Rehabilitation

As noted in the introductory sections of these guidelines, there is a vast amount of preventable injury-related disability, especially due to fractures and burns of the extremities. Efforts to prevent such disabilities are needed in acute care, as covered in the preceding sections 5.8 (Management of extremity injury) and 5.10 (Management of burns and wounds). Efforts are also needed in the rehabilitation of people with injuries after the acute treatment phase is over, to maximize recovery of independent function. Rehabilitative services have been considered briefly in some of the preceding sections. The current section covers these more comprehensively for all types of injuries.

The following recommendations concentrate on injuries to the extremities, the anatomic pattern of injury-related disability that is most common and most likely to be improved through low-cost modifications to rehabilitation services. Hence, basic physiotherapy/occupational therapy for those recovering from extremity injuries (especially fractures and burns) is deemed essential at all hospital levels. This includes such activities as the proper use of splints to prevent burn wound contractures, and range-of-motion and strengthening exercises for recovery from all types of extremity injuries. In the light of the fact that many injured patients receive follow-up care at basic facilities after hospital discharge, such capabilities are desirable at this level of facilities. Obviously, it would be ideal to have fully trained physiotherapists and occupational therapists providing such care at all levels. However, given limitations of cost, appropriate elements of training in physiotherapy/occupational therapy might reasonably be provided to key personnel. This might involve a specifically designated nurse (or other appropri ate person) who would take on the role of providing physiotherapy at a GP-level hospital.

The fields of physiotherapy and occupational therapy overlap somewhat and vary between countries. For the purposes of these guidelines, physiotherapy refers to those services needed to improve range of motion, strength and mobility. Occupational therapy refers to those services needed to improve range of motion and strength, specifically for the upper extremities, and to assist patients in regaining independent function for tasks such as self-care (e.g. dressing, feeding). The latter includes the provision of adaptive devices and training in their use.

The full spectrum of physiotherapy, including that appropriate for patients with injuries of the head and spinal cord, is deemed desirable at specialist and tertiary care hospitals. The full spectrum of occupational therapy is deemed desirable at specialist and tertiary care hospitals. As indicated above, the provision of fully trained professionals in each field is ideal. However, given limitations of cost, appropriate elements of training in these fields might reasonably be provided to key personnel at each facility as a way of maximizing the availability of such rehabilitation services. The key elements of such care that might be promoted in the face of a lack of fully trained personnel still remain to be defined.

Prosthetic services are deemed essential at the tertiary-care-level and desirable at the specialist-level hospital. These services include the provision of the prostheses themselves, as well as personnel with suitable expertise to fit patients with the prostheses properly and to handle problems that may arise in their use.

Given the mental distress of severe injury and the resulting high incidence of post-injury psychological problems, psychological counselling in some form is deemed essential at all hospital levels. This includes capabilities for both screening of injured persons for incipient psychological problems and appropriate treatment. It also includes assisting patients in psychological adjustment to their disabilities. The provision of fully trained mental health workers and psychologists would be ideal. However, given the shortages of such trained personnel, appropriate elements of training in psychological counselling might reasonably be provided to a number of key personnel, such as nursing and medical staff (or other persons with suitable qualifications).

Two additional specialized rehabilitative services include neuropsychology for the diagnosis and treatment of cognitive dysfunction, and speech pathology for the diagnosis and treatment of disorders of communication and swallowing. Both are especially useful in the recovery of head-injured patients. These are both deemed desirable at specialist and tertiary care levels. Fully trained professionals for each field would be ideal. However, given the shortages of such personnel, appropriate elements of training in speech therapy and therapy for cognitive dysfunction might reasonably be provided to a number of key personnel, such as medical and nursing staff (or other suitable persons).

The functional recovery of severely injured or ill patients often involves complicated rehabilitation issues, coordination of the input of multiple professionals, and treatment of ongoing medical problems. The field of physical medicine and rehabilitation has arisen in response to this need. Fully trained specialists in this field would be desirable at hospitals that care for severely injured patients and hence discharge severely disabled survivors. This would primarily involve specialist and tertiary care facilities. The low level of availability of physical medicine and rehabilitation specialists worldwide prevents this recommendation from being deemed essential. Similar considerations apply to specialized rehabilitation nurses. These personnel have specialized training in the management of severely disabled persons, including neurogenic bladder management, bowel programmes, prevention of pressure ulcers and monitoring for nosocomial infections. Such expertise is deemed desirable at specialist and tertiary care facilities. Low availability of such expertise prevents this recommendation from being considered essential.

A useful adjunct to the work of physical medicine and rehabilitation specialists is electromyography (EMG), which is of benefit in the evaluation and treatment of peripheral nerve injuries. This is deemed desirable at specialist and tertiary facilities.

Finally, many injured persons will never regain the functional status they enjoyed before they were injured. Enabling them to function optimally in society is one of the goals of rehabilitation. The Disability and Rehabilitation (DAR) department of the WHO has been addressing the needs of such individuals through its work in community-based rehabilitation (45). This has involved collaboration between different sectors, including ministries of health, ministries of

TABLE II Rehabilitation

Facility level

Rehabilitation

Basic

GP

Specialist

Tertiary

PT/OT1 for recovery of extremity injuries

D

E

E

E

Full spectrum of physiotherapy

I

I

D

D

Full spectrum of occupational therapy

I

I

D

D

Prosthetics

I

I

D

E

Psychological counselling

D

E

E

E

Neuropsychology for cognitive dysfunction

I

I

D

D

Speech pathology

I

I

D

D

Physical medicine and rehabilitation specialist-level care

I

I

D

D

Electromyography

I

I

D

D

Specialized rehabilitative nursing

I

I

D

D

Discharge planning

I

E

E

E

1 PT/OT: physiotherapy/occupational therapy

1 PT/OT: physiotherapy/occupational therapy education, and ministries concerned with social services, as well as nongovernmental organizations and local government. The Guidelines for essential trauma care recognize the importance of such efforts. As the guidelines focus on facility-based trauma care, further details of the elements of community-based rehabilitation will not be addressed here. However, a knowledge of existing community services and the capability to assist disabled patients in accessing and utilizing such services after discharge (e.g. discharge planning) are considered essential at all hospital levels.

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