Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Initial assessment and early interventions for people with complex rehabilitation needs

1.1.1

Be aware that the severity of a person's traumatic injury does not necessarily correlate with the complexity of their rehabilitation needs, so assess the impact of the injury using a person-centred, individualised and holistic approach at all stages of their care pathway.

1.1.2

After a traumatic injury, assess the person's rehabilitation needs as an integral part of their care pathway from admission. This may include:

  • discussing findings from early rehabilitation assessments with the person, and their family members or carers (as appropriate)

  • helping the person, and their family members or carers (as appropriate), to think about preferred rehabilitation goals to inform shared decision making about medical or surgical options

  • involving rehabilitation specialists (ideally including a consultant in rehabilitation) alongside acute care teams to discuss the implications for rehabilitation depending on different medical and surgical options.

1.1.3

All practitioners involved in the person's care should provide immediate psychological and emotional support for people who are mentally distressed and/or cognitively impaired after a traumatic injury. Request additional support and/or advice from psychology services as needed.

1.1.4

After a traumatic injury:

  • Avoid delays in acute treatment so that rehabilitation can start as soon as possible, for example, to maintain movement.

  • Start rehabilitation when the person is ready and able to engage and participate (see also recommendation 1.2.5). For people who lack capacity to engage in making decisions about their rehabilitation, follow the NICE guideline on decision making and mental capacity.

1.1.5

Provide access to rehabilitation therapies:

  • before surgery, to maintain respiratory function and functional abilities (if surgery is delayed) and

  • as soon as possible after surgery (starting ideally no later than the following day).

1.1.6

As soon as possible after the traumatic injury, assess how the person's physical impairments might affect their ability to engage in activities of daily living. Involve occupational therapy for:

  • input and advice on therapies and referral for aids and

  • equipment and adaptations.

1.1.7

As soon as possible after a traumatic injury, start to assess whether the person has new or existing cognitive, hearing, visual or communication impairments or emotional difficulties that might affect their ability to engage in rehabilitation and in activities of daily living. Involve occupational therapy, psychology and speech and language therapy as appropriate.

1.1.8

Use equipment as appropriate to encourage movement (for example, walking aids and transfer devices) and to protect the injury (for example, splints or orthotics).

1.1.9

Ask about the person's diet and nutrition, including their weight, eating habits and any use of health supplements such as vitamins and minerals or high-calorie drinks.

1.1.12

Monitor the person's nutritional intake and weight throughout their hospital stay, provide nutrition support in line with the NICE guideline on nutrition support for adults, and refer for a specialist dietitian review if needed.

1.2 Multidisciplinary team rehabilitation needs assessment

1.2.2

In addition to the holistic rehabilitation needs assessment in recommendation 1.2.1, the multidisciplinary team should complete specialist assessments for the following injuries:

1.2.3

Always think about the mechanism of injury and whether the person may have had a head injury. Be aware that the symptoms of traumatic brain injury can be subtle and regular screening may be necessary. If there are clinical symptoms, refer the person for a specialist assessment with healthcare professionals with expertise in traumatic brain injury rehabilitation. See also the NICE guideline on head injury.

1.2.4

The multidisciplinary team involved in assessing people's rehabilitation needs in hospital should consist of healthcare professionals and practitioners with expertise in rehabilitation after traumatic injury. Depending on the nature of the injury, the setting for assessment and treatment, the age of the person and other pre-existing health or care issues, the multidisciplinary team could involve:

  • surgeons, rehabilitation medicine specialists, intensive care specialists, elderly care specialists and/or paediatricians (as appropriate)

  • allied health professionals such as occupational therapists, physiotherapists, dietitians, orthotists and speech and language therapists

  • practitioner psychologists

  • specialist nurses

  • play therapists

  • pharmacists

  • a trauma coordinator and/or rehabilitation coordinator

  • when planning discharge:

    • a social worker

    • a discharge coordinator.

1.2.5

The multidisciplinary team should assess the person's rehabilitation needs as soon as possible after the traumatic injury, when measures are being taken to optimise their ability to engage in the assessment process. These measures include:

  • pain management

  • resolution of infections

  • resolution of acute confusion or delirium

  • consideration of psychological wellbeing

  • making available hearing aids, glasses, dentures and other orthodontic appliances

  • access to communication aids (if needed)

  • access to interpreters (for example, for people who do not speak English)

  • having in place drug or alcohol dependence withdrawal management

  • restarting long-term medications to maintain physical and mental health; see also the NICE guideline on medicines optimisation.

1.2.6

Be aware that traumatic injury may affect sexual function. Discuss this with people at assessment and review, and seek specialist advice about sexual function, fertility issues and psychological support.

1.2.8

As part of the rehabilitation needs assessment, the multidisciplinary team should ask about the person's pre-injury activities, for example:

  • the person's background, personal history, relationships, work, education, meaningful activities, spiritual and religious practices, and hobbies and interests

  • usual activities of daily living, including mobility and other physical activity

  • motivational factors such as the person's lifestyle, previous ability, future aspirations, priorities and core values.

1.2.9

The multidisciplinary team should allow adequate time to:

  • liaise with the clinical team managing any pre-existing, long-term conditions that may affect rehabilitation

  • complete the rehabilitation needs assessment, which should include a detailed and accurate analysis of the person's injuries, impairments, goals and likely rehabilitation needs and

  • discuss the findings together, to reduce the need to repeat questions and to improve the efficiency of the assessment process.

1.2.10

When discussing rehabilitation needs with people, and their family members or carers (as appropriate):

  • be sensitive about the timing because pain, confusion, fatigue and trauma can make it more difficult for people to absorb and retain information

  • give people sufficient time to process information about their injuries and rehabilitation options, to help them adjust after the traumatic injury and engage more readily in the rehabilitation therapy

  • if people ask for information about the likely long-term prognosis, recognise that this may be difficult to predict and should only be discussed with the person after multidisciplinary team review.

1.2.11

Use validated tools (for example, the rehabilitation complexity scale [RCS], patient categorisation tool [PCAT], complex needs checklist [CNC] or post-ICU presentation screen [PICUPS]), in the rehabilitation needs assessment to determine the need for early referral to specialist rehabilitation units.

1.2.12

Regularly reassess (using clinical assessment and validated tools) whether referral for specialised rehabilitation is still needed and what other referrals may now be needed.

Assessing physical functioning

1.2.13

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.

1.2.14

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).

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on assessing physical functioning.

Full details of the evidence and the committee's discussion are in evidence review B.1: physical interventions for people with complex rehabilitation needs after traumatic injury.

Assessing cognitive functioning

Please note this guideline does not cover assessment or specific rehabilitation interventions for people with traumatic brain injuries. See recommendation 1.2.3 in the section on multidisciplinary team rehabilitation needs assessment.

1.2.16

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.

1.2.17

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).

1.2.18

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

1.2.19

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.

1.2.20

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.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on assessing cognitive functioning.

Full details of the evidence and the committee's discussion are in evidence review B.2: cognitive interventions for people with complex rehabilitation needs after traumatic injury.

Assessing psychological functioning

1.2.21

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.

1.2.22

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.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on assessing psychological functioning.

Full details of the evidence and the committee's discussion are in evidence review B.3: psychological and psychosocial interventions for people with complex rehabilitation needs after traumatic injury.

1.3 Setting rehabilitation goals

Also see the section on supporting access and participation in education, work and community (adjustment and goal setting).

1.3.1

Agree short-term and long-term rehabilitation goals with the person and their family members or carers (as appropriate), and review them regularly based on:

  • what is most important to the person and what they most value

  • activities that are meaningful for the person and relate to what is important

  • a strengths-based approach, which builds on positive function and ability

  • the person's home circumstances

  • the person's aspirations about returning to work or education, and their preferred timeframe

  • developing the knowledge, skills and confidence to manage their own health and wellbeing

  • an understanding that there may be setbacks as well as gains, so goals should be flexible.

1.3.2

When setting long-term rehabilitation goals, agree small steps so that progress can be monitored in a way that is meaningful and motivational for the person.

1.3.3

Members of the multidisciplinary team involved in setting rehabilitation goals should be skilled and competent in:

  • helping people identify goals that are right for them

  • understanding how the psychological impact of trauma can affect goal setting and rehabilitation planning.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on setting rehabilitation goals.

Full details of the evidence and the committee's discussion are in evidence review D.4 (service coordination): support needs and preferences following discharge to outpatient or community rehabilitation services for people with complex rehabilitation needs after traumatic injury.

1.4 Developing a rehabilitation plan and making referrals

1.4.1

Use the rehabilitation needs assessment (see the section on multidisciplinary team rehabilitation needs assessment) and the person's rehabilitation goals (see the section on setting rehabilitation goals) to develop a rehabilitation plan for the person (this may be in the form of a rehabilitation prescription). The rehabilitation plan should include:

  • information about the person's injuries

  • the person's short-term and long-term rehabilitation goals (see the section on setting rehabilitation goals)

  • information about the person's needs and preferences

  • a suggested rehabilitation programme of therapies and treatments (see the section on rehabilitation programmes of therapies and treatments)

  • how the rehabilitation programme of therapies and treatments will be delivered

  • information and sources of further information about returning to vocational or leisure activities

  • information about associated risks, responsibilities, and possible legal issues about returning to driving and sources of specific advice (for example, the DVLA [Driver and Vehicle Licensing Agency])

  • information about referrals or sources of further information

  • any follow-up arrangements (especially when transferring to home or community settings)

  • who the rehabilitation plan should be shared with (with the person's consent) and details about any information that the person wants to remain confidential

  • details of a rehabilitation coordinator or key worker, and the lead healthcare professional involved in the person's care.

1.4.2

The rehabilitation plan should be:

  • a tailored and personalised journey towards the person's agreed goals, focusing on what is important to them

  • developed with the person, and their family members or carers (as appropriate)

  • based on advice and input from all members of the multidisciplinary team

  • written in clear English

  • a single document or file

  • shared with the person, their families and carers (as appropriate), the person's GP, and healthcare professionals involved in their ongoing care

  • regularly updated in partnership with the person to reflect their progress, goals, ongoing needs and key contact information, particularly at key points of transition in care.

1.4.3

Where it is not possible or appropriate for the person to have access to all of the information in a rehabilitation plan, ensure that important components of the plan are included in a summarised patient-held document that is regularly updated with progress, appointment times and contact details.

1.4.4

If there are aspects of the rehabilitation plan that the multidisciplinary team cannot implement, the rehabilitation coordinator or another senior member of the multidisciplinary team should make appropriate referrals without delay, including referrals to specialised rehabilitation services.

1.4.5

Manage the care of adults with fragility fractures of the femur within a specialist pathway involving orthogeriatricians. Also see the NICE guideline on hip fracture.

1.4.6

If an older person with a traumatic injury is on a care pathway that does not routinely involve geriatrician support, consider referral to an orthogeriatrician, a surgical liaison or a perioperative physician (as appropriate).

1.4.7

For adults with a fragility fracture, assess bone health and refer as necessary, for example, to a specialist bone health clinic or outpatient service. Also see the NICE guideline on osteoporosis.

1.4.10

Provide information about, or refer people to, services that may help prevent future injury, such as falls prevention, safeguarding services, domestic abuse services, violence prevention programmes, and condition-specific support organisations.

1.4.11

For people admitted to hospital with violent injuries related to suspected criminal activity, consider a violence prevention programme and follow-up as part of their rehabilitation plans. This could include psychological support (for example, counselling), substance abuse rehabilitation, employment or education training, group sessions, family development, liaison with the police, social worker involvement, and rehousing, when needed.

1.5 Rehabilitation programmes of therapies and treatments

General principles for rehabilitation programmes

1.5.1

Rehabilitation programmes of therapies and treatments should:

1.5.2

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).

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on general principles for rehabilitation programmes.

Full details of the evidence and the committee's discussion are in evidence review B.1: physical interventions for people with complex rehabilitation needs after traumatic injury.

Intensive rehabilitation programmes

1.5.3

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).

1.5.4

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.

1.5.5

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.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on intensive rehabilitation programmes.

Full details of the evidence and the committee's discussion are in evidence review B.1: physical interventions for people with complex rehabilitation needs after traumatic injury.

Guided self-managed rehabilitation

1.5.6

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.

1.5.7

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.

1.5.8

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.

1.5.9

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.

Monitoring progress against the rehabilitation plan, goals and programme of therapies and treatments

1.5.10

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.

1.5.11

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.

1.6 Principles for sharing information and involving family and carers

1.6.1

Involve people, and their families and carers (as appropriate), in assessments, in planning their coordination of care and in making decisions at all stages of the rehabilitation process. This should include discussing medical or surgical treatment options, discussing findings from assessments, setting goals, discussing potential discharge destinations and examining the different rehabilitation options after discharge.

1.6.2

Encourage and support children and young people to be actively involved in decision making about their rehabilitation to the best of their ability.

1.6.3

Be aware that encouragement from family members, carers, friends and healthcare professionals can all have a positive effect on a person's rehabilitation after a traumatic injury, so involve the person's family members, carers and friends (as appropriate) as much as possible throughout the person's rehabilitation journey.

1.6.4

In discussions and when giving information to people, and their family members or carers (as appropriate), use clear language, and tailor the timing, content and delivery of information to the needs and preferences of the person. Information should be:

1.6.5

Be aware that if a person has severe and complex rehabilitation needs after a traumatic injury, if they have had a brain injury or if they have problems with cognitive functioning after a traumatic injury, information giving may need to be enhanced and reinforced by:

  • repeating information on several occasions

  • providing information in a suitable format (for example, Easy Read)

  • giving information in the presence of family members or carers (as appropriate).

1.6.7

Advise carers about their right to a carer's assessment, an assessment for replacement care, and other support (see the NICE guideline on supporting adult carers for recommendations on identifying, assessing and meeting the caring, physical and mental health needs of families and carers).

1.7 Coordination of rehabilitation care in hospital

From admission to hospital

1.7.1

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

1.7.2

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.

1.7.3

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.

1.7.4

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

1.7.6

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.

When transferring between services and settings

1.7.7

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.

1.7.8

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.

1.7.9

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.

1.7.10

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.

1.8 Coordination of rehabilitation care at discharge

Discharge planning and a multidisciplinary approach

1.8.1

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

1.8.2

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.

1.8.3

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.

1.8.4

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.

1.8.5

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.

1.8.6

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).

1.8.7

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).

1.8.8

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.

1.8.9

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.

1.8.10

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

1.8.11

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.

1.8.12

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.

Planning for rehabilitation and other support following discharge

1.8.13

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.

1.8.14

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.

1.8.15

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.

1.8.16

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.

1.8.18

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.

1.8.19

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

1.8.20

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).

A single point of contact, key contact and key worker after discharge

1.8.21

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).

1.8.22

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.

1.8.23

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.

1.9 Supporting access and participation in education, work and community (adjustment and goal setting)

Also see the section on setting rehabilitation goals.

1.9.1

Help and support the person to adjust after a traumatic injury by asking them and their family members or carers (as appropriate) about:

  • their life, hobbies, occupation, usual activities, and personal and family history, and finding out what is important to them

  • their views and feelings about their injuries and rehabilitation options

  • the support they think they will need by asking about their views and feelings

  • allowing time for adjustment and considering this before starting any new rehabilitation therapies or interventions.

1.9.2

Support the person to achieve realistic rehabilitation goals for life skills, work-related training or education (see the section on setting rehabilitation goals). Support should be tailored to the person's needs and may include:

  • providing equipment and adaptations (for example, wheelchairs and seating)

  • increasing independence in activities of daily living (for example, personal care, dressing and bathing, housework, shopping, food preparation, eating and drinking, managing money, how to access carers' and disability benefits and grants, driving or using public transport)

  • work-related training (for example, careers advice and retraining)

  • advice from job centres (for example, disability employment advisers and access to work scheme)

  • access to adult education settings

  • access to education for children and young people (for example, special educational needs and disabilities [SEND] adjustments in school, or new school placements).

1.9.3

Revisit rehabilitation goals with the person at regular intervals and align them with ongoing emotional and psychological adjustment.

1.9.4

Give people information about opportunities for engaging in daily meaningful activity (for example, hobbies, social activities or voluntary work) while they are in the process of a staged return to work.

1.9.5

Adapt rehabilitation activities to promote social interaction and participation in the person's normal activities of daily living consistent with the person's lifestyle and preferences.

1.9.6

Provide information for the person's employer or education provider about:

  • the person's rehabilitation needs and

  • how they can make adjustments to support the person's rehabilitation goals, for example, a staged or part-time return to work or education, and/or amended duties.

1.9.8

Provide information for early years settings or schools about the child or young person's rehabilitation needs, and the adjustments needed to enable their return to education and sports, for example, a staged return.

1.9.9

Give children and young people, and their families and carers (as appropriate), information about educational support and return to school.

1.9.11

Community practitioners should offer emotional and psychological support to adults and their families and carers to help with lifestyle adjustments and the effects of the traumatic injury (for example, prolonged hospitalisations), and support their gradual return to work, education, social roles and leisure activities.

1.9.12

The team around the child should offer emotional and psychological support to children, young people and their families and carers to help with lifestyle adjustments and the effects of the traumatic injury (for example, prolonged hospitalisations), and support their gradual return to education, play, social and leisure activities.

1.10 Commissioning and organisation of rehabilitation services

Commissioning

1.10.1

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.

1.10.2

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.

1.10.3

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

1.10.4

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.

1.10.5

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.

Organisation

1.10.6

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.

1.10.7

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.

1.10.8

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.

1.10.9

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

1.10.10

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.

1.10.11

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

Rehabilitation skills, knowledge and expertise in the workforce

1.10.12

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.

1.10.13

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

1.10.14

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.

1.11 Physical rehabilitation

Physical rehabilitation – early interventions and principles

1.11.1

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

1.11.2

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

1.11.3

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.

1.11.4

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).

1.11.5

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.

1.11.6

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.

1.11.7

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.

1.11.8

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.

1.11.9

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

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on physical rehabilitation – early interventions and principles.

Full details of the evidence and the committee's discussion are in evidence review B.1: physical interventions for people with complex rehabilitation needs after traumatic injury.

Early weight-bearing

1.11.10

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.

1.11.11

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.

1.11.12

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.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on early weight-bearing.

Full details of the evidence and the committee's discussion are in evidence review B.1: physical interventions for people with complex rehabilitation needs after traumatic injury.

Aerobic and strengthening exercises

1.11.13

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).

1.11.14

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

1.11.15

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

1.11.16

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.

1.11.17

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

1.11.18

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 a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on aerobic and strengthening exercises.

Full details of the evidence and the committee's discussion are in evidence review B.1: physical interventions for people with complex rehabilitation needs after traumatic injury.

Gait training and re-education

1.11.19

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.

1.11.20

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.

1.11.21

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.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on gait training and re-education.

Full details of the evidence and the committee's discussion are in evidence review B.1: physical interventions for people with complex rehabilitation needs after traumatic injury.

Manual therapies and maintaining joint range of movement

1.11.22

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

1.11.23

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

1.11.24

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.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on manual therapies and maintaining joint range of movement.

Full details of the evidence and the committee's discussion are in evidence review B.1: physical interventions for people with complex rehabilitation needs after traumatic injury.

Splinting and orthotics

1.11.25

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.

1.11.26

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.

1.11.27

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.

1.11.28

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

1.11.29

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.

1.11.30

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.

1.11.31

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.

1.11.32

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.

1.11.33

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.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on splinting and orthotics.

Full details of the evidence and the committee's discussion are in evidence review B.1: physical interventions for people with complex rehabilitation needs after traumatic injury.

Management of swelling and oedema, and scars

Swelling and oedema management
1.11.34

Discuss with people what swelling to expect after a traumatic injury. Explain how to monitor swelling on a daily basis, and advise them about signs or symptoms that they should seek medical advice for.

1.11.35

Consider alternative medical causes for unexpected swelling such as deep vein thrombosis, and investigate as necessary.

1.11.36

Start a programme of circulation exercises and elevate the person's affected limb to prevent and reduce swelling after a traumatic injury, for example, by using elevating leg rests for wheelchairs.

1.11.37

Consider providing compression bandaging under specialist supervision, for example, from a specialist in hand therapy.

Scar management
1.11.38

Help the person desensitise themselves to their injury by encouraging them to:

  • look at the affected area

  • gently touch the affected area

  • move their affected limb.

1.11.39

For children and young people, keep their hospital bed as a 'safe' space, and carry out potentially painful scar management techniques such as massage, or other painful treatments, away from their bed if possible.

1.11.40

Reassure people that unpleasant sensations (for example, pain and itchiness) in the area of wounds or skin injuries are normal after a traumatic injury, and may change as recovery progresses.

1.11.41

Discuss and give people information about scar management such as keeping the wound out of direct sunlight for 1 year, and using recommended emollients.

1.11.42

Provide a massage programme for scar tissue after healing, to desensitise the affected area and increase tissue mobility.

1.11.43

Consider referral for specialist treatments for people with problematic scars such as hypertrophy or contracture across joints.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on management of swelling and oedema, and scars.

Full details of the evidence and the committee's discussion are in evidence review B.1: physical interventions for people with complex rehabilitation needs after traumatic injury.

Nutritional supplementation

1.11.45

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.

1.11.47

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.

1.11.48

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

1.11.50

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.

1.11.51

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.

1.11.52

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).

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on nutritional supplementation.

Full details of the evidence and the committee's discussion are in evidence review B.1: physical interventions for people with complex rehabilitation needs after traumatic injury.

1.12 Cognitive rehabilitation

Please note this guideline does not cover assessment or specific rehabilitation interventions for people with traumatic brain injuries. See recommendation 1.2.3 in the section on multidisciplinary team rehabilitation needs assessment.

1.12.1

Reassure people that most trauma-related problems with cognitive functioning are temporary.

1.12.2

Adapt rehabilitation therapy to the person's current cognitive function and emotional needs, taking into account any problems with motor development and skills, and any coexisting neurodevelopmental conditions.

1.12.3

If problems with cognitive functioning persist, get worse or recur, carry out further assessments to understand the cause.

1.12.4

If a person has problems with cognitive functioning after a traumatic injury, provide information:

  • using clear language

  • with the timing, content and delivery tailored to the person's needs and preferences

  • in a suitable format (for example, Easy Read)

  • with written plans to aid recall

  • that uses pictures, symbols and objects of reference

  • with calendar or diary prompts for sessions or appointments.

1.12.5

Share information with family members or carers (as appropriate) so they can help the person understand the key messages and aid recall.

1.12.6

For children and young people:

  • ask parents and carers if there are any pre-injury cognitive issues, for example, any known special educational needs

  • liaise with their education provider if information about their pre-injury cognitive performance is needed

  • inform education providers and teachers, including those in the hospital setting, about the child or young person's needs and any problems with cognitive functioning.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on cognitive rehabilitation.

Full details of the evidence and the committee's discussion are in evidence review B.2: cognitive interventions for people with complex rehabilitation needs after traumatic injury.

1.13 Psychological rehabilitation

1.13.1

Reassure people that short-term psychological problems in the form of an acute stress response are common after a traumatic injury. Symptoms can last for 4 to 6 weeks and may include:

  • disturbed sleep

  • intrusive thoughts and memories

  • nightmares

  • bedwetting in children

  • flashbacks

  • low mood

  • anxiety.

1.13.2

Be aware that:

  • there is an ongoing risk of low mood in people after a traumatic injury

  • psychological problems and mental distress commonly accompany ongoing emotional and psychological adjustments, for example, as a result of life-changing injuries

  • psychological problems and mental distress can recur or deteriorate when a person is discharged home or transferred to another setting

  • anxiety, depression and post-traumatic stress disorder (PTSD) can occur or recur at any time after a traumatic injury.

1.13.3

Discuss psychological support with the person, and their family members or carers (as appropriate), and offer psychological and emotional support that is tailored to their rehabilitation goals, needs and preferences as part of an overall rehabilitation treatment programme.

1.13.4

If the person's rehabilitation is adversely affected by their psychological problems (for example, if the person is struggling to engage with the rehabilitation process), refer them urgently to psychology services for psychological assessment and treatment, ideally to a practitioner psychologist with appropriate expertise with physical trauma and rehabilitation.

1.13.5

Ask about thoughts of self-harm and suicide regularly, as part of psychological assessment, and particularly at key milestones such as hospital discharge and changes of setting.

1.13.6

The multidisciplinary team should regularly check for signs and symptoms of anxiety, depression and PTSD when reviewing the person's progress against rehabilitation goals and plans.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on psychological rehabilitation.

Full details of the evidence and the committee's discussion are in evidence review B.3: psychological and psychosocial interventions for people with complex rehabilitation needs after traumatic injury.

1.14 Rehabilitation after limb reconstruction, limb loss or amputation

This section covers specific rehabilitation for people after limb reconstruction, limb loss or amputation. The recommendations in this section should be read together with all the recommendations in the rest of the guideline apart from those specific to spinal cord injury, nerve injury or chest injury.

Rehabilitation after limb-threatening injury – early assessment, decision making and support

1.14.1

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.

1.14.2

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.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on rehabilitation after limb-threatening injury – early assessment, decision making and support.

Full details of the evidence and the committee's discussion are in evidence review C.1: specific programmes and packages in amputation for people with complex rehabilitation needs after traumatic injury.

Rehabilitation after limb reconstruction

1.14.5

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.

1.14.6

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.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on rehabilitation after limb reconstruction.

Full details of the evidence and the committee's discussion are in evidence review C.1: specific programmes and packages in amputation for people with complex rehabilitation needs after traumatic injury.

Rehabilitation after limb loss or amputation

1.14.8

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.

1.14.9

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

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on rehabilitation after limb loss or amputation.

Full details of the evidence and the committee's discussion are in evidence review C.1: specific programmes and packages in amputation for people with complex rehabilitation needs after traumatic injury.

Pain management after limb loss or amputation
1.14.10

Plan analgesia with the person before surgery, and ensure that their pain is managed after surgery so that they can effectively participate in rehabilitation therapies.

1.14.11

Manage the different types of pain that can develop, for example, phantom limb pain, neurogenic pain, psychogenic pain, myogenic pain and complex regional pain, and refer the person to a specialist pain team if needed.

1.14.12

Consider visualisation interventions such as graded motor imagery or mirror therapy to manage phantom limb pain in people who have had an amputation or limb loss after trauma.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on pain management after limb loss or amputation.

Full details of the evidence and the committee's discussion are in evidence review C.1: specific programmes and packages in amputation for people with complex rehabilitation needs after traumatic injury.

Residual limb oedema and shaping after limb loss or amputation
1.14.13

Manage residual limb oedema using elevation and compression therapy to reduce swelling and improve shaping in preparation for prosthetics fitting.

1.14.14

For people with a below-knee amputation, keep the limb elevated using a residual limb (stump) board when using a wheelchair.

1.14.15

Avoid residual limb swelling when using walking aids, for example, by using crutches or a frame with the limb in a dependent position.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on residual limb oedema and shaping after limb loss or amputation.

Full details of the evidence and the committee's discussion are in evidence review C.1: specific programmes and packages in amputation for people with complex rehabilitation needs after traumatic injury.

Range of movement and strengthening after limb loss or amputation
1.14.16

Maintain and improve range of movement and strength after limb loss or amputation (particularly in hip flexors, hip abductors and knee flexors) by starting rehabilitation therapy that includes:

  • exercise

  • mobility, including early walking aids (for example, amputee-specific early walking aids) after surgery when the wound has settled

  • positioning.

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on range of movement and strengthening after limb loss or amputation.

Full details of the evidence and the committee's discussion are in evidence review C.1: specific programmes and packages in amputation for people with complex rehabilitation needs after traumatic injury.

Functional independence after limb loss or amputation
1.14.17

Do not wait for prosthetics to be fitted before starting rehabilitation after limb loss or amputation.

1.14.18

Ensure that wheelchairs:

  • are provided as early as possible

  • include appropriate accessories (for example, anti-tippers and residual limb [stump] boards)

  • are adjusted to accommodate the changes in the person's weight distribution after limb loss or amputation.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on functional independence after limb loss or amputation.

Full details of the evidence and the committee's discussion are in evidence review C.1: specific programmes and packages in amputation for people with complex rehabilitation needs after traumatic injury.

Psychological support after limb loss, amputation or limb reconstruction

1.14.19

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.

1.14.20

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

1.14.21

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).

1.14.22

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.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on psychological support after limb loss, amputation or limb reconstruction.

Full details of the evidence and the committee's discussion are in evidence review C.1: specific programmes and packages in amputation for people with complex rehabilitation needs after traumatic injury.

Continuing rehabilitation after limb reconstruction, limb loss or amputation and after discharge

1.14.23

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.

1.14.24

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.

1.14.25

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

1.14.26

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 a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on continuing rehabilitation after limb reconstruction, limb loss or amputation and after discharge.

Full details of the evidence and the committee's discussion are in evidence review C.1: specific programmes and packages in amputation for people with complex rehabilitation needs after traumatic injury.

1.15 Rehabilitation after spinal cord injury

This section covers specific rehabilitation for people after spinal cord injury. The recommendations in this section should be read together with all the recommendations in the rest of the guideline apart from those specific to limb injury, nerve injury or chest injury.

These recommendations focus on the rehabilitation and supportive needs of people with spinal cord injury (after initial acute assessment) who are not currently in a regional specialist spinal cord injury centre. See also the NICE guideline on spinal injury: assessment and initial management.

Rehabilitation after spinal cord injury – referral, assessment and general principles

1.15.2

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.

1.15.3

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.

1.15.5

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.

1.15.6

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

1.15.7

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.

1.15.8

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.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on rehabilitation after spinal cord injury – referral, assessment and general principles.

Full details of the evidence and the committee's discussion are in evidence review C.3: specific programmes and packages in spinal cord injury for people with complex rehabilitation needs after traumatic injury.

Bladder and bowel function

1.15.9

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

1.15.10

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.

1.15.11

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.

1.15.12

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.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on bladder and bowel function.

Full details of the evidence and the committee's discussion are in evidence review C.3: specific programmes and packages in spinal cord injury for people with complex rehabilitation needs after traumatic injury.

Respiratory function, swallowing and speech

1.15.13

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

1.15.14

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.

1.15.15

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.

1.15.16

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

1.15.17

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

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on respiratory function, swallowing and speech.

Full details of the evidence and the committee's discussion are in evidence review C.3: specific programmes and packages in spinal cord injury for people with complex rehabilitation needs after traumatic injury.

Preventing complications

1.15.18

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.

1.15.19

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

1.15.20

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 a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on preventing complications.

Full details of the evidence and the committee's discussion are in evidence review C.3: specific programmes and packages in spinal cord injury for people with complex rehabilitation needs after traumatic injury.

Maintaining mobility and movement

1.15.21

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).

1.15.22

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

1.15.23

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

1.15.24

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.

1.15.25

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

1.15.26

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.

1.15.27

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

1.15.28

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

1.15.29

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.

1.15.30

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.)

1.15.31

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.

1.15.33

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.

Low mood and psychological support

1.15.34

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.

1.15.35

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.

1.15.36

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).

1.15.37

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.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on low mood and psychological support.

Full details of the evidence and the committee's discussion are in evidence review C.2: specific programmes and packages in nerve injury for people with complex rehabilitation needs after traumatic injury.

1.16 Rehabilitation after nerve injury

This section covers specific rehabilitation for people after nerve injury. The recommendations in this section should be read together with all the recommendations in the rest of the guideline apart from those specific to limb injury, spinal cord injury or chest injury.

Rehabilitation after nerve injury – general principles

1.16.1

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.

1.16.2

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).

1.16.3

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

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on rehabilitation after nerve injury – general principles.

Full details of the evidence and the committee's discussion are in evidence review C.2: specific programmes and packages in nerve injury for people with complex rehabilitation needs after traumatic injury.

Therapies and referral

1.16.4

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.

1.16.5

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

1.16.6

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.

1.16.7

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.

1.16.8

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).

1.16.9

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.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on therapies and referral.

Full details of the evidence and the committee's discussion are in evidence review C.2: specific programmes and packages in nerve injury for people with complex rehabilitation needs after traumatic injury.

1.17 Rehabilitation after chest injury

This section covers specific rehabilitation for people after chest injury. The recommendations in this section should be read together with all the recommendations in the rest of the guideline apart from those specific to limb injury, spinal cord injury or nerve injury.

1.17.1

Start rehabilitation after chest injury as soon as possible to optimise respiratory function and prevent deconditioning.

1.17.2

Assess pain regularly and provide adequate analgesia to allow people to be able to breathe deeply, cough, start moving around early and participate in rehabilitation activities.

1.17.3

If oral or intravenous analgesia is inadequate to enable people to breathe deeply, cough or start engaging in rehabilitation, consider early neuraxial (for example, epidural catheter) or regional (for example, paravertebral, erector spinae plane or serratus anterior blocks) analgesia delivered by an appropriately qualified healthcare professional.

1.17.4

Encourage people with chest trauma to start moving around as soon as it is safe to do so, to optimise respiratory function and prevent deconditioning.

1.17.5

Offer a range of rehabilitation therapies to prevent atelectasis and promote deep breathing and secretion clearance. Therapies may include:

  • supported cough to brace chest wall

  • active cycle breathing technique

  • incentive spirometry

  • portable intermittent positive pressure breathing (IPPB) devices.

1.17.6

Be aware that stiffness of the upper limbs is a common complication of chest and rib injury on the affected side.

1.17.7

The multidisciplinary team should discuss the risks and benefits of the use of spinal orthoses in people with a combination of spine injury and rib fracture.

1.17.8

Prevent stiffness of the upper limbs with range of movement exercises and advice about maintaining function. Encourage children to play to maintain their range of movement.

1.17.9

Give people information about what they can do to help themselves return to their normal activities of daily life (for example, how to increase their exercise tolerance), and how to seek help if they are worried about problems such as:

  • pain

  • shortness of breath

  • fatigue

  • cough.

1.17.11

If people have complex chest injuries that affect communication and swallowing skills, consider referral to speech and language therapy.

1.17.12

Consider assessing children and young people with rib fractures for bone density disorder and for the possibility of non-accidental injury (see recommendation 1.1.13 on safeguarding).

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on rehabilitation after chest injury.

Full details of the evidence and the committee's discussion are in evidence review C.4: specific programmes and packages in chest injury for people with complex rehabilitation needs after traumatic injury.

Terms used in this guideline

Complex rehabilitation needs

Complex rehabilitation needs cover multiple needs due to traumatic injury or injuries (polytrauma), and will involve coordinated multidisciplinary input from 2 or more allied health professional disciplines.

Controlled motion device

A device that gently flexes and extends the knee joint (usually after surgery) to allow the joint to bend without the person needing to exert any effort. Sometimes called a continuous passive motion machine.

Key worker

A key worker is a named member of clinical staff (for example, a senior nurse, physiotherapist or occupational therapist) assigned at each stage of the care pathway who coordinates the person's rehabilitation and care; this may continue post-discharge. They act as a single point of contact for the person and their family and carers, and will support liaison with other services, such as social care. The person who fulfils this role may be different along the pathway, for example, following hospital discharge. This role may also be performed by case managers or case coordinators, who would coordinate care as well as liaise with insurers and legal teams, particularly following discharge.

For major trauma, the role of key worker is defined further in recommendation 1.6.3 in the NICE guideline on major trauma: service delivery.

Neurovestibular disorders

Dizziness or problems with balance caused by damage to parts of the inner ear and/or the brain that process the sensory information involved with controlling balance and eye movements.

Orthostatic hypotension

Low blood pressure on changing position from lying to sitting, and sitting to standing.

Practitioner psychologists

The definition of practitioner psychologists is based on the Health and Care Professions Council (HCPC) registration criteria and standards of proficiency.

Pre-amputation rehabilitation assessment and consultation

This follows the principles of the initial rehabilitation assessment in the section on assessment and early interventions for people with complex rehabilitation needs, and also takes into account implications for rehabilitation such as recovery timescales, quality of life and goal setting for different surgical options that may include amputation of all or part of the limb, or reconstructive surgery of the limb. Decisions about surgical interventions would affect the kind of rehabilitation interventions and therapies the person would need, the timescales involved and their personal goals.

Rehabilitation coordinator

Rehabilitation coordinators are rehabilitation specialists, for example, allied health professionals such as physiotherapists, occupational therapists, speech and language therapists, or clinicians who play an active role in the multidisciplinary team. They are usually responsible for decisions about rehabilitation treatment options at the beginning of the pathway and for the implementation of the pathway, including referral or transfer to other services. They are usually part of the team that delivers the rehabilitation care, and the lead contact for the person receiving care.

Rehabilitation plan

This may be in the form of a rehabilitation prescription. It may also come in different versions such as the rehabilitation passport, which is a patient-held document, and may be a simplified version of the plan. It is carried with the person and also communicated between rehabilitation teams and updated accordingly and used to document information about injuries and rehabilitation treatments in an accessible format.

Single point of contact

A single point of hospital contact following discharge may be a key worker, trauma coordinator or a rehabilitation coordinator, or it may simply be a link to a unit, team or person that formed part of the person's rehabilitation care while in hospital. The point of contact may not be able to offer advice directly but can seek information and input from others if this is needed for a defined period post-discharge.

Specialised rehabilitation services

Specialised elements of care pathways would include options for people with complex rehabilitation needs, for example, level 1, level 2a and level 2b units within a local area.

Strengths-based approach

Strengths-based (or asset-based) approaches focus on the person's strengths (including personal strengths, and social and community networks) and not on their deficits. Strengths-based practice is holistic and multidisciplinary, and works with the individual person to promote their wellbeing.

Team around the child

A group of professionals who work with an individual child or young person with a disability or complex needs who come together to share information and agree a plan – along with parents and carers – to meet the child's needs. The emphasis should be on the needs of the child and the aim is to provide joined-up support.

Trauma coordinator

This person would work closely with the multidisciplinary team to coordinate the patient pathway between relevant specialties involved in the treatment, including acute surgical and medical teams and rehabilitation, from admission to discharge, particularly for people with highly complex traumatic injuries and rehabilitation needs. They offer clinical advice and sometimes this role is performed by a nurse and is sometimes called a nurse coordinator. This role may also include the responsibilities of a key worker, liaising with family and carers, especially in the early stages of the pathway.

Traumatic injury

This includes multiple, major and severe injuries, sometimes referred to as polytrauma, and any musculoskeletal, visceral, nerve, soft tissue, spinal or limb injury that requires admission to hospital at the time of injury.

Vocational therapy

Focuses on the rehabilitation interventions needed to help people with long-term health conditions or disabilities return to or stay in work, education or training. This may involve adapting working conditions, job roles or retraining.