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Trauma is the main cause of significant disability in adults of working age, and on average 36 life-years are lost per trauma death1, 2. According to the World Health Organization (WHO), trauma is associated with moderate to severe disability for over 45 million people each year worldwide1. Trauma, therefore, involves a large socioeconomic burden and has a significant impact on healthcare costs, due both to lost economic opportunity and to the direct costs of treatment (medical and rehabilitation). The aggregate lifetime costs for all injured patients in the USA were estimated to be US $158 billion in 20012. In Australia, in 2000–2001, Australian $4 billion was spent on trauma survivors3. In the UK, the cost to the National Health Service of treating major trauma is up to £0·4 billion per annum4.
Rehabilitation is defined as ‘a problem-solving educational process aimed at reducing disability and handicap (participation) experienced by someone as a result of disease or injury’5. The principal focus of rehabilitation is on reducing symptoms and limitations at the level of activity and participation, and includes personal and environmental factors. Trauma rehabilitation extends beyond acute injury or wound management, to reintegration of the patient into the home and community. The cognitive and neuropsychological sequelae of trauma are also well recognized2, 6, 7.
The trauma systems model enhances community health through an organized system of injury prevention, acute care and rehabilitation that is fully integrated into the public health system of a community8. Trauma care is multidisciplinary and provided along a continuum that includes all phases of care. Rehabilitation is often the longest and most difficult phase of the trauma care continuum for patients and families. However, few patients have access to optimal rehabilitation programmes owing to lack of political commitment for reform and financially supported infrastructure9, and fragmented healthcare systems10, 11. Moreover, rehabilitation services tend to be constructed around specific patterns of injury or functional impairments; thus providing care for the complex needs of patients with multiple injuries can be challenging12. Similarly, most rehabilitation literature has examined interventions for specific trauma conditions (Table S1 and references, supporting information); and few reviews have examined the effectiveness of multidisciplinary rehabilitation programmes for patients with multiple injuries.
The objective of this review was to identify studies reporting rehabilitation outcomes for patients with multiple trauma, especially the approaches that are effective (setting, intensity, type of rehabilitation) and the outcomes that are affected (function, social reintegration, work, quality of life (QoL)), in order to guide treating clinicians and identify gaps in current knowledge.
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This review has highlighted the lack of high-quality studies for effective multidisciplinary rehabilitation in survivors of multiple trauma in terms of: types of rehabilitation setting, components, modalities and duration of therapy, lack of effective care pathways and long-term functional outcomes (including societal reintegration). However, it adds to the existing evidence base in a limited way by providing low-quality evidence from observational studies to support multidisciplinary intervention in this population.
The gaps in the evidence-based rehabilitation practice for multiple trauma survivors identified in this review are similar to issues in rehabilitation research outlined previously for persons with complex chronic neurological conditions33–35. These include the lack of robust trials in rehabilitation settings and methodological challenges for research; discrepancy in clinical agreement and practice amongst treating clinicians; lack of incorporation of the perspective of the person with multiple trauma injuries (and their carers); and difficulties with outcome measurement in this population.
Although RCTs are appropriate for studying the effects of an intervention and considered the ‘gold standard’ for high-level evidence, they are much less suited to studying ‘complex’ interventions such as rehabilitation34–36. The many challenges in rehabilitation for traditional research designs include: heterogeneous interdependent components; different patient populations and contexts; and treatments that are multifaceted, multilayered and involve organizational restructure and individual intervention33, 34, 36. An alternative methodology is the use of ‘clinical practice studies’ that acquire prospective and retrospective observational data without disrupting the natural milieu of treatment37. This routine data collection provides additional information about the nature of services provided, the outcomes of rehabilitative care, and implications for clinical practice. Further, it can provide answers to what models of care work in which trauma patient populations, the intensity of rehabilitation required, and assessment of care management processes37, 38. This approach has been used in other complex conditions39 to quantify intensity of rehabilitation in inpatient rehabilitation programmes, and to determine patient complexity and need for therapy. More research in multiple trauma survivors is needed to build the evidence base in rehabilitation.
A major gap in rehabilitation research is the absence of an internationally agreed framework for the assessment of disability and function. The WHO ICF framework may provide a solution to this. The ICF categories provide information for clinicians about domains considered important by patients, and can be incorporated into their care programmes. These categories provide a common language for effective communication and agreement amongst the treating clinicians. The ICF framework has been applied successfully to outcomes from various neurological diseases37, 38, 40. A similar exercise has yet to be undertaken in patients with multiple trauma to facilitate communication and clinical care between treating clinicians for improved patient outcomes.
Analysis, comparison and agreement on clinical outcomes in trauma rehabilitation programmes are difficult, owing to heterogeneity in the types of programme and use of outcome measures. Despite the widespread usage of acute trauma registries, those that collate data for rehabilitation outcomes are scarce. A comprehensive report used a National Rehabilitation Dataset to review outcomes of inpatient rehabilitation for persons after various conditions, including major trauma (more than 45 000 episodes of care), from 162 accredited rehabilitation facilities across Australia41. The results showed a reduction in disability, hospital length of stay and increased discharge of these persons back to the community following inpatient rehabilitation programmes. Such analyses assist in reviewing rehabilitation outcomes nationally and internationally, highlighting areas requiring improved data collection and identifying future clinical needs for planning health service provision. A collaborative integrated practice model for multiple trauma care is needed (acute care and rehabilitation) to address issues of participatory restriction, especially those relating to psychological issues, work, family and social reintegration. This involves education and support for survivors, and for the treating multidisciplinary teams.
Although significant improvements in the coordination and organization of trauma care and services have reduced patient mortality42, this has not extended to include rehabilitation services. Most literature on rehabilitation care in trauma survivors exists in ‘silos’ for isolated conditions such as brain injury, fractures and burns. Although WHO recommends implementation and access to rehabilitation services in developed and developing countries43, there are no national or internationally coordinated expanded trauma rehabilitation guidelines to date.
At the global level, injury-related death rates in low- and middle-income countries are higher today than in high-income countries44. Despite the high burden of death and disability from injury worldwide, policy responses have been disproportionately low. Trauma-related research lags by 30 per cent behind cancer or heart disease research in the USA, and is much worse in low–middle-income countries45. This is due to a population and government belief that injury is different to disease, instead attributing it to carelessness or ‘bad luck’, and believing that little can be done to prevent this. The death and disability rates from injury can be lowered by addressing the spectrum of injury control as outlined by Mock and colleagues46; this includes essentials such as surveillance, prevention and treatment, including rehabilitation care.
There is a need for the ongoing collection of data regarding the extent and characteristics of injury and targeted interventions, and assessment of their success or failure in rehabilitation settings. Most high-income countries have well developed acute surveillance systems for injury, for example the Fatality Analysis Reporting System for automotive death in the USA47, and various national trauma registries (Australia, UK, Europe). However, these systems are not so well developed in rehabilitation care. In the USA and Australia, national data sets for outcomes of rehabilitation care exist48 and are a valuable source for studying outcomes in rehabilitation for trauma and injuries. The UK is currently developing a similar system to that in Australia (L. Turner-Stokes, King's College London, personal communication). The Australian Rehabilitation Outcomes Centre (AROC) data set41 currently has 170 accredited Australian rehabilitation facilities that submit rehabilitation data to the national data set (including ambulatory data). However, ongoing analysis is needed to improve the quality of data submitted for improved understanding of rehabilitation outcomes. Few low–middle-income countries have surveillance systems specific for injury and/or rehabilitation, and less than 10 per cent of injury-related events or deaths are recorded46. One example is the South African National Non-natural Mortality Surveillance System, which collates data from mortuaries49. Data from countries such as Burma, Pakistan and others collate data from governmental and non-governmental sources (such as police reports and vital statistics), and have issues relating to lack of public access to data, under-reporting and questionable data. Although WHO has published guidelines for collecting and processing injury data in acute care43, there are currently no such guidelines for rehabilitation. As discussed, the ICF supporting info, ref. 3 can develop data item lists or ‘core sets’ that need to be addressed in multidisciplinary care settings, and work is in progress to develop valid outcome measurement tools using ICF item banking and scale development techniques50.
Globally, the enactment of organized trauma systems and advances in acute care have reduced trauma-related mortality and morbidity rates; these, however, have been successful in high-income countries, but less so in low–middle-income countries. Trauma outcomes from different countries vary, based on economic level. For example, the mortality rate among patients with an ISS of 9 or above increased from 35 per cent in high-income countries (for example, the USA), to 55–63 per cent in low–middle-income countries (for example, Mexico and Africa)46. Persons with salvageable injuries (ISS 15–24) in low–middle-income countries have an increased mortality rate; this can be improved upon considerably by means of organized rehabilitation pathways and processes46.
The WHO International Guidelines for Essential Trauma Care43 could be expanded to incorporate rehabilitation intervention. The WHO guidelines utilize the international public health concepts, low-cost and high-yield services, ensuring care to the majority of people in a population. Trauma systems development in rehabilitation, for example, should include minimal training for medical and nursing staff, documentation of care processes, and provision of equipment such as gait aids. In addition, the systems development in high-income countries should be blended within the international public health concepts to establish and promote a core set of essential trauma services and rehabilitation that, if applied widely, would decrease injury-related deaths and disabilities worldwide51.
Rehabilitation services development guidelines are needed urgently and should include items such as human resources, skilled and trained staff, and adequate resources (equipment, supplies), made available in institutions of varying levels worldwide. These may range from small rural clinics staffed by health workers, to rural hospitals staffed by general medical staff, to specialist facilities with organized rehabilitation services. However, access to specialized brain, spinal or burn rehabilitation units for injured persons is not universally affordable.
Finally, rehabilitation guidelines should provide governments and health agencies with resource recommendations such as training programmes, performance improvement strategies, organization of rehabilitation services, site inspections and accreditation systems, and political interactions among stakeholders46. As WHO dedicated this decade to reducing ‘road traffic trauma’, there is now opportunity to prioritize trauma rehabilitation, disability management and social reintegration of trauma survivors.
Additional supporting information may be found in the online version of this article:
Table S1 Current evidence for various rehabilitation interventions in trauma categorized according to study design using evidence defined by the National Health and Medical Research Council programme for intervention studies (Word document)
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