NICE publish important new Guidelines dealing with rehabilitation after traumatic injury

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On the 18 January 2022, the first NICE Guidelines on Rehabilitation After Traumatic Injury were published. The Guidelines provide valuable guidance and support for specialist rehabilitation following major trauma, highlighting best practice in this field.

The Guidelines address complex rehabilitation needs after traumatic injury, including assessment and goal setting, rehabilitation plans and programmes, physical, psychological and cognitive rehabilitation, rehabilitation for specific injuries, coordination of rehabilitation in hospital, at discharge and in the community, and commissioning and organising rehabilitation services.

Traumatic injury is defined for the purpose of the Guidelines as any injury that requires admission to hospital at the time of injury. This could include musculoskeletal injuries, visceral injuries, nerve injuries, soft tissue damage, spinal injury, limb reconstruction and limb loss. Minor injuries can also lead to a hospital admission.

A set of recommendations are set out within the Guidelines, which apply to all people with complex rehabilitation needs after a traumatic injury, unless specified otherwise.

These recommendations are then helpfully broken down into sub-categories.

Firstly, the initial recommendation topics cover:

  • initial assessment and early interventions for people with complex rehabilitation needs
  • multidisciplinary team rehabilitation needs assessment
  • setting rehabilitation goals
  • developing a rehabilitation plan and making referrals
  • rehabilitation programmes of therapies and treatments
  • principles for sharing information and involving family and carers
  • coordination of rehabilitation care in hospital
  • coordination of rehabilitation care at discharge
  • supporting access and participation in education, work and community (adjustment and goal settings)
  • commissioning and organisation of rehabilitation services

This is then followed by specific rehabilitation therapies and interventions:

  • physical rehabilitation
  • cognitive rehabilitation
  • psychological rehabilitation

There are then further Injury-specific sections which are to be read together with the rehabilitation therapies and interventions sections):

  • rehabilitation after limb reconstruction, limb loss or amputation
  • rehabilitation after spinal cord injury
  • rehabilitation after nerve injury
  • rehabilitation after chest injury

Each of these recommendation sections sets out bullet point guidance and advice about how to approach rehabilitation in that specific area.

The recommendation section also contains useful hyperlinks which take a user to other parts of the Guidelines, so that they can be used interactively to cross reference.

By way of example as to how these recommendations address the relevant sub-topics, the section for rehabilitation after limb reconstruction, limb loss or amputation helpfully breaks down further into sub-categories:

  1. Rehabilitation after limb-threatening injury – early assessment, decision making and support
  2. Rehabilitation after limb reconstruction
  3. Rehabilitation after limb loss or amputation
  4. Pain management after limb loss or amputation
  5. Residual limb oedema and shaping after limb loss or amputation
  6. Range of movement and strengthening after limb loss or amputation
  7. Functional independence after limb loss or amputation
  8. Psychological support after limb loss, amputation or limb reconstruction
  9. Continuing rehabilitation after limb reconstruction, limb loss or amputation and after discharge

Recommendations include:

‘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.’

‘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.’

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

Similarly, in relation to rehabilitation after spinal cord injury’, the sub-sections addressed are:

  1. Rehabilitation after spinal cord injury – referral, assessment and general principles
  2. Bladder and bowel function
  3. Respiratory function, swallowing and speech
  4. Preventing complications
  5. Maintaining mobility and movement
  6. Low mood and psychological support

Recommendations include:

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

‘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.’

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

By way of example of how the Guidelines deal with categories of people, the spinal injuries section specifically addresses rehabilitation for young persons:

‘Refer children and young people with a spinal cord injury: to specialist play services to support their emotional and physical development and wellbeing and to education services to support their ongoing educational development.’

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

Similarly, the limb reconstruction, limb loss or amputation section provides specific recommendations for young persons such as:

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

‘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.’

At this stage the Guidelines do not cover the management of traumatic brain injury, except in relation to early screening for onward referral and the coordination of services for people with multiple injuries, one of which may be traumatic brain injury. It is understood that the specialist assessment and delivery of rehabilitation services for traumatic brain injury will be covered in a new NICE guideline on rehabilitation for chronic neurological disorders including traumatic brain injury.

Under the Rehabilitation Code 2015, practitioners must continually consider rehabilitation needs and requirements in regard to early and ongoing rehabilitative treatments.

These Guidelines are a positive development in the field of serious and catastrophic injury. They will provide practitioners with a useful point of reference when assessing rehabilitative needs and assist in streamlining discussions as to the appropriate rehabilitation approach and ongoing funding.

Featured Counsel

Lucy Lodewyke

Call 2018

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