Rehabilitation and intensity

Rehabilitation is provided through a DMRC consultant-led multidisciplinary team. The core clinical team consist of specialist surgeons, rehabilitation and subject matter expert (SME) consultants, physiotherapists, occupational therapists, exercise rehabilitation instructors and social workers. Additional support is provided by pain management teams, mental health practitioners, prosthetic specialists, orthotic specialists (including podiatry), vocational staff, speech and language therapists, dieticians and social workers. This multidisciplinary coordination allows for complex case discussions and coordinated intervention planning. By acting as the team lead, the DMRC consultants can co-ordinate various inputs – a key role to the success of the patient pathway.

For rehabilitation to be effective it should comply to the same rules of drug prescription. This is not static. Rehabilitation is most effective when the right input is prescribed at the right time, at the right frequency and ‘dose’ for the right length of time. This is different for each individual, and therefore intensive rehabilitation will differ between people. The DMRC uses patient goals to define input duration. While it is not open ended, there isn’t a standard time limit. Patients can stay longer than the 6 weeks if healthcare professionals feel it is needed, and this flexibility can increase the likelihood of a successful return to work. Evidence shows that intensive rehabilitation can benefit most people (except for post-viral patients or patients with chronic conditions), and there is no evidence of harm in people after traumatic injury.

Differences between military model and NHS

The DMRC is funded as an occupational healthcare system, with the aim of ensuring individuals return to full fitness and can return to work in a role within the military. If that is not possible, the next goal is to ensure patients are rehabilitated to their maximum potential, minimising the impact on quality of life and future career prospects outside of the military. Therefore, it is resourced with those goals in mind. The applicability to the NHS is decreased when factoring in the amount of trained healthcare professionals and concentrated resources needed to provide a holistic approach. Discharge from NHS rehabilitation services tends to be resource driven and time dependent, rather than outcome-based as at the DMRC.

Another difference is the population being served. DMRC tends to treat a younger population with less comorbidities. Military professionals are used to training in a group environment and generally thrive on a group rehabilitation approach. Military patients are still being paid while receiving rehabilitation and their attendance is seen as part of their job. Additionally, they are actively encouraged by their employer to participate as fully as possible. Finally, it should be considered whether civilian patients will be willing to spend a prolonged period away from home to receive intensive residential rehabilitation.

Keys to success

There are 6 areas that are the ‘keys to success’ in delivering rehabilitation:

1. Coordinated tertiary level care delivery with all relevant specialists;
2. A care model delivery which is matched to the circumstances of the patient population;
3. Timing and nature of rehabilitation and treatment that is matched to tissue pathology;
4. A holistic approach to rehabilitation to maximise success (i.e. not just exercise based or a single disease-specific input);
5. Real world goal identification accompanied by periodic reviews;
6. Coordinating with occupational health elements to maximise return to work rates.

Initial assessment and early interventions for people with complex rehabilitation needs

No evidence was identified for very early, acute physical rehabilitation interventions after traumatic injury (for example, in the immediate days following trauma). Therefore, all recommendations in this section were made by the committee using their experience and expertise.

The committee discussed that physical function assessment and treatment at the early, acute stage after traumatic injury should be undertaken because gaps in care during this time period can lead to complications in later rehabilitation stages.

The committee discussed that the acute treatment stage of traumatic injury includes input from many different healthcare disciplines, in order to ensure that all of a person’s injuries and medical needs are treated. However, they highlighted that it was important to minimise rehabilitation delays as much as possible. This was supported by evidence from the inpatient coordination review (D.1) that showed the minimising delays led to better rehabilitation outcomes. Rehabilitation should be a high priority and begin as soon as patients are assessed as being ready and able to engage with decisions about their rehabilitation care because in the experience of the committee, this is associated with better outcomes than starting rehabilitation later because it prevents further deconditioning and loss of function. For people who lack capacity to engage in rehabilitation decision-making, the committee signposted the NICE guideline on decision making and mental capacity which can be used as a guide to ensure that people are supported to make decisions for themselves when they have the mental capacity to do so or, where they lack the mental capacity to make specific decisions, they remain at the centre of the decision-making process.

Assessment of physical functioning and injuries should be carried out as soon as possible after traumatic injury, to determine what therapies would be best suited to a person’s rehabilitation. This will ensure that physical functioning is maintained as much as possible because muscle mass and physical fitness can quickly decline after traumatic injury, and it will also prevent complications further along the rehabilitation pathway, by for example, using chest physiotherapy to treat weak respiratory muscles. To facilitate engagement in rehabilitation, it is also important to determine if people need to be provided with equipment to encourage movement (for example, crutches or wheelchairs) or protect the injury during rehabilitation (for example, splints or orthoses).

The committee discussed assessment for nutritional support after traumatic injury. Nutrition after traumatic injury is an important area for several reasons. In general, people will require an increased caloric intake to promote wound healing and for people to participate fully in rehabilitation exercises. However, many people find themselves unwilling to eat due to parallel clinical reasons (for example, loss of appetite, constipation, past history of anorexia). Conversely, obesity is a common hindrance for engagement with rehabilitation exercises and weight-loss might be appropriate for overweight individuals. The committee recommended healthcare professionals obtain a full dietary history and a person’s risk of malnutrition (for example, Malnutrition Universal Screening Tool (MUST) for adults or Screening Tool for the Assessment of Malnutrition in Paediatrics (STAMP) score in children and young people under 16 years old), in order to identify possible complications during rehabilitation. They highlighted that it is also important to assess swallowing function during the initial assessment, as this will determine the safest way to deliver nutrition and hydration. Healthcare professionals should continue to monitor a person’s nutritional intake and weight, making changes to nutritional support and rehabilitation plans as necessary. If nutrition and hydration complications persist, a referral to a specialist dietician may be needed for further advice and treatment. Further information can be found in recommendation 1.11.45 and the NICE guideline on nutrition support for adults.

Multidisciplinary team rehabilitation needs assessment

The committee used their experience and expertise to agree that information on a person’s pre-injury activities should be gathered as soon as people are able to engage in the rehabilitation needs assessment. This should include usual activities of daily living (including mobility and other physical activities), hobbies and interests. This is to help the rehabilitation multi-disciplinary team to determine an individual’s pre-injury level of physical fitness and functioning, which will then be used to inform the rehabilitation plan. This recommendation was strengthened using evidence from the accessing rehabilitation services review (D.3).

The committee also discussed the negative impact of traumatic injury on sexual function (for example, decreased libido or pain). In their experience, this is often not adequately addressed by rehabilitation professionals, and the people undergoing rehabilitation may feel embarrassed to raise the matter themselves. If not treated, this can have a large impact on someone’s quality of life. The committee therefore recommended that sexual functioning be included in assessment and review discussions. Specialist advice may need to be sought for certain issues (for example, cognitive-genital dissociation).

Assessing physical functioning

No evidence was identified for assessment of physical functioning. Therefore, all recommendations in this section were made by the committee using their experience and expertise.

When a person’s physical functioning is assessed, it needs to be a comprehensive and multi-disciplinary assessment of both current and pre-injury levels so that healthcare professionals have a complete picture of how the injury has impacted a person’s physical functioning, and thereby also an understanding of possible rehabilitation goals. A comprehensive neuromusculoskeletal assessment (including range of movement and mobility) also need to be performed as part of the physical needs assessment. The committee discussed that specialist assessment might be needed to determine appropriate splints and orthoses. Splints and orthoses can be used to protect injuries during the rehabilitation process. However, the restricted mobility that they cause will also need to be factored into the rehabilitation plan, as certain rehabilitation exercises will no longer be possible. External fixation may also require specialist advice, as the position of external fixators can prevent standard splints fitting properly. Nerve injury and sensory loss should also be referred for specialist assessment due to the complexity of treatment and rehabilitation. The committee discussed that it is important to assess people for any factors or conditions that might affect their ability to participate in rehabilitation, as this will inform which rehabilitation exercises are most appropriate to include in their rehabilitation plan going forward and what adjustments might need to be made (for example, neurovestibular disorders or newly acquired vision or hearing loss). If there is a possibility of a person having neurovestibular disorders, they should be assessed for balance and coordination, as this might require further treatment. If indicated, people should be referred to specialist services. Further guidance can be found in the NICE guideline on hearing loss in adults. It should be noted that children’s physical functioning will still be developing at the time of injury, and therefore previous development attainment should be ascertained (for example, continence skills).

General principles for rehabilitation programmes

The committee discussed an important part of the expert witness testimony relating to the keys to success noted for delivering effective rehabilitation. In their experience, all of the 6 aspects were relevant and they used their expertise and evidence from the rehabilitation support and needs evidence review (D.4) to expand and modify these to suit the rehabilitation patients within the NHS. Using the ‘holistic approach’ bullet point, they agreed that rehabilitation should be as holistic as possible to receive the best result. Combining this with the co-ordinated tertiary level care delivery with all relevant specialists’ aspect, the committee recommended that the best way of achieving this is employing a multidisciplinary approach within a rehabilitation package. Rehabilitation programmes should also have access to a variety of specialist healthcare services. People undergoing rehabilitation may face multiple other complex issues alongside their rehabilitation, which may need referral to specialist services (for example, fertility after trauma). These specialised services will not be needed by all patients and do not need to be included in the core multidisciplinary team, but access should be provided. Another aspect of success that feeds into this is ‘co-ordinated with occupational health elements to maximise return to work success’. The expert witness stressed that rehabilitation programmes should include ‘real-world goal identification’, focused on return to work outcomes and activities of daily life. The committee discussed the importance of rehabilitation goals in the rehabilitation plan and has made several recommendations on the subject (see setting rehabilitation goals to inform a rehabilitation plan). However, they agreed that it should be a consideration when designing a rehabilitation package. The committee discussed ‘timing and nature of input matched to tissue pathology’, expanding it to rehabilitation should be delivered at the right time with the right frequency, intensity and duration for the person. This also allows healthcare professionals flexibility to provide a rehabilitation programme best suited to their patient, rather than a prescriptive recommendation (for example, including a short and intensive rehabilitation component at a key time point rather than weekly sessions over a long period). Finally, although not included in the keys to success, the committee wished to highlight the importance of including educational materials in order to help prepare people for the process of rehabilitation. The expert witness described that, as part of the COVID-19 changes, the Defence Medical Rehabilitation Centre has recently switched to a partially-virtual rehabilitation delivery, with 1 week of their 3 week block now being remote learning using standardised learning materials. The committee discussed the testimony that this has not led to an impact on rehabilitation outcomes, and that this is supported by several qualitative themes in the coordination reviews.

Intensive rehabilitation

Evidence was searched for on the effectiveness of higher intensity rehabilitation programmes on rehabilitation outcomes after traumatic injury. Only 1 study was identified comparing different intensities of rehabilitation packages that was judged to be suitable for exploratory economic analysis. This RCT compared a balancing exercise programme with standard physiotherapy in patients with hip fractures. However, due to the fact that only a single study was identified, the specific needs of the hip fracture population and the older age of the included participants, this evidence was not considered sufficient to make recommendations on rehabilitation intensity. The committee therefore invited a military expert witness to give evidence on the provision of intensive rehabilitation after traumatic injury. They discussed this in combination with the exploratory economic analysis (see below). The committee agreed with the expert testimony that rehabilitation is most effective when the right input is prescribed at the right time, at the right frequency and ‘dose’ for the right length of time. This is different for each individual and will depend on a number of different factors in addition to their actual rehabilitation needs, including their physical, emotional and psychological state. Due to the potential resource impact and the fact that not everyone will benefit from intensive rehabilitation, the committee recommended for healthcare professionals to consider offering people an intensive rehabilitation programme. This should be offered to people where it is likely to have a significant impact on functioning (for example, people who would be more likely to return to work with intensive rehabilitation), at the most appropriate time for an individual. An example of 3 weeks was given to align with the exploratory economic analysis and the evidence provided by the expert witness. However, the committee agreed that this duration should be determined by individual patient goals.

The expert witness described ‘keys to success’ when delivering effective rehabilitation. The committee combined this testimony with their own experience and expertise to recommend several considerations when offering intensive rehabilitation programmes. Education and learning materials will help to prepare people for upcoming periods of intensive rehabilitation. The committee agreed with this, having made several other recommendations throughout the guideline emphasising communication and keeping people informed of their rehabilitation journey. Intensive rehabilitation may benefit from including rest days (for example, at the weekend), in order to allow people to recover and review progress. The committee agreed that rest days were important, but discussed that weekday only provision could force rehabilitation services to change their service provision, increasing waiting lists and delays in rehabilitation. They therefore recommended that weekend rest days be considered, as this tends to fit better with people’s lifestyle. The committee highlighted the importance of communication throughout intensive rehabilitation, ensuring that people undergoing rehabilitation are well-informed of their rehabilitation and other healthcare professionals are kept up-to-date on rehabilitation progress and goals.

The committee discussed that, although they were able to use expert witness testimony and their own experience to recommend considering offering intensive rehabilitation, they were unable to issue definite recommendations due to a lack of quantitative evidence and potential resource implications. Therefore, they made a research recommendation in both the adult population and children and young people populations. By conducting research in this area, it is hoped that a more definitive NICE guidance on intensive rehabilitation can be issued in future updates of this guideline. The committee thought it was important to emphasise that research be carried out in both populations, as there may be differences in the long-term functional and economic outcomes between them.

Guided self-management rehabilitation programme

The expert witness described a recent development in their centre, where residential rehabilitation is now preceded by a 1 week online education programme. This allows people to prepare for periods of intensive rehabilitation, giving them time to identify any further information they might want. Additionally, it also means that the residential portion has been shortened by a week, which means people have to spend less time away from home and it is less costly while the same level of input is still maintained. This has not been in effect long enough for the expert witness to present data but initial experiences have been positive. The committee discussed that this evidence is supported by evidence in the psychological interventions review (B.3), as well as qualitative themes from the coordination reviews (D.1, D.2, D.3 and D.4) such as flexibility, delivering rehabilitation at home and technology. The committee discussed the benefits of including a self-managed component to rehabilitation programmes for increasing flexibility of rehabilitation around daily life, but were concerned that these may be used to replace face-to-face sessions. Additionally, not everyone will be comfortable with a self-managed rehabilitation programme. Therefore, the committee recommended considering using a self-management programme to supplement supervised sessions and regular reviews with rehabilitation healthcare professionals and practitioners. These review appointments with rehabilitation services will allow progress to be monitored by healthcare professionals, for people undergoing rehabilitation to ask any questions that they have (for example, how to correctly perform a certain exercise), and for any changes to be made to the rehabilitation programme if needed. The committee also included a research recommendation to investigate the effectiveness of a self-management intervention for rehabilitation after traumatic injury in order for stronger recommendations to be made in future updates (included in evidence report B.3). The committee discussed the education aspect of a self-managed rehabilitation programme that was mentioned in the expert witness testimony. There were concerns about the unknown resource impact of providing online education, as no economic evidence was identified for this intervention. The committee agreed that this would be resource intensive at the start, in order to develop the materials, but that it should not continue after the initial stage. However, taking ito account this potential resource impact and lack of effectiveness evidence identified, the committee recommended rehabilitation services to consider providing online educational materials alongside the guided self-management rehabilitation, to support implementation. The committee further highlighted that not everyone will have access to the internet (and therefore these education materials), but that this should not affect their ability to access these materials. In these cases, healthcare professionals should explore other methods of providing the same education. The committee used their experience and expertise to recommend a range of topics that people undergoing rehabilitation after traumatic injury commonly ask about where standardised information and educational materials can be useful.

However, the committee highlighted that children, young people and vulnerable adults may need additional support from healthcare professionals to develop (for example, advantages and disadvantages of certain options may need to be explained multiple times to ensure they are understood) and deliver (for example, a larger amount of monitoring appointments included in the delivery plan) an appropriate self-management programme. The additional time needed for these people should be factored in to the rehabilitation plan.

Monitoring progress

No evidence was identified for the most effective methods of monitoring a person’s progress after starting rehabilitation. Therefore, the following recommendation was made by the committee using their experience and expertise.

The committee discussed and agreed that monitoring a person’s progress throughout rehabilitation was very important, and that this should be standardised by using a validated instrument. This allows a clinician to chart progress and highlight possible rehabilitation barriers, using a stable measurement throughout to prevent artificial variation. Therefore, they recommended that patient- and clinician- reported outcomes be used to monitor a person’s rehabilitation progress. They discussed that different outcome measurements are suitable for different populations, injuries and rehabilitation goals and therefore did not recommend specific tools for healthcare professionals to use. Paediatric experts on the committee recommended using a measurement tool containing both child and parent reported sections, as children might not be able to answer all questions and parents may have to supplement some areas. Other measures including relatives and/or carers should be used if more appropriate to children and young people’s circumstances.

Commissioning and organisation

The expert witness detailed their current residential intensive rehabilitation programme, which they have been running for a number of years with good rehabilitation outcomes. The committee discussed the caveats that the expert witness had highlighted regarding offering such an intensive rehabilitation programme to the whole population. Specifically, they were concerned about the applicability of offering intensive rehabilitation to the general population as the Defence Medical Rehabilitation Centre tends to treat young, fit and otherwise healthy patients. They also discussed the resource impact of recommending a programme that is so different from current practice in the NHS. However, they were aware that, if targeted correctly, intensive rehabilitation can increase the effectiveness of rehabilitation and lead to better outcomes for some people. They therefore decided to recommend the possibility of commissioning intensive rehabilitation programmes to enhance existing rehabilitation pathways, rather than commissioning them for everyone with rehabilitation needs after traumatic injury. This allows commissioners the flexibility to consider their local population and the appropriateness of offering intensive rehabilitation.

The expert witness discussed the beneficial impact of group rehabilitation sessions on delivering effective rehabilitation at a reduced cost. In their experience, group rehabilitation sessions provide motivation and peer support for participants, increasing engagement in the rehabilitation process. Based on their own knowledge and experience, the committee agreed with both of these opinions. However, they also discussed that this beneficial effect is not seen by everyone. Some patients might compare their progress with their peers and become discouraged if they are not achieving what they feel they should be. The committee discussed the military background of the expert witness, and the fact that people in that vocation are used to group exercises, which other people might not be. The committee recommended that this style of rehabilitation delivery be considered, but that it might not be suitable for every person undergoing rehabilitation after traumatic injury.

Physical rehabilitation early interventions and principles

The committee discussed the importance of highlighting principles of early physical rehabilitation, which should be considered for all people after traumatic injury. There was no evidence identified, and so the committee used their own experience and expertise to make the recommendations. The committee agreed that individualised rehabilitation exercises should begin as soon as possible after traumatic injury. People can lose function very quickly when not weight-bearing, and early commencement of individualised exercises will help to prevent this, and prepare people for future rehabilitation. Pain is often a very big barrier to starting and continuing rehabilitation. The committee discussed the importance of providing people with adequate pain medication to complete rehabilitation exercises comfortably. They also highlighted that certain groups of people will need to be proactively supported to take analgesia as appropriate (for example, people with cognitive impairment may not understand the instruction or some people could be worried about the addictive properties of certain medications). Pain assessment scales should also be chosen that are appropriate to the individual and their ability to report pain reliably (for example, developmental age or presence of communication difficulties).

Healthcare professionals should use their own expertise and experience to determine the most effective intensity of rehabilitation for a person after traumatic injury (for example, otherwise healthy and physically fit people may benefit from a higher frequency of rehabilitation sessions per week). This should not be static, and may change throughout an individual’s rehabilitation journey.

Maintaining a person’s range of movement is vital for patient able to achieve functional tasks (for example, walking or climbing stairs). Range of movement can quickly decrease after traumatic injury (for example, due to pain or restricted weight-bearing), leading to soft tissue contraction. In turn, this can cause physical impairment which will prolong rehabilitation. Splints and orthoses can be used both to maintain range of movement and to protect an injured area from further damage during rehabilitation and allowing optimal healing. For these reasons, the committee recommended providing splints and orthoses to maintain range of movement after traumatic injury (for example, ankle-foot orthosis in nerve injuries affecting muscles required for ankle dorsiflexion) and protect injuries (for example, knee braces).

The committee discussed that poorly managed low blood pressure can lead to further injury, and possible delays in rehabilitation. Therefore, the committee agreed that healthcare professionals need to monitor people for hypotensive symptoms when starting rehabilitation. Prophylactic treatment can also be used to minimise adverse effects of low blood pressure (for example, thromboembolic stockings, hydration, medication review).

Traumatic injury can greatly affect voice quality, speech intelligibility and swallowing difficulties, either as a direct result of injuries (for example, facial trauma or loss of dentition) or healthcare interventions (for example, intubation). In order to ensure people receive the most effective treatment and rehabilitation (both exercises and communication), the committee recommended that early referral to appropriate healthcare professionals is considered (for example, maxillofacial surgeons for facial trauma or speech or ear, nose and throat services for voice problems caused by intubation).

The committee discussed the importance of individuals retaining as much independence as possible when receiving rehabilitation, especially as inpatients. When people are admitted after traumatic injury, most of their everyday tasks are being done for them by healthcare staff. However, many may be able to still complete some activities of daily living if they are given the opportunity. Occupational therapists would be able to help with promoting independence while an inpatient, so the committee recommended referral if appropriate.

Early weight-bearing

The review found 4 studies investigating early weight-bearing in rehabilitation after traumatic injury. One study examined early weight-bearing with ambulation in unstable ankle fractures, and the other 3 examined early weight-bearing after hip fracture. The committee discussed the evidence, noting the mixture of outcome measures reporting a clinically important difference favouring early weight-bearing with the outcome measures reporting no clinically important difference. They noted that the quality of evidence was all low or very low, and was only presented for 2 trauma populations (people with unstable ankle fractures and people with hip fractures). Additionally, 1 of the interventions (comprehensive geriatric care) was a multi-component programme which only included early weight-bearing as a component. Because of this, the committee were not convinced that the results were generalizable to the whole trauma population and mostly did not use the evidence to make recommendations. They decided to make general recommendations substantially informed by their experience and expertise, but guided by the evidence if available. This has been discussed where appropriate. They highlighted that differences between people and injuries make it difficult to issue blanket recommendations.

Low to very low quality evidence of at least 1 clinically important difference in mobility measurements between early weight-bearing versus delayed weight-bearing groups was reported by 3 out of 4 studies. In the committee’s experience and in line with current practice, weight-bearing should be encouraged as soon as possible for patients, in order to encourage mobility and maintain postural reflexes, muscle mass, strength and function. The committee also agreed that a targeted weight-bearing exercise programme should be started for people with lower limb injuries, in order to not only improve function, but also with the aim to progress the person’s ability to perform weight-bearing tasks such as mobility, ability to move from sitting to standing, and ability to lateral step. The committee agreed that all of these functions are necessary for people to be discharged home and for independence in their daily lives once back into the community.

The committee discussed the importance of communication between surgical and rehabilitation teams regarding weight-bearing status after surgery. Patients returning from surgery often have a non-weight-bearing order in place, but the rationale behind this is less often communicated (for example, non-weight-bearing for a limited period of time to aid immediate healing). This results in patients being left on bed rest for longer than they may need, preventing weight-bearing from commencing, which in turn may lead to less optimal outcomes.

Paediatric experts on the committee recommended that play therapy should be included as an important component of any weight-bearing interventions for children and young people. This can either be as part of a formal rehabilitation programme or incorporated into usual play activities if appropriate. The committee discussed the importance of allowing children and young people to retain aspects of normal life where possible.

Aerobic and strengthening exercises

Due to the similarities in the interventions identified for ‘Exercise class, reconditioning, cardiovascular or fitness training’ and ‘Strengthening, balance, proprioception, vestibular rehabilitation or training’, the committee discussed evidence from both these sections and developed recommendations together.

The review found 4 studies investigating aerobic exercise interventions in rehabilitation after traumatic injury, all in the adult population. One study examined aerobic exercise in spinal cord injury, and the other 3 examined aerobic exercise programmes after hip fracture. The committee were concerned about the low to very low quality of evidence, the mixture of results with some outcomes found to clinically importantly favour aerobic exercises while for other outcomes no differences were observed between the intervention groups, and the fact that only 2 trauma populations are covered (hip fracture and spinal cord injury).

The review found 19 studies investigating strengthening exercises. 17 of these were found in the adult population: 9 studies examined strengthening exercises after hip fracture; 1 study examined strengthening exercises after general trauma; 3 studies examined strengthening exercises after SCI; 1 study examined strengthening exercises after injurious falls; 2 studies examined strengthening exercises after amputation; and 1 study examined strengthening exercises after traumatic hand injury. The remaining 2 studies investigated strengthening exercises after burn injury in children and young people. Although there was a wide range of traumatic injuries covered, the committee raised concerns about the quality of the evidence as the majority was very low or low quality. The committee discussed the heterogeneity of the interventions presented, which made identifying effective components difficult. Additionally, the results showed a mixture of results, with some outcomes clinically importantly favouring strengthening programmes while other outcomes did not differ between the groups.

Because of the above considerations, the committee were not convinced that the results were generalizable to the whole trauma population and mostly did not use the evidence to make recommendations. They decided to make general recommendations substantially informed by their experience and expertise, but guided by the evidence if available. This has been discussed where appropriate. They highlighted that differences between people and injuries make it difficult to issue blanket recommendations.

The committee recommended starting a tailored exercise programme as soon as possible after traumatic injury, to prevent deconditioning, enable the person to meet the physical demands of their subsequent rehabilitation and their desired mobility needs for work, education and leisure. The exercise programme will also improve respiratory function, and that way help prevent atelectasis which is a common complication of trauma and surgery. This programme should be started irrespective of age (for example, older people should not have aerobic exercise withheld due to perceived lack of physical fitness), rehabilitation stage or combination of injuries, although the committee acknowledged that each of these considerations will require modifications to an exercise programme (for example, people whose lower limb mobility has been affected after trauma can be offered upper body or seated exercises). The committee used their expertise and experience to suggest components of this exercise programme, including general aerobic fitness, strengthening exercises and balancing exercises. These exercises should be tailored to a person’s rehabilitation and goals (and incorporated into usual play activities for children) in order to increase engagement and adherence to the programme and increase rehabilitation outcomes.

In order to ensure that aerobic and physical fitness is maintained throughout the rehabilitation pathway, a continued element of aerobic exercise should be considered when agreeing a rehabilitation plan because building and maintaining this fitness will help the person fully engage in other aspects of their rehabilitation and facilitate their return to pre-injury activities of daily living and function. However, as every traumatic injury and person in different, the committee did not specify any further. This should also be offered once a person has been discharged home. Participation and progress should be reviewed regularly in order to ensure that exercises are still appropriate to a person’s circumstances and benefiting rehabilitation outcomes.

Gait training and re-education

The review found 5 studies (reported in 6 papers) investigating gait training and re-education in rehabilitation after traumatic injury. One study examined gait training and re-education after hip fracture, and the remaining 4 examined gait training and re-education after SCI. The committee discussed the evidence presented, noting the mixture of outcome measures reporting a clinically important difference favouring gait training or re-education with the outcome measures reporting no clinically important difference in 3 of the studies. This evidence was judged to be low to very low quality. One study investigated body-weight supported treadmill training versus over ground gait training and found clinically important differences favouring body-weight supported treadmill training in 7 measures of mobility after a 12-week intervention. However, this is not current practice and requires settings to have certain equipment which could have a resource impact. Due to the fact that these results were only supported by 1 small study in the spinal cord injury population, the committee did not think these results would be generalizable to the whole traumatic injury population and did not make recommendations based on this evidence.

Due to the low quality of evidence, the committee did not use the evidence to make recommendations. They decided to make general recommendations informed by their experience and expertise. They highlighted that differences between people and injuries make it difficult to issue blanket recommendations.

The committee highlighted the need to start physiotherapy as soon as possible after traumatic injury, even for people who are unable to weight-bear. Prolonged periods of immobility can rapidly decrease a person’s physical fitness and muscle tone. An exercise programme for people who are unable to weight-bear will minimise these affects, as well as prepare them for gait training when possible. Once weight-bearing can begin, a gait re-education programme should be started in order to restore gait patterns and reduce the impacts of non-weight-bearing on physical functioning. Passive stretched and range of movement exercises should be included in this to maintain joint mobility.

Manual therapies and maintaining joint range of movement

The review identified 6 studies investigating manual therapies in rehabilitation after traumatic injury. One study examined massage after burn injury and 2 examined manual therapy after fracture (early muscle energy technique after elbow fracture and active controlled motion after unstable ankle fracture. The remaining 3 RCTs examined manual therapy interventions after SCI (1 investigated passive ankle movement, 1 investigated ankle stretching and the last investigated hamstring stretching). The committee discussed the evidence, noting the mixture of outcome measures reporting a clinically important difference favouring manual therapy with the outcome measures reporting no clinically important difference or even a clinically important difference favouring no manual therapy. Additionally, the majority of measures were very low to low quality. Because of this, the committee mostly did not use the evidence to make recommendations. They decided to make general recommendations substantially informed by their experience and expertise, but guided by the evidence if available. This has been discussed where appropriate. They highlighted that differences between people and injuries make it difficult to issue blanket recommendations.

The committee agreed on the importance of maintaining joint range of movement after traumatic injury, as prolonged periods of immobility can cause soft tissue contraction around joints, limiting movement. This will impact on a person’s ability to perform both rehabilitation exercises and activities of daily living. To prevent this, the committee recommended using a programme of passive, active assisted or active range of movement exercises. The committee specified a range of exercises to be inclusive, regardless of a person’s level of physical functioning, while still encouraging independence.

Controlled motion devices can also be used in people who are unable to engage in range of movement exercises independently, as they allow smaller graduation of independence. One RCT was identified investigating active controlled motion and physiotherapy versus physiotherapy alone in unstable ankle fracture. This study reported clinically importantly better mobility measures (5 out of 6 measured in the study) in the intervention group at 6 weeks follow-up after intervention completion. Rates of return to work was also clinically importantly better in the intervention group at intervention completion. However, while ankle range of motion was clinically importantly better in the group receiving active controlled motion at intervention completion, this was not sustained at 6 weeks follow-up. The committee noted that, while controlled motion devices are present in most acute wards, they are not in all. Due to the poor quality evidence, the conflicting evidence of sustained benefits, and potential resource implications of rehabilitation settings having to procure these devices, the committee recommended that these devices should be considered but are not mandatory.

The committee discussed the evidence regarding stretching interventions. Two studies investigated the effectiveness of stretching on mobility in the SCI population (1 investigated ankle stretching and the other hamstring stretches). No clinically important differences was found between groups for changes in mobility and evidence was judged to be mainly low quality. However, the committee agreed that there is no evidence of harm or targeted stretching and it represents current practice in most patients. However, this might not be suitable for everyone or all types of injuries and so the committee recommended considering providing targeted stretching to also assist range of movement programmes.

Splinting and orthotics

The review found 5 studies investigating the use of splinting or orthotics in rehabilitation after traumatic injury. Two examined orthoses after thoracolumbar burst fracture without neurological deficit, 2 examined splinting and orthotics after burn injury. The remaining RCT investigated paraplegic gait orthosis and function training after SCI.

The committee discussed the conflicting evidence presented between the 2 studies investigating the use of thoracolumbosacral orthosis (TLSO) after thoracolumbar burst fracture without neurological deficit. One study reported very low quality evidence of no clinically important difference in activities of daily living, quality of life or pain between people receiving TLSO and those receiving ambulation encouragement. However, the other study found high quality evidence of clinically important differences favouring TLSO in patient acceptability, changes in mobility, quality of life and pain. The committee disagreed with the results of this study, noting that the study participants were all young and otherwise healthy individuals. While TLSO can be beneficial to some people, geriatric specialists on the committee mentioned that there can be significant adverse effects in this population, leading to longer hospital stays and poorer rehabilitation outcomes. The committee therefore did not use this evidence to make recommendations, and highlighted that healthcare professionals should be aware of potential complications for certain populations. Due to the evidence contradicting the committee’s experience and expertise so dramatically, the committee decided to make a research recommendation and to recommend that if spinal orthoses are used and adverse effects develop that affect rehabilitation performance, the surgical team should be consulted to see if any other treatment options are possible.

Two of the remaining studies reported very low to low quality evidence on upper limb function, patient acceptability, changes in activities of daily living, quality of life and pain in people receiving metacarpophalangeal orthosis and shoulder splints in the burn injury population,. With the exception of 2 measures of upper limb functioning, none of the outcomes showed any clinically important differences between groups. As burn injury treatment can be difficult to extrapolate evidence to other traumatic injury populations, the committee were not convinced that the results were generalizable to the whole trauma population and did not use the evidence to make recommendations.

The committee discussed the many benefits of using splints and orthoses to maintain range of movement around joints and to protect injured areas from further damage during rehabilitation. This was supported by evidence from the remaining RCT, which investigated paraplegic gait orthoses plus functional training in people with SCI. This study reported clinically important increased changes in ADL at 3 months follow-up, which was judged to be moderate quality evidence. The committee recommended providing splints and orthoses to maintain range of movement after traumatic injury (for example, ankle-foot orthosis in nerve injuries affecting muscles required for ankle dorsiflexion) and protect injuries (for example, knee braces). However, they are also associated with complications such as pressure sores and nerve injury. The committee recommended that splint usage should be gradually commenced and reviewed at least once a day (for example, during donning and doffing) to ensure that complications are not developing and that usage is still appropriate. The risk of splinting or orthoses causing skin damage is increased in people with reduced cutaneous sensation (because people cannot feel symptoms of skin damage) or in people who have recently had skin grafts or flaps (as these areas of skin are very fragile). Therefore, the committee recommended that skin condition is well monitored in these individuals and advice is sought from tissue viability service or plastic surgery specialists (depending on healthcare setting) if indicated. Due to the possible complications that accompany orthoses and splints, the committee also recommended that people receive education in how to wear them, when to wear them, and side effects that will require assistance from healthcare professionals. This information should also be given to families and carers if appropriate.

The committee agreed that specific examples of splints should be considered for certain injuries. Early loss of ankle range of movement is common in lower limb fractures and/or nerve injuries, due to muscle shortening if not managed with an exercise programme and appropriate orthosis (for example, dorsi-wedge in a moon boot or ankle-foot orthosis). This can lead to pain, physical impairment and prolonged rehabilitation. However, this might not be appropriate for everyone so the committee highlighted that this intervention should be considered but is not mandatory. People with external fixators for lower limb fractures are also at risk of rapid muscle shortening. However, due to the position of the external fixator, standard splints often do not fit and people may require specialised splinting instead. People with upper limb injuries often need hand and finger splinting to maintain range of movement. However, due to the differences in hand shape and size between individuals, bespoke splints will need to be made for these to be effective. Hand injuries can be complex and may require a referral to hand therapy specialists.

Splints should be positioned with consideration given the impact on future functioning of joints and may need specialist input. An example that the committee highlighted was people with higher level cervical spinal injury, where wrist extension splinting may not be advisable. These people will find their fingers naturally curling up with time. In other types of spinal cord injury, splinting would be used to correct this but this would be at the expense of shortened tendons. People with mid-spinal incomplete SCI use these shortened tendons to their advantage later on in rehabilitation, to develop a tenodesis grasp (opening and closing hands by using wrist movements). This expands the amount of activities of daily living they can perform (for example, holding objects or operating self-propelled wheelchairs). If their hands were splinted early in recovery, this adaptation would be lost.

Management of swelling and oedema, and scars

The review identified 4 studies investigating the management of swelling and oedema or scar management after traumatic injury. One RCT investigated the use of compression for swelling after ankle fracture, and 2 RCTs examining laser therapy for scar management after burn injuries. The remaining RCT was a 4-arm trial investigating combinations of presure garment therapy, silicon gel sheeting and massage after burn injury

The committee discussed the evidence presented for swelling and oedema management after ankle fracture. No clinically important differences in patient acceptability, changes in mobility or pain were reported for either constant compression bandage or intermittent compression versus ice and elevation. The committee noted that the evidence was very low quality, only identified in 1 specific trauma population, and that the results disagreed with their own clinical experience and expertise. Because of this, the committee were not convinced that the results were generalizable to the whole trauma population and did not use the evidence to make recommendations. They decided to make general recommendations informed by their experience and expertise.

The committee discussed that swelling after any type of injury is very common. People should expect a certain level of swelling and oedema and they should be reassured that this is a normal response. However, the committee agreed that people should be educated in how to monitor their swelling, what symptoms to note and when to seek medical advice. This will allow for early detection of possible medical complications which, if left untreated, can affect rehabilitation progress. After trauma and surgery, patients are often sedentary for long period of time, which leads to a high risk of developing deep vein thrombosis (a lifethreatening condition). The committee agreed that unexpected swelling should be investigated, and alternative causes be ruled out.

The committee recommended starting a programme of circulation exercises and elevation to both prevent and reduce swelling and oedema after traumatic injury. There is equipment available to do this even if people are in a sitting or lying position (for example, elevating leg rests for wheelchairs). Additionally, the committee recommended for healthcare professionals to consider using compression bandaging to prevent and reduce swelling and oedema. However, effective limb wrapping using compression bandages requires a certain level of training and should be done under specialist supervision (for example, hand therapy). If appropriate, a specialist may train a family member or carer to provide bandaging after people are discharged, with the specialist providing oversight and an ongoing review of the bandaging technique.

The committee discussed the evidence presented for scar management interventions for rehabilitation after traumatic injury. One study investigated the use of laser therapy versus a placebo laser treatment, reporting a clinically important better quality of life (moderate to low quality evidence) and decreased pain (low quality evidence) in adults receiving active laser treatment compared to the placebo treatment. The other study investigating the use of laser therapy versus placebo laser treatment did not find a clinically important difference in pain measurements between groups (very low quality evidence). The committee discussed this conflicting evidence of effectiveness, noting that laser treatment is not current practice for scar management and that it would expensive for healthcare services to implement any recommendations in this area. The other study was a 4-arm trial, investigating combinations of pressure garment therapy, silicone gel sheeting and massage therapy versus massage therapy only in adults with burn injuries. The committee discussed that no clinically important differences in the only reported outcome (pain) were found between groups for the majority of time points, and that all the evidence was of very low quality evidence. The study also only investigated the interventions in 1 trauma population and, as noted, reported only 1 outcome of interest which was not a critical outcome.

The committee discussed that burn injury has a very different rehabilitation pathway compared to other traumatic injuries, and therefore they were not convinced that the results were generalizable to the whole trauma population. Because of this, the conflicting effectiveness evidence and potential resource impact, the committee did not use the evidence to make recommendations and made general recommendations informed by their experience and expertise.

The committee discussed the psychological impact of scarring on people after traumatic injury, which can lead to a poorer body image. The committee recommended desensitising people to their scarring in order to increase their acceptance of the injury and increase engagement in treatment (for example, being able to perform massage therapy on oneself). However, the committee highlighted that for some people this may not be enough and agreed that people should be referred to psychological services for additional treatment or support groups for peer support if scarring has a significant psychological impact on them.

Paediatric experts on the committee raised the issue of performing painful scar management techniques away from hospital beds, in order to keep this as a safe space. This is important for children and young people, as it allows them a secure area to rest and socialise, which is not associated with unpleasant sensations or memories.

The committee noted that unpleasant sensations (for example, pain and itchiness) in the area of wounds or skin injuries are normal after a traumatic injury, but recognised that people do not necessarily know is. They therefore recommended reassuring people that unpleasant sensations are normal for scars and skin injuries, and that they are not necessarily indicative of additional clinical problems. These may change throughout the recovery period (for example, increase in itchiness as wounds heal). General scar management information should be given to people (for example, keeping the wound out of direct sunlight for at least 1 year). This will prevent deterioration in skin integrity, maintain tissue mobility and increase wound healing. The committee also recommended that, once healthcare professionals have deemed that a scar has appropriately healed, a massage programme is started. This will help to desensitise the area further and maintain range of movement in the affected limb. Maintaining range of movement is important both for activities of daily living and performing rehabilitation exercises. Due to the complexity of scar management and treatment, general rehabilitation services often do not have the expertise or equipment to manage and treat people with problematic scars (for example, hypertrophic scars or contracture across the joint). In these cases, healthcare professionals should consider referral for further specialist advice and treatment.

Nutritional supplementation

There were 5 studies investigating the use of nutritional supplementation in rehabilitation after traumatic injury. Four investigated additional nutrition after hip fracture, with the remaining study investigating nutritional supplements after spinal cord injury. The majority of evidence was low to very low quality, and outcome measures reported were not clinically important. The committee discussed that, while 2 of the studies did report clinically important changes in mobility, evidence was of very low quality and the studies also reported conflicting mobility measures with some showing no clinically important differences. Because of this, the committee were not convinced that the results were generalizable to the whole trauma population and did not use the evidence to make recommendations. They decided to make general recommendations informed by their experience and expertise.

The committee discussed the importance of maintaining adequate nutrition after traumatic injury. The inflammatory response after trauma causes the body to become catabolic, a process whereby muscle is broken down to provide energy for healing. This results in people losing significant muscle mass, weight and strength for a long period after trauma. This will affect the ability of a person to perform and engage in rehabilitation exercises. Due to the complexity of nutritional needs and weight management after traumatic injury, the committee recommended that a dietician specialising in trauma care should assess people after traumatic injury and be involved in maintaining a person’s nutritional supply (for example, via nasogastric tube or total parenteral nutrition). Food and drink intake should continue to be monitored, in order for people to maintain their weight despite the increased caloric needs of healing. The committee highlighted several conditions that might affect weight maintenance, and for these people, the results of nutrition and weight monitoring should be checked against the dietary plan, with amendments made as necessary. Specifically, people with multiple injury, gastrointestinal health issues, severe kidney impairment or fragility fracture may have different nutritional needs, which should be overseen by the specialist dietician. Further advice can be found in the NICE guidelines on nutritional support for adults and vitamin D supplementation for specific populations.

The committee discussed protecting people from unsafe swallowing and aspiration after traumatic injury, which can lead to choking or pneumonia. Therefore, the committee recommended an appropriately trained healthcare professional carrying out a swallowing assessment. Some committee members reported that, in their settings, this would be a speech and language therapist, which is not a 7 day-per-week service. In order to prevent patients being left nil by mouth for prolonged periods of time (for example, over weekends), the committee recommended that this happens as soon as possible to minimise dehydration and discomfort. This committee also stressed that, in settings where this assessment is not available immediately, hydration and nutrition can and should be maintained by non-oral means.

Throughout this review, the committee identified several areas that either did not identify any evidence or only identified very low or low quality evidence. They discussed that these areas might benefit from research recommendations. However, they are aware that only a certain number of research recommendations can be selected. Therefore, they chose the area where they feel additional research would have the most impact, allowing stronger recommendations to be made in future guidelines. They prioritised rehabilitation intensity, and made 2 research recommendations (1 in the adult population and 1 in the children and young people). Any other potential research recommendations, while still important gaps in evidence to rectify, were not prioritised.