about treatment pathways and assessing rehabilitation options. Recognise that, for some people who have had a complex limb-threatening injury, amputation may be the option that best delivers the person's most important rehabilitation goals.

Members of a specialist multidisciplinary team (for example, a limb reconstruction team or prosthetics team) alongside the trauma rehabilitation team should discuss the implications of the following, as part of assessing rehabilitation needs, as soon as possible with the person, and their family members or carers (as appropriate):

• rehabilitation pathways

• pain management

• recovery timescales

• long-term expectations

• impact on daily life, for example, work, hobbies, activities, education and play.

When amputation is being considered and if time permits before surgery, a member or members of the specialist multidisciplinary team with expertise in prosthetic prescription and rehabilitation should carry out a pre-amputation rehabilitation assessment and consultation.

Offer psychological support before limb reconstruction or amputation (see the section on psychological support).

After limb reconstruction, start rehabilitation therapy as early as possible (ideally the day after surgery) to maintain range of movement. This may include:

• splinting

• exercise

• pain management

• swelling and oedema management

• hand therapy

• mobility

• positioning.

Avoid early rapid irreversible loss of range of movement after limb reconstruction by ensuring that the person carries out range of movement exercises for the affected joint and other joints to optimise recovery and avoid contractures.

Continue psychological and emotional support after limb reconstruction (see the section on psychological support).

After limb loss or amputation, refer the person to the amputee and prosthetic rehabilitation service as soon as possible if the referral was not made before the surgery.

After limb loss or amputation, start rehabilitation therapy as early as possible and ideally the day after surgery. This may include:

• pain management (see the section on pain management)

• residual limb oedema and shaping (see the section on residual limb oedema and shaping)

• range of movement and strengthening exercises (see the section on range of movement and strengthening)

• functional independence, including play for children (see the section on functional independence)

• psychological support (see the section on psychological support).

Continue psychological support and ensure that the multidisciplinary team has access to a practitioner psychologist with appropriate expertise in physical trauma and rehabilitation, ideally with experience of working with people with limb loss, amputation or limb reconstruction.

For children, consider play or play therapy when offering psychological and emotional support.

For children and young people, the team around the child should actively monitor for any emerging emotional difficulties as the child or young person grows and develops (for example, moving schools, puberty and emotional relationships).

Take into account the long-term psychological impact of change in body image as a result of injury for all people and the psychological impact for children and young people as they grow.

When completing a rehabilitation plan (see the section on developing a rehabilitation plan and making referrals) for people after limb reconstruction, limb loss or amputation, ensure that the following are always included in the person's rehabilitation programme:

• exercise and mobility

• psychological and emotional support

• referral and signposting to support groups

• pin-site review (for limb reconstruction)

• frame adjustment (for limb reconstruction)

• prosthetics team review, if relevant.

The specialist multidisciplinary team should offer psychological and emotional support to enable the person to adjust to their altered body image, manage pain and cope with the possibility that they may need further procedures. Psychological and emotional support should involve:

• listening carefully and validating feelings

• supporting reflection and reasoning around realistic goals and care

• supporting planning

• offering feedback about progress towards goals.

Carry out reviews of the rehabilitation plan (for example, equipment, home environment, clothing and footwear needs) at key points, for example:

• at discharge

• when an external-fixation frame is removed

• when weight-bearing status changes

• when prosthetics are changed

• when the person starts to go outside

• when the person starts to return to education, work or community activities

• if the person is readmitted because of complications.
  
  (Also see the section on monitoring progress against the rehabilitation plan, goals and programme of therapies and treatments.)

For children and young people, monitor the impact of growth on the residual limb and prosthetic fitting, and refer without delay for specialist assessment when there are changes.

For people with a spinal cord injury:

• ensure that ongoing contact with the regional specialist spinal cord injury centre is made in line with the recommendations on communication with tertiary services in the NICE guideline on spinal injury and

• refer using the national spinal injuries database within 24 hours of the diagnosis.

Seek advice from the regional specialist spinal cord injury centre outreach team throughout the person's inpatient stay and at discharge to support their rehabilitation.

A healthcare professional with appropriate clinical skills should complete an assessment using an American Spinal Injury Association (ASIA) chart as soon as possible after a spinal cord injury, and repeat this as clinically indicated.

Be aware that spinal cord injury may affect areas of physical function including bowel, bladder and sexual function, and seek specialist advice as appropriate (see also recommendation 1.2.6 in the multidisciplinary team rehabilitation needs assessment section).

Refer children and young people with a spinal cord injury:

• to specialist play services to support their emotional and physical development and wellbeing

• to education services to support their ongoing educational development.

For children and young people, monitor growth and nutrition throughout the rehabilitation process.

When discharge planning for children and young people after a spinal cord injury, ensure that meetings take place early and involve the child or young person, and their parents and carers (as appropriate), together with the local education authority, specialist play services and multidisciplinary teams involved in their care.

After hospital discharge, consider ongoing contact between the rehabilitation team and the person, and their family members and carers (as appropriate), with education and a structured review of progress in rehabilitation as part of outpatient follow-up. This could be offered by telephone or video link.

Assess and manage bladder function after a spinal cord injury as follows:

• protect upper renal function at all times by maintaining safe bladder emptying (inserting a urinary catheter if necessary), and ensuring that people understand and use bladder management techniques as a key part of their rehabilitation (see also the monitoring and surveillance section in the NICE guideline on urinary incontinence in neurological disease)

• identify acute kidney injury in line with the NICE guideline on acute kidney injury

• identify renal tract stones (see also the NICE guideline on urinary incontinence in neurological disease).

Regularly assess and manage bowel function after a spinal cord injury as follows:

• assess anal tone and sensation

• start and review a bowel management plan that includes laxatives, enemas, suppositories and manual evacuation, depending on the level and severity of the spinal injury.

Keep the person nil by mouth until their bowel function has been assessed because of the risk of neurogenic bowel stasis and aspiration pneumonia. Avoid unnecessary delays to assessing bowel function to avoid prolonged periods of nil by mouth.

For younger children, ask their parents and carers (as appropriate), about their pre-injury continence skills, and take their age and ability into account when assessing and managing bladder and bowel function.

Keep the person nil by mouth until their risk of aspiration has been assessed (see recommendation 1.11.51).

Be aware that people with cervical spine injuries and those managed on flat bed rest, are particularly at risk of swallowing and speech difficulties and should be assessed early for risk of aspiration.

Assess and manage respiratory function (taking into account age and ability when assessing children and young people) as follows:

• use spirometry to measure vital capacity in line with the NICE guideline on spinal injury

• consider prophylactic respiratory support with, for example, active cycle of breathing techniques, incentive spirometry, intermittent positive pressure breathing (IPPB) or non-invasive ventilation (NIV), to maintain forced vital capacity (FVC) and prevent chest complications

• consider use of cough-assist techniques or devices.

Consider critical care management for people with a high-level spinal injury.

Assess voice quality and refer to a speech and language therapist and/or ear, nose and throat specialist as needed.

Assess skin and pressure care after a spinal cord injury as follows:

• start a 24‑hour positioning and turning programme and use a pressure mattress if appropriate (ensuring that the spinal column has been assessed as mechanically stable) or indicated and

• give information about skin protection for people with sensory deficits.

Be aware of the risk of autonomic dysreflexia, and treat it as a medical emergency.

Be aware that most people who have had a spinal cord injury will develop orthostatic hypotension, which can affect their participation in rehabilitation. Consider interventions to optimise blood pressure, for example, medication review, graduated positioning, abdominal binders and compression stockings.

For people with a spinal cord injury who are using a spinal orthosis (for example, cervical collar or thoraco-lumbar spinal orthosis), regularly assess them for complications such as pain, pressure sores, swallowing or breathing difficulties (particularly in older people or those with dementia or delirium).

If spinal orthoses are causing side effects or are significantly affecting the person's engagement with rehabilitation, inform the relevant surgical team.

Maintain joint range of motion after a spinal cord injury and consider early use of splints and orthoses.

Seek specialist advice about hand splints for people with a higher level cervical spinal injury to maintain tenodesis grasp and release ability where indicated; for example, do not splint into wrist extension if there is C6 involvement.

Consider interventions (for example, progressive sitting, tilt table) to increase mobility and aid early sitting as soon as possible after a spinal cord injury.

Consider additional techniques and specialised equipment (for example, functional electrical stimulation, gait orthoses, bodyweight-supported gait training and robotic devices) to promote mobility, upper limb function and independent walking.

Assess people's needs and refer them to specialist services without delay if assistive technology, such as environmental control systems, is needed.

For adults, treat spasticity to prevent losing range of joint movement and avoid contractures.

For adults, consider oral medications to treat spasticity or botulinum toxin type A targeted muscle injections, depending on the clinical circumstances.

In January 2022, botulinum toxin type A was an off-label use for some of the available brands. See individual summaries of product characteristics and NICE's information on prescribing medicines.

Stop oral medications and targeted muscle injections for spasticity if there is no benefit at the maximum tolerated dose. (Explain to the person that special precautions may be needed when stopping certain medicines.)

If spasticity is causing significant impairments in mobility, posture or function, and initial treatments are unsuccessful, refer the person to a multidisciplinary team experienced in the management of spasticity for assessment and treatment planning.

For children and young people, assess spasticity and follow the recommendations in the NICE guideline on spasticity in under 19s.

Be aware that pre-pubertal children have a high risk of early or late onset kyphoscoliosis, so monitor their spinal shape and curvature at regular intervals and refer early for specialist assessment if needed.

Be aware that there is significant risk of low mood and psychological trauma for people with spinal injury, and that this may have an impact on rehabilitation.

Consider psychological support after spinal cord injury, and ensure that the multidisciplinary team has access to a practitioner psychologist with appropriate expertise in physical trauma and rehabilitation, ideally with experience of working with people with spinal cord injury.

For children and young people, the team around the child should actively monitor for any emerging emotional difficulties as the child or young person grows and develops (for example, moving schools, puberty and emotional relationships).

Take into account the long-term psychological impact of change in body image as a result of injury for all people and for children and young people as they grow.

Be aware that nerve injuries may be hidden, particularly if the person:

• has multiple injuries

• has a cognitive impairment or a learning disability

• has a head injury

• is in critical care (adults) or paediatric intensive care (children and young people)

• has a pre-existing neurological condition or injury

• has a complex fracture.

If nerve injury is suspected, assess the peripheral nerves of the affected limb to identify the involved nerve and functional deficit. The surgical team should decide whether early surgical intervention is necessary (see also the section on assessing physical functioning).

Be aware of the risk to tissue viability if there is sensory or motor loss secondary to peripheral nerve injury.

After nerve injury, start rehabilitation therapy to maintain range of movement and regain function. This may include:

• splinting

• exercise (passive and active range of movement)

• play therapy (for children)

• pain management

• sensory interventions (including mirror therapy, electrical stimulation and hand therapy)

• hydrotherapy (where available)

• functional or vocational therapy.

Regularly assess for signs of nerve recovery and review the programme of therapy as needed.

Consider nerve conduction or a specialist opinion to help determine prognosis and guide future therapy and management if early surgical intervention was not needed and:

• there are no signs of nerve recovery 6 weeks after the injury or

• if recovery is not as expected.

For people who have a poor prognosis for recovery after rehabilitation therapy and nerve conduction studies, consider referral to a specialist peripheral nerve injury service, for example, for surgery.

Be aware that people recovering from nerve injury may experience low mood, anxiety and lack of motivation because recovery may be a lengthy and ambiguous process (for example, because of uncertainty about the long-term prognosis).

Consider psychological support after nerve injury, and ensure that the multidisciplinary team has access to a practitioner psychologist with appropriate expertise in physical trauma and rehabilitation, ideally with experience of working with people with nerve injury.