EARLYREHABILITATIONIn Conflicts and Disasters

Edited by: Charmi Lathia, Peter Skelton and Zoe CliftPROJECT
COORDINATOREDITORS
Charmi Lathia
Peter Skelton
Zoe Clift

Charmi Lathia

CONTRIBUTORSHumanity & Inclusion
AO
WHO
ICRC

Livability
CBM
MSF-France

ACKNOWLEDGEMENTS
Jane Wiedler, Michiel Steenbeek, Stephen Muldoon, Jody-Anne Mills, Leslie Angama-Mueller, Andre
Da-Silva, Claire O’Reilly, Claude Tardif, Tom Potokar, Alice Harvey, Gaelle Smith, Debbie Gray, Alberta
Rockson, Michelle Fitzgerald, Sudan Rimal , Lauren Eve, Pushpak Newar, Julien Clausse, Erica Bleakley,
Penny Broomhead, Caroline Cater, Eric Weerts, Fiona Stephenson, Michael Baumberger, Esha Tapa
Dungana, Holly Soper-Doyle, Claire Downs, Lucia Olive Lennon, Laura Cocco, Caroline Jagoe, Amelia
Shaw, Fiona Craven Bernhard, BACPAR and Interburns. Thanks to content reviewers and endorsers
GRA, WCPT, WFOT, ISPO, ISPRM and ISCoS.

Photograph Credits:

Davide Preti © Davide Preti/HI
Cover: © Hardy Skills/HI
Handicap International © Handicap International
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Attribution:

You must give appropriate credit, provide a link to the license, and indicate if changes were made. You may
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DISCLAIMER:

This handbook is written for rehabilitation professionals (physiotherapists and occupational therapists)
living in, working in, or preparing to work in conflict or disaster settings.
1st Edition, January 2020
EARLY REHABILITATION IN CONFLICTS AND DISASTERSFOREWORD
From the first world war to more recent disasters, such as the 2015 Nepal earthquake, theimportance of integrating rehabilitation into emergency responses to conflicts and disasters
has been clear. The World Health Organization emergency medical team standards andrecommendations for rehabilitation, launched in 2016, signalled significant progress inrecognising the role that rehabilitation professionals play and the necessity of early intervention.
However, while the emergency medical community takes strides towards integrating earlyrehabilitation in conflict and disaster response, early rehabilitation remains an emerging area.
Rehabilitation professionals face unique challenges associated with complex trauma, injury
surge and resource scarcity that many have never encountered before.
Practical guidance to deliver quality early rehabilitation in these contexts is essential if conflictand disaster response is to evolve beyond its life- and limb-saving mandate to deliver carethat maximises patient outcomes. Rehabilitation professionals need to be equipped withthe knowledge and skills to meet patient needs and navigate the demands of emergency
medical response.
This field handbook, the outcome of a highly collaboration process among key internationalorganisations and experts, is an invaluable resource for rehabilitation professionals preparing
to work in conflict and disaster response. It has the potential to have a major impact on thecare that people injured in conflicts and disasters receive and will go far to ensuring they
achieve the outcomes that enable them to return to work, school and community life.

FLAVIO SALIOManager, Emergency Medical Teams
World Health Organization
Geneva, Switzerland

ALARCOS CIEZA
Coordinator, Vision, Hearing, Disability andRehabilitation
World Health Organization
Geneva, Switzerland

1 | EARLY REHABILITATION IN CONFLICTS AND DISASTERS FOREWORD

PREFACE
Conflicts and Disasters affect societies at a profound level, with consequences often lasting for
generations. Early rehabilitation for patients with traumatic injuries is a crucial element of theacute medical response and is a vital step towards long-term recovery strategies.
As a leader in innovation in research and development in trauma and musculoskeletal disorders,and as a premier provider of education for surgeons and operating room personnel, all AO
activities are focused on the goal of delivering improved patient outcomes.
Humanity and Inclusion (HI) is an independent non-governmental organisation that provides
essential rehabilitation services in situations of poverty, exclusion, conflicts and disasters. Overthe past 38 years, HI has been present as a core leader in rehabilitation and capacity building of
rehabilitation staff and partners in areas of conflicts and disasters around the world.
Together, AO and HI are convinced that this comprehensive, evidence-based field handbook
will address the need to prepare rehabilitation professionals for emergency settings as wellas acting as a reference for safe practice of early rehabilitation of major trauma in challenges
environments.
We are honoured to contribute to this multidisciplinary project, in collaboration with the ICRC,
WHO, MSF-France, CBM, and Livability. We welcome this opportunity to share our expertisein relevant areas, supporting healthcare professionals across the world as they work on earlyrehabilitation in conflicts and disasters.
We thank all those who made this humanitarian project possible, and look forward to continuing
our global endeavour to improve patient outcomes.

ROBERT MCGUIRE, MD
AO President

ISABELLE URSEAU
Humanity and Inclusion Rehabilitation
Division Director

2 | EARLY REHABILITATION IN CONFLICTS AND DISASTERS PREFACECONTENTS
CHAPTER 1: INTRODUCTION
Early Rehabilitation in Conflicts and Disasters Introduction.................................................. 07

CHAPTER 2: KEY CHALLENGES
Key Challenges in Delivering Early Rehabilitation in Conflicts and Disasters......................... 29

CHAPTER 3: PATIENT ASSESSMENT AND TREATMENT - THE BASICS
Early Rehabilitation Patient Assessment and Treatment - the Basics................................... 45

CHAPTER 4: FRACTURES
Early Rehabilitation of Fractures.......................................................................................... 67

CHAPTER 5: PERIPHERAL NERVE INJURIES
Early Rehabilitation of Peripheral Nerve Injuries.................................................................. 89

CHAPTER 6: AMPUTEES
Early Rehabilitation of Amputees...................................................................................... 115

CHAPTER 7: ACQUIRED BRAIN INJURIES
Early Rehabilitation of Acquired Brain Injuries.................................................................... 149

CHAPTER 8: SPINAL CORD INJURIES
Early Rehabilitation of Spinal Cord Injuries........................................................................ 169

CHAPTER 9: BURNSEarly Rehabilitation of Burns............................................................................................. 191

3 | EARLY REHABILITATION IN CONFLICTS AND DISASTERS CONTENTS

SELECTED DEFINITIONS
These definitions are taken from the United Nations Office for Disaster Risk Reduction (UNISDR)
unless stated:
Disaster — a serious disruption of the functioning of a community or a society involving
widespread human, material, economic or environmental losses and impacts, which exceeds
the ability of the affected community or society to cope using its own resources.
Disaster preparedness — pre-disaster activities that are undertaken within the context ofdisaster risk management and are based on sound risk analysis. This includes the development/enhancement of an overall preparedness strategy, policy, institutional structure, warning andforecasting capabilities, and plans that define measures geared to helping at-risk communities
safeguard their lives and assets by being alert to hazards and taking appropriate action in theface of an imminent threat or an actual disaster.
Disaster prevention — ‘is the outright avoidance of adverse impacts of hazards and related
disasters. Prevention expresses the concept and intention to completely avoid potential
adverse impacts through action taken in advance. Examples include dams or embankments thateliminate flood risks, land-use regulations that do not permit any settlement in high risk zones,
and seismic engineering designs that ensure the survival and function of a critical building in
any likely earthquake. Very often the complete avoidance of losses is not feasible and the task
transforms to that of mitigation. Partly for this reason, the terms prevention and mitigation are
sometimes used interchangeably in casual use.’
Disaster risk — the potential disaster losses, in lives, health status, livelihoods, assets andservices, which could occur to a particular community or a society over some specified future
time period.
Disaster risk management — the systematic process of using administrative directives,
organisations, and operational skills and capacities to implement strategies, policies andimproved coping capacities in order to lessen the adverse impacts of hazards and the possibilityof disaster.
Disaster risk reduction — the concept and practice of reducing disaster risks through systematicefforts to analyse and manage the causal factors of disasters, including through reduced
exposure to hazards, lessened vulnerability of people and property, wise management of land
and the environment, and improved preparedness for adverse events.
Emergency management — the organisation and management of resources and responsibilities
for addressing all aspects of emergencies, in particular preparedness, response and initialrecovery steps.
Emergency Medical Team – EMTs are groups of health professionals (doctors, nurses, paramedicsetc.) that treat patients affected by an emergency or disaster. They come from governments,
charities (NGOs), militaries and international organizations such as the International Red Cross/
Red Crescent movement (WHO).

4 | EARLY REHABILITATION IN CONFLICTS AND DISASTERSDEFINITIONS

Hazard — a dangerous phenomenon, substance, human activity or condition that may cause lossof life, injury or other health impacts, property damage, loss of livelihoods and services, socialand economic disruption, or environmental damage.
Risk — the combination of the probability of an event and its negative consequences.
Risk assessment — a methodology to determine the nature and extent of risk by analysing
potential hazards and evaluating existing conditions of vulnerability that together could
potentially harm exposed people, property, services, livelihoods and the environment on which
they depend.
Risk management — the systematic approach and practice of managing uncertainty to minimise
potential harm and loss.
Vulnerability — the characteristics and circumstances of a community, system or asset thatmake it susceptible to the damaging effects of a hazard.
Vulnerable groups — include indigenous peoples, ethnic minorities, refugees, migrant workers,
women, children, people with HIV/AIDS, persons with disabilities and older persons. People
belonging to these groups have certain common characteristics or are in a situation that havebeen shown to make these people more vulnerable to discrimination. They are especially“vulnerable”, because these grounds for discrimination have been overlooked or insufficiently
addressed

Video icon:
Refers to an educational YouTube Channel; Early Rehabilitation in Conflicts and Disasters.
https://www.youtube.com/c/EarlyRehabilitationinConflictsandDisasters
Webpage icon:
Refers to accompanying web resources designed to be used in conflict and disasters settings;
available on https://www.disasterready.org

5 | EARLY REHABILITATION IN CONFLICTS AND DISASTERS

SELECTEDABBREVIATIONS
CBM:International non-governmental organisation, formerly Christian Blind Mission

CBR:

community based rehabilitation

DH:

Drug History

DPO:

disabled people’s organisation

EMT:

emergency medical teamHI:

Humanity and Inclusion (previously Handicap International)

HIC:

high income countries

IASC:

Inter Agency Standards Committee

ICRC:

International Committee of the Red Cross

INGO:

international non-governmental organisation

LMIC:

low and middle income countries

OCHA:

Office for the Coordination of Humanitarian Affairs

MDT:multi-disciplinary teamMH:

Medical History

MHPSS: Mental Health and Psychosocial Support
NEPTA:

Nepal Physiotherapy AssociationNGO:

non-governmental organisation

PMH:

Past Medical History

SCI:

spinal cord injury

SH:

Social History

SOD:

Sudden onset disaster

UKEMT: United Kingdom Emergency Medical TeamUNISDR: United Nations Office for Disaster Risk Reduction
UN:

United Nations

WASH:

Water, sanitation and hygiene

WHO:

Word Health Organization

6 | EARLY REHABILITATION IN CONFLICTS AND DISASTERSCHAPTER 1 | INTRODUCTION

CHAPTER 1
EARLY REHABILITATION IN CONFLICTS
AND DISASTERS INTRODUCTION

AIMS:
By the end of this chapter you should be able to:Understand the different types of conflicts and disasters and the
injury patterns that result from them
Understand what early rehabilitation is and its role in conflict anddisaster settings
Understand the importance of preparedness for rehabilitation
professionals
Understand who is involved in conflict and disaster responses

7 | EARLY REHABILITATION IN CONFLICTS AND DISASTERS INTRODUCTION

CHAPTER 1 | INTRODUCTION

CHAPTER 1:
EARLY REHABILITATION IN CONFLICTS ANDDISASTERS INTRODUCTIONINTRODUCTION
The role of rehabilitation professionals in responding to conflicts and disasters is constantly
evolving, and the development of our professions are intertwined with global events that havegenerated the need to provide care for overwhelming numbers of injured people. From theevolution of the early rehabilitation professions during the first world war, to the emergence of
the ICRC rehabilitation program for victims of armed conflict and violence in 1979 and the birthof Handicap International in 1982 on the Thailand/Cambodia border to support victims of landmines, to the rapid advancement in rehabilitation for war wounded military personnel made insome countries in the early 21st century, our professions have developed to meet the needs ofa changing world. Lessons learned from more recent disasters, such as the 2010 Haiti and 2015
Nepal earthquakes, have underlined the importance of integrating rehabilitation into emergency
responses in disasters, as well as conflicts.
With the strengthening of emergency medical preparedness and response, improvements inbattlefield medical care and the continued development of humanitarian health coordination,
we now face a paradox where we are getting better and better at saving lives in conflicts anddisasters, but where the effective rehabilitation required to change these lives still lags behind.
While in many countries rehabilitation now begins at the earliest possible point in a patient’scare, too often in conflict and disasters, when faced with overwhelming numbers or insecurity,
it remains an afterthought. Even where therapists are present, they sometimes lack the major
trauma skills to work effectively. Patients who miss out on quality early rehabilitation are then atincreased risk of developing complications, poor outcomes or being lost to follow-up altogether.

WHAT ARE DISASTERS AND CONFLICTS?
Disasters:
When we think of disasters, we often automatically think of the phenomenon that has caused
them – for example the earthquake, cyclone, or flood. In reality, though, this event is simply the‘hazard’ – and the disaster itself is caused by a combination of the hazard, our own exposure to
the phenomenon (such as whether we live in the area affected) and our vulnerability to it (howwe have prepared or mitigated for it). To illustrate this, we can consider two tropical cyclones(hazards) in 2019 with similar wind speeds; one in Mozambique (a low-income setting with low
preparedness) that killed 1,297 people and involved a major international emergency medical
response, and one in Japan (a high-income setting with high preparedness) that killed 86 people
and where no request for international emergency medical assistance was made. Put simply, adisaster occurs when a hazard impacts on vulnerable people.
A disaster is formally defined by the UN office for Disaster Risk Reduction as: A serious disruptionof the functioning of a community or a society at any scale due to hazardous events interacting

8 | EARLY REHABILITATION IN CONFLICTS AND DISASTERS INTRODUCTION

CHAPTER 1 | INTRODUCTION

with conditions of exposure, vulnerability and capacity, leading to one or more of the following:
human, material, economic and environmental losses and impacts.
This then leads to the equation: Disaster = Hazard x Vulnerability x Exposure.
We understand now that the vulnerability and exposure of people are just as important as thehazard itself when we think about disaster severity. Vulnerability and exposure can also beinterpreted on individual, community, regional or national levels. Trends of urbanisation andgreater populations will increase exposure to hazards; whilst factors such as policies, laws,
preparedness, economic situation, environmental degradation, infrastructure, construction
quality, health system strength, and health and education status can all impact on the vulnerabilityof a population. This also explains why low-income countries have taken the brunt of economic
and human impact from disasters in the last ten years. Critically, low-income countries often
have weak health systems, and weak health systems also generally mean reduced quality andquantity of rehabilitation services. Furthermore, in many cases disaster and conflict co-exist,
compounding and increasing vulnerabilities and exposure.
Every disaster is different, but by understanding basic trends we can better prepare andrespond to them.
Diagram 1: Global annual deaths from natural disasters, by decade
Absolute number of global deaths from natural disasters, per year. This is given as the annual average per decade(by decade 1900s to 2000s; and then six years from 2010-2015)
550,000

500,000

500,000

450,000

450,000

400,000

350,000

300,000

250,000

200,000

150,000

Annual deaths from natural disasters

550,000

400,000
350,000
300,000
250,000
200,000
150,000

100,000

100,000

50,00050,0000

1900s

ImpactImpactWildfire
Wildfire
Landslide
Landslide
Mass moveme
Mass movement (dry)Volcanic activit
Volcanic activity
Storm
Storm
Flood
Flood
Extreme temperatureExtreme temp
Earthquake
Earthquake
Drought
Drought

0

1910s

1900s
1920s

1910s
1930s

1920s
1940s

1930s
1950s

1940s
1960s

1950s
1970s

1960s
1980s

1970s
1990s

1980s
2000s

1990s
2010s

2000s

Source:EMDAT (2017):
OFDA/CRED
Disaster Database,catholique
Louvain - Brussels - Belgium.
EMDAT (2017):
OFDA/CREDInternational
DisasterInternational
Database, Université
catholiqueUniversitéde Louvain- Brusselsde- Belgium.
data visualisation
is available at OurWorldinData.org.
There
findvisualisations
research andon
more
on this topic.
a visualisationTheis available
at OurWorldinData.org.
There you find research
andyoumorethisvisualisations
topic.
Licensed
uncer
CC-BY-SAby theauthoers
HannahRitchie and Max Roser.
d uncer CC-BY-SA
by theauthoers
HannahRitchieand Max
Roser.

9 | EARLY REHABILITATION IN CONFLICTS AND DISASTERS INTRODUCTION

2010s

CHAPTER 1 | INTRODUCTION

Sudden Onset Disasters (SODs)
SODs are usually the result of sudden-onset hazards, although the term ‘sudden onset’ canbe misleading; with advancement in warnings of major storms and knowledge of where major
earthquakes are likely to strike. Multiple factors contribute to the variety of type and distributionof injuries:
Type and severity of hazard
Time of day
Local preparedness and risk mitigation, including building quality and density
Level of health infrastructure
Across all hazards, it should be remembered that their health impact is not limited to the deaths
and injuries they cause directly, but also the damage and disruption of the existing health system.
Earthquakes: Between 2010 and 2019, 350,000 people have been killed, and more than
1,000,000 people have been injured by earthquakes. Injury numbers and patterns vary between
events, but mortality: morbidity is typically around 1:3 or 1:4. Factors including time of day,building materials and depth and strength of earthquakes will impact injury type and number.
Orthopaedic injuries make up the bulk of injury burden, with past figures suggesting 65% of thesewere fractures (predominantly lower limb), with other injuries including compartment syndromes,
Diagram 2: Global earthquake mortality risk distribution

Mortality risk is found by weighting the value of population exposure to earthquakes for each grid cell by a vulnerability
coefficient to obtain an estimate of risk. The vulnerability weights are based on historical losses in previous disasters.
The mortality weights are applied to population exposure to obtain mortality risks. The weights are an aggregate
index relative to losses within each region and country wealth class (classifications based on 2000 GDP) over the
20-year period from 1981-2000.
Source: Dilley, Maxx, Robert S. chen, Uwe Deichmann, Arthur J. Lerner-Lam, and Margaret Arnold. 2005. Natural Disaster Hotspots:
A Global Risk Analysis. Washington, D.C.: World Bank.
This Document is licensed under a Creative Commons 3.0 Attribution License. http://creativecommons.org/licenses/by/3.0/
Copyright 2005 International Bank for Reconstruction and Development/The World Bank and Columbia University.

10 | EARLY REHABILITATION IN CONFLICTS AND DISASTERS INTRODUCTION

CHAPTER 1 | INTRODUCTION

major soft-tissue injuries and crush syndromes. Other injuries seen include amputations, spinal
cord injuries and traumatic brain injuries, although numbers seen may depend on a numberof additional local factors, including the speed and quality of extraction and the availability of
appropriate intensive care and surgical interventions. Complications from crush injuries suchas rhabdomyolysis and compartment syndrome are common. Burns may occur as a result of
secondary fires, electrocution or due to local cooking practices (both during and after the disaster).

KEY ISSUES
Potential key issues for acute rehabilitation providers: Damage to health infrastructure acrossa wide area, overwhelming numbers of complex trauma patients, internal displacement
creating challenging discharge environments and ongoing risk of aftershocks and secondary
disasters, such as landslides.
Picture 1: Earthquake aftermath in Nepal,
2015; Lady stood outside her home
© William Daniels / Handicap International

Tropical cyclones: Known as hurricanes, cyclones and typhoons depending on where in theworld they appear, these storms typically occur in seasons and with lead times of several days,
although their paths can alter.
Diagram 3: Tropical cyclones

11 | EARLY REHABILITATION IN CONFLICTS AND DISASTERS INTRODUCTION

CHAPTER 1 | INTRODUCTION

Much of the mortality and morbidity data from cyclones comes from high-income countries, but
figures indicate that most deaths and injuries do not normally arise directly from the wind, butfrom sequelae such as flooding and landslides. Storm surges in coastal areas can be particularly
dangerous. Contusions and lacerations (particularly to the head and extremities) are the widest
reported injuries, particularly in strong cyclones where shelter has been limited. Serious injuries
such as fractures may constitute as low as 1% of all injuries. As with earthquakes, there may be
a significant proportion of indirect injuries reported, such as electrocution and burns, as well as
injuries that occur during clean-up activities. As with earthquakes, preparedness can significantly
lower mortality and morbidity.
Scales for measuring tropical cyclones vary depending on where in the world they occur, but
the Saffir-Simpson Hurricane scale provides a useful illustration of the impact of windspeeds:
Diagram 4: Saffir - Simpson hurricane scale

Category 1
Winds 119-153 km/h (74-95 mph). Some damage andpower cuts.

Category 2
Winds 154-177 km/h (96-110 mph). Extensive damage.

Category 3
Winds 178-208 km/h (11-129 mph). Well-built homes
suffer major damage.

Category 4
Winds 209-251 km/h (130-156 mph). Sever damage towell-built homes, trees blown over.

Category 5
Winds 252+ km/h (157+ mph). Many buildings
destroyed, major roads cut off.

KEY ISSUES
Potential key issues for acute rehabilitation providers: Damage to health infrastructure
across a wide area, small surges in complex trauma cases, internal displacement creating
challenging discharge environments. Possible spikes in infectious diseases.

12 | EARLY REHABILITATION IN CONFLICTS AND DISASTERS INTRODUCTION

CHAPTER 1 | INTRODUCTION

Picture 2: Cyclone Idai (Mozambique, 2019) © C.Briade/HI
Tornados: Tornados can cause death and injury, in particular if they hit areas with lightly
constructed homes. The March 2019 southern Nepal tornado (Nepal’s first confirmed tornado)
killed 28 people and injured over 1,000, while a tornado in Dhaka (Bangladesh) in 1989 wasestimated to have killed over 1,000 people and injured around 12,000. Tornadoes occur mostfrequently in North America, particularly in central and south-eastern regions of the UnitedStates, as well as in southern Africa, north-western and south-eastern Europe, western andsouth-eastern Australia, New Zealand, Bangladesh and adjacent eastern India, eastern China
and south-eastern South America. Data on injuries is limited. A study in China of 451 patients
injured in a 2016 tornado found most had minor injuries. Minor and soft-tissue injuries weremost common, although head (46.63%), and lower-limb (29.43%) injuries were present andover one-third of injuries were fractures.

KEY ISSUES
Potential key issues for acute rehabilitation providers: Localised damage to infrastructure,
surges in complex trauma cases and displacement.
Picture 3: HI responders providing earlyrehabilitation in the community following the 2019
Nepal Tornado© Handicap International

13 | EARLY REHABILITATION IN CONFLICTS AND DISASTERS INTRODUCTION

CHAPTER 1 | INTRODUCTION

Floods: Flooding can occur as a result of tropical cyclones, prolonged heavy rainfall or due tofailures of critical infrastructure, such as dams. Floods are the most common natural hazard
worldwide, with drowning the number one cause of death. Studies indicate that most injuries
are mild lacerations due to floating debris, with a high risk of infection. Flood water is typicallyheavily contaminated, and open injuries sustained are likely to be contaminated. Long-term
health issues, such as spread of communicable diseases and compromised access to healthcare
facilities, cause more problems than acute injuries.

KEY ISSUES
Potential key issues for acute rehabilitation providers: Damage to health infrastructure,small surges in trauma cases with a high risk of infection, internal displacement creating
challenging discharge environments, risk of infectious disease outbreaks.

Picture 4: Crowded evacuation centre during
Sri Lanka floods, 2015
© Handicap International

Picture 5: HI intervention during the floods in
Jammu & Kashmir state, 2014
© Handicap International

Landslides: These have a high death-to-injury ratio (4.5:1). Most deaths are due to suffocation.
Survivor injuries range from lung injuries, thoracic and pelvic injuries and most commonly:
mild bruising and lacerations. A recent review of landslides in Bangladesh in 2017 found ahigh number of minor injuries reported. Authors suggest that ‘physical rehabilitation treatment
capacity in future landslides may be increased by providing rehabilitation technical skills training
to responders and augmenting the emergency response structure with individual rehabilitation
specialists and/or teams of rehabilitation professionals’.

KEY ISSUES
Potential key issues for acute rehabilitation providers: Small surges in complex trauma
cases, localised displacement creating challenging discharge environments.

14 | EARLY REHABILITATION IN CONFLICTS AND DISASTERS INTRODUCTION

CHAPTER 1 | INTRODUCTION

Tsunamis: These are caused by the displacement of large volumes of water, most commonly
resulting from earthquakes. There is a high death-to-injury ratio (4:1) with almost all deaths
caused by drowning. Reports have suggested large proportions of injuries are mild extremity
trauma, including lacerations and also minor fractures. Due to delayed care, challenging discharge
environments and contaminated wounds, infections are common. Of note, a common adverse
health effect after a tsunami is pneumonia, due to aspiration of seawater. This has implications
for the need for respiratory therapy. If the tsunami hits an area affected by an earthquake, it ispossible that responders have to manage both events simultaneously.

KEY ISSUES
Potential key issues for acute rehabilitation providers: Damage to health infrastructure in
low-lying coastal areas, small surges in complex trauma cases with a high risk of infection,
potential respiratory care needs.

Picture 6: Consequences of the Tsunami inIndonesia, 2004
© P. Maury/HI

Picture 7: Tsunami aftermath at a hospital inIndonesia, 2004
© A. Simonazzi/HI

Volcanic eruptions: Major urban centres are commonly found within close proximity to volcanoes,
including Naples and the capital cities of Mexico, Japan and the Philippines, with the highest population
densities in close proximity to volcanoes in south-east Asia and Central America. There is currently
limited evidence for mortality and morbidity figures, with large variations between eruptions. A
median death/injury ratio of 0.63 has been postulated, though morbidity from eruptions, in particularrespiratory complications, are likely to be underestimated. Leading causes of death are asphyxiationfrom ash, thermal injuries from pyroclastic flow and trauma. Traumatic injuries are less common,but can include burns or trauma from projectile impact or collapse of ash-covered roofs. Respiratorycomplications are well-documented, particularly for those with pre-existing respiratory conditions.

KEY ISSUES
Potential key issues for acute rehabilitation providers: Potential surges in burns cases,
small surges in complex trauma, and more widespread surges in respiratory complications.

15 | EARLY REHABILITATION IN CONFLICTS AND DISASTERS INTRODUCTION

CHAPTER 1 | INTRODUCTION

Man-made disasters
Man-made disasters are those resulting entirely or predominantly from human activities andchoices. Such disasters may arise from chemical, nuclear or radiological hazards, as well astransport hazards. Examples include industrial pollution, ionising radiation, toxic wastes, dam
failures, building collapses, transport accidents, factory explosions, ﬁres and chemical spills.
Case Study: The 2013 Dhaka garment factory collapse (also referred to as the Rana Plaza
collapse) was a structural failure that occurred on 24 April 2013 in Bangladesh, where an eightstorey commercial building called Rana Plaza collapsed. The disaster killed 1,134 people, while
approximately 2,500 people were injured.

KEY ISSUES
Potential key issues for rehabilitation provision: These vary widely depending on the hazard.
There may be a need for specialised rehabilitation (such as for burns) and overburdened
local health facilities. Healthcare staff (or family members) may also be affected. There may
be unknown long-term effects of the hazard, and therefore unknown medium- to longterm rehabilitation needs. There may be an additional requirement for isolation of exposed
patients to certain hazards – making treatment more challenging.
Conflict and terrorist attacks
Conflict: Numerous armed conflicts are currently taking place around the world, including
those involving warring parties within a single state (non-international armed conflicts) andthose involving armed forces from two or more states (international armed conflicts). There
were 52 active conflicts in 36 different countries in 2018, causing death, injury, displacement
and suffering on a massive scale. Indirect mortality and morbidity due to destruction of
infrastructure (including the specific targeting of health facilities), displacement of people andfood and water insecurity is also significant.
The type and impact of conflict varies enormously. Weapons can vary from knives andmachetes to explosive weapons capable of causing massive destruction. Those injured andkilled will be both civilians and members of the armed groups. Since 2013, over 90% of
casualties from explosive weapons used in populated areas were civilians.
When compared to disasters, conflicts are often less predictable, often with no one single surgeof trauma cases. Additional security constraints, including the targeting of health staff, meanthat conflict and protracted conflict and their associated displacement of populations are an
extremely complex setting for early rehabilitation provision. There may be a constant influx ofpatients or surges in patients, depending on conflict activity; injury mechanisms and complexity
will be varied and often require long-term specialist interventions. While some civilian and military
rehabilitation providers may operate in the midst of active conflict, in other cases, rehabilitation
may only begin once the patient is removed from an area of active fighting, with patients beingstabilised and then transferred to safer areas for definitive care, including rehabilitation. An
example of this is the trauma pathway utilised by the World Health Organization (WHO) in the
2016-2017 Battle of Mosul.

16 | EARLY REHABILITATION IN CONFLICTS AND DISASTERS INTRODUCTION

CHAPTER 1 | INTRODUCTIONLEVELS OF CARE

1

TRAUMA STABILIZATION POINTS
•
•
•
•

2
3

Located within 5km, or 10 minutes, of the frontline
Provide life-saving triage and resuscitation
Transfer seriously injured patients to field hospitals for care
Move with the battle

FIELD HOSPITALS•••

Located within an hour of the frontline
Provide life and limb-saving surgery and emergency care
Keep patients for 48-72 hrs max, transfer more complex cases totertiary facilities

TERTIARY REFERRAL CARE•••

Refferal centers for more complex surgical cases (burns,
neurosurgery, complex orthopedics
Often located in Erbil or other cities away from the battlefield
Post-operative rehabilitation care

Please see the ICRC/TED Talk by Alberto Cairo here on the importance of continuing
rehabilitation provision during conflict: https://www.ted.com/talks/alberto_cairo_there_are_no_scraps_of_men?language=en

KEY ISSUES
Potential key issues for rehabilitation provision: Access to injured people, safety andsecurity, very short hospital admissions for life-saving care only, a breakdown in referral
pathways, resource constraints, psychological distress of patients and healthcare staff,
long-term rehabilitation uncertainties, movement constraints and population displacement,challenges in identifying patients, ethical challenges, and targeting of health professionals(see Chapter 2).
Terrorist attacks: Terrorism remains a highly contentious term, but for the sake of this publication
we will consider a terrorist attack to be an act that deliberately and violently targets civilians forpolitical or ideological purposes, occurring either in peace time or in the context of war.
Methods of attack include explosive devices such as car-bombs, suicide bombs or improvised
explosive devices (IEDs), close quarter attacks using firearms or blades and chemical, biologicalor radiological (CBR) devices. As with conflicts, the type of injury and implications for earlyrehabilitation vary wildly.

CASE STUDY
The 2017 Manchester Arena suicide bombing killed 22 people, with 800 injured, of which 112 wereadmitted to hospital. The blast resulted in injury patterns (and poly-trauma) not normally seen by
medical teams away from the battlefield, while the scale (and need for ongoing complex medical,
surgical and rehabilitation input) was sufficient to challenge the regional health system, and underlined
the need for whole team preparedness for mass casualty events, even in high-income settings.

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CHAPTER 1 | INTRODUCTION

KEY ISSUES
Potential key issues for rehabilitation provision: A localised surge in highly complex polytrauma cases that can overwhelm both general and specialist services.
Like many disasters, conflicts and terrorist attacks can cause overwhelming numbers of
causalities with complex traumatic injuries. However, injuries sustained in conflict and terrorist
attacks present unique challenges which differ from disasters above, and are also rarely seen in
day-to-day practice away from the conflict zones. Working in situations of conflict, it is importantto understand what weaponry is commonly used and the typical injury patterns and surgicaland rehabilitation implications. In conflict medicine, the concept of ballistics and energy transfer
plays an important role. In short, the level of tissue damage will depend on the efficiency of theenergy transfer of the missile – whether this be a bullet or blast fragment. The ICRC and AO
Foundation Field Guide ‘Management of limb injuries during disasters and conflict’ summarises
this excellently. https://icrc.aoeducation.org/files/downloads/A_Field_Guide_Low_res.pdf
Limitations to healthcare can also result from a restricted ability to access patients, and otherfactors such as infrastructure breakdown, shortage of medical supplies, lack of human resources
and threats of kidnappings and attack. More information on working in conflict, including the
Humanitarian Principles and Healthcare in Danger, can be found in Chapter 2.
The following table summarises common conflict related injuries and their implications forrehabilitation:
Injury typeImplications for rehabilitation

Explosive
weapons andtheir subsequent
blast injuries

This includes missiles, grenades, mortars, landmines and improvised
explosive devices, unexploded ordnance or explosive remnants of war.
Blast injuries are the injuries caused by the multiple effects of explosive
weapons and the ‘overpressure’ created by them. There are four blast
injury types: primary, which is from the blast itself commonly damaging
the lungs and brain; secondary is the result of fragments, which can bebomb casing, shrapnel or even rubble; tertiary injuries are caused bypeople being thrown by the blast and finally, quaternary injuries are fromother things caused by the blast, such as burns or inhalation injury.
The damaging effects of blasts are exacerbated in enclosed spaces, suchas buildings or public transport, where the blast wave undergoes multiple
reflections and causes greater morbidity.
Common injuries include blast lung injury and tympanic membrane
perforation (more common in enclosed spaces), fractures, penetrating
wounds and burns. Treatment is often damage limiting, followed, whereavailable, by extensive reconstruction. Complex poly-trauma (at times
combining neurological, orthopaedic and soft-tissue injury), missed
injuries and the associated psychological impact of blast injuries can allcomplicate early rehabilitation.

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CHAPTER 1 | INTRODUCTION

Injury typeImplications for rehabilitation

Bullet wounds

Can cause extensive soft-tissue, muscle, nerve and bone damage. Exit
wounds, the level and extent of penetration and degree of cavitation will
depend on the type of weapon and ammunition, as well as proximity
and path. Wide excision or fasciotomy may be required to clear foreignmaterial and dead tissue. Primary suture is frequently delayed for highvelocity injuries with grafting and suture at 3-5 days. Fractures are typicallyseverely comminuted.

Chemical,biological,
nuclear orradiologicalincidents (CBRN)

The health impact will be determined by the agent, concentration of theagent, the route of exposure, the rate of exposure and the transmissibility/
potential for spread of the agent or contamination of others. Potential
routes of exposure include: inhalation, ingestion, irradiation, dermal
exposure through intact or non-intact skin and injection. Training in
Personal Protective Equipment (PPE) use is essential for all staff, including
rehabilitation personnel. Long-term effects of CBRN exposure are often
unknown and patients may require extensive follow-up and rehabilitation.

Knife/machete
attacks

Machete attacks and survivors’ resulting amputations became a symbolof genocide in Rwanda and civil war in Sierra Leone in the mid to late
1990s, and such weapons continue be used in attacks in a variety ofcontexts. Often resulting in trauma to the upper limbs, torso and head, thepsychological trauma associated with this type of attack is likely to be high,while traumatic brain injury should be considered with scalp lacerations.

Infectious disease outbreaks
Although not classed as sudden onset disasters or causes of major trauma, infectious disease
outbreaks are worthy of mention and can occur as a result of (or be exacerbated by) conflict anddisaster. Some outbreaks have specific implications for rehabilitation professionals, including viralhaemorrhagic fevers (such as Ebola), measles and pandemic flu. Rehabilitation input will depend
entirely upon the specific disease, context and skill of the rehabilitation professional. Patients treatedin isolation or with prolonged illness can develop secondary complications like blood clots, muscle
wasting, weakness and deconditioning. 70% of Ebola survivors reported musculoskeletal pain andfunctional difficulties, while Diphtheria can lead to cases of polyneuropathy similar to Guillaume
Barré syndrome. Measles can lead to severe pneumonia and also encephalitis, and particularly
affects young children, with a clear role for acute paediatric respiratory therapy. Respiratory therapy
also undoubtedly has a significant role in pandemic flu management, particularly around bronchialsecretion management and supporting those with exacerbations of chronic respiratory conditions.
Due to infection control risks during these procedures, appropriate Personal Protective Equipment(PPE) should be a key feature in the preparation for such events (see Chapter 3).
What is early rehabilitation in conflicts and disasters?
In disaster and conflict settings, rehabilitation is a vital part of healthcare provision required
from the onset of the event providing timely rehabilitation is essential to offer patients the best
outcome.
According to the WHO: ‘Rehabilitation is a set of interventions designed to optimize functioning
and reduce disability in individuals with health conditions in interaction with their environment.’
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CHAPTER 1 | INTRODUCTION

Emergency care and surgical responses have historically been at the forefront of emergencies(particularly conflicts and earthquake response); with rehabilitation previously considered only inthe later stages. This is changing with the concept of ‘early rehabilitation’ positioning itself firmly
within the initial emergency in recent responses and in international guidelines.
There are, however, challenges in defining what exactly ‘early’ rehabilitation is, particularly indisaster settings. Often, it is considered as beginning on acute admission to a health facility,
but in emergencies, some patients requiring early rehabilitation may never be admitted to an
inpatient facility, or may be rapidly discharged due to limited bed capacity or insecurity, meaningthat early rehabilitation actually starts in the community. It can also be defined in terms oftimeliness (from initial injury), but what then of the patient rescued after days trapped in acollapsed mountain home, days from their nearest hospital? Or the patient with the bilateralamputation who is lost to follow-up and only starts rehabilitation one month after the disaster?
Would this still be early rehabilitation?
For the sake of this resource, we will consider early rehabilitation to be the initial rehabilitationthat takes place around the time of initial injury and the onset of acute medical care. It often
has both preventative and rehabilitative components, with a strong emphasis on patient andcaregiver education, and is complicated by the fact that those receiving care may still beacutely unwell. It aims to prevent complications, optimise the potential for long-term functional
recovery and quality of life, reduce length of stay at hospital level and to ensure links to ongoing
services. Early rehabilitation may include the provision of mobility devices, acute burn care andsplinting, peri-operative fracture and amputation care, the prevention of complications of spinal
and nerve injuries, early mobilisation and respiratory care, patient and caregiver education, pain
management and early supported discharge planning or coordination. Provision of such carefollowing an injury can significantly improve outcomes for patients, but also support overall
healthcare delivery by decongesting crowded health facilities, preventing readmission andimproving discharge planning.
Though poorly defined, early rehabilitation is now grounded in international guidelines, including
The Sphere Handbook: universal minimum standards for the delivery of quality humanitarian
response and Emergency Medical Teams: minimum technical standards and recommendations
for rehabilitation
The context, requirements and challenges for early rehabilitation provision will varyenormously between emergency situations. In general, with the acceptance of the World
Health Organization Trauma Pathway (http://www.emro.who.int/images/stories/palestine/
documents/trauma-pathway-4.pdf) and continued strengthening of the national andinternational health system preparedness, surgical and immediate trauma response duringconflict and disasters is becoming more effective and efficient. Patients with life-changing
injuries who would previously have died are now surviving. This implies improved outcomesfor patients, but only if early rehabilitation can capitalise on these advances.

The realities of providing rehabilitation care in a mass casualty situation in conflict or disaster:
The health system may be overwhelmed, damaged or destroyed – this includes thepossibility that healthcare staff have themselves been injured or killed
Patients may present with complex trauma, including poly-trauma
Patients may experience a much shorter length of stay in hospital than in times ofstability – leading to an increased burden on community care

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CHAPTER 1 | INTRODUCTION

Due to resource and time limitations there may be sub-optimal or adjusted medical or
surgical management of injuries, with limited access to services, such as imaging or
specialist surgery
Rehabilitation equipment may also be in limited supply
There may be a breakdown of record systems and patient follow-up
Patients’ homes may be damaged, destroyed or inaccessible, creating challenges for safe
discharge planning
There may be multiple actors on the ground, with potential for confusion between
providers and for local populations
There may be ongoing risks to local populations and health workers, either from enduring
hazards or continued armed conflict
Patients and staff may have experienced, or continue to experience, psychological distress
For a 30-minute talk on being a rehabilitation professional working in conflict and disasters, listen
to this global physio podcast here, presented by Peter Skelton from HI: https://globalphysio.ca/
gp012-deployments-with-peter-skelton/
What exactly is the role of rehabilitation professionals within conflicts and disasters?
The disaster management cycle is actually a continuum of four phases: preparedness, response,
recovery and mitigation. Each phase often blends into the next, with no clear beginning or end.
Diagram 5: Disaster management cycle

Reducing riskof disasters

DisasterDisasterDisasterDisastermanagement

Preparingfor disasters

Responding
to disasters

Recovering from disasters

Reducing risk of disasters

International Federationof Red Cross and Red Crescent Societies

For the purposes of early rehabilitation, we will focus on the role of rehabilitation professionals
in preparedness and response here.

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CHAPTER 1 | INTRODUCTION

Preparedness
Rehabilitation professionals can make significant contributions to disaster management
preparedness. As such, they should be aware of any specific hazards and the vulnerability of
their country/region, and the likely consequences of disasters that could occur. This should
include consideration of likely specific disease or injury types, as well as response capacity andpossible impact on existing healthcare services. Early rehabilitation should then be incorporated
into the healthcare disaster management plan, ensuring an integrated response with clear roles
for rehabilitation professionals from the outset and definitive referral pathways for patients.

The Inform Database (www.inform-index.org) is a global, open-source risk assessment forhumanitarian crises and disasters. It provides an excellent overview of the risk profiles ofindividual countries based on the likelihood of emergencies, vulnerability and coping capacityof the country.
One way to consider preparedness for early rehabilitation in emergencies can be to consider it
in four domains: staff, stuff, systems and space:
Staff

Stuff

SystemsSpace

Should havepersonal
preparedness
plans to look after
themselves andtheir families

Equipment is
stockpiled to
manage immediate
surges (wheelchairs,
crutches, splints,
dressings, etc.)

Rehabilitation is
included in local
and national
health emergency
management plans

Existing
rehabilitation spaces
would withstandand continue tofunction during
identified hazards

Are aware of workbased emergency
plans (including
evacuation)

Equipment isavailable to create
overflow or stepdown areas (seespace)Can be rapidly
mobilised inan emergency(sometimes via aregional or nationalroster)
Are trained to
manage major
trauma (or likely
event related health
events)as part of ateam.
Know their roles(and colleagues
also know andunderstand theirroles).

Rehabilitation
providers/services
are mapped andtheir capacities noted
MDT clinicalprotocols are in
place
There is an agreed
data management
system to measure
injury type andseverity (not justmortality)
There are agreed
emergency referral
pathways forcertain conditions(e.g. burns, SCI,
patients sustaining
amputations)Overflow areas are
identified
Rehab and nursing
step-down forstable patients
is considered
as a means ofdecompressing
acute ward areas
Cohorting ofcertain patients
is considered (forexample patientswith spinal cord
injury)There are agreed
methods to be able
to rapidly assessneed and capacity
following an event.

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CHAPTER 1 | INTRODUCTION

Picture 8: Equipment stockpile being released in Nepal, 2015
© Brice Blondel / Handicap International

A short video from WCPT on the importance of preparedness can be found here: https://www.
youtube.com/watch?v=EgIVz6VrRV4
Preparedness planning should take place on the level of the individual (personal), their placeof work (organisational) and their locality (both regional and national). Mapping of human andinstitutional resources from across the rehabilitation sector is critical and aids a coordinateddisaster response; it informs training needs and the prepositioning of equipment. An example
of a personal preparedness plan template can be found at the end of the chapter.
Further detailed information (and case studies) concerning the role of occupational therapists
and physical therapists in disaster preparedness and response can be found here:
Occupational Therapy in Disaster Risk Reduction (DRR) (World Federation of
Occupational Therapists)
https://www.wfot.org/resources/occupational-therapy-in-disaster-risk-reduction-drr
The role of physical therapists in disaster management (World Confederation for Physical
Therapy) https://www.wcpt.org/sites/wcpt.org/files/files/resources/reports/WCPT_DisasterManagementReport_FINAL_March2016.pdf
Response
The first people to respond to conflicts and disasters are those affected by them, withlocal, national or international support arriving over the first days and weeks. The response
phase can last from a few days to several months, and much longer in many conflicts. The
role of rehabilitation professionals in this phase will be dependent on the nature and scale of

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CHAPTER 1 | INTRODUCTION

emergency, the experience and training of individuals, as well as local health and rehabilitation
infrastructure. In sudden onset disaster scenarios, such as the Nepalese earthquake of 2015,
where rehabilitation has been appropriately embedded into trauma emergency plans, physicaland occupational therapists have been involved in the response from the initial few hours.
Rehabilitation professionals may be required to work outside of their usual workplace, in other
healthcare facilities, community venues and with national or international emergency medical
teams.
Responsibilities in the initial response may include:
Early rehabilitation for those with injuries
Assessing, advising, fitting and providing assistive devices, as well as providing training intheir use and maintenanceRapidly discharging existing patients to free up bed space for incoming acute patients
Providing guidance and education to patients, carers and other healthcare professionals
Coordinating discharge, onward referrals and follow-up of patients once they leave
healthcare facilities
Assessing environments and environmental adaptations needed to ensure accessibility
Additional responsibilities are context specific, and specific to the skills and experience ofindividuals. These can include:
Conducting rehabilitation needs assessments in the disaster context, mapping available
resources and gaps and coordinating an integrated rehabilitation response at either local
or national level
TriageProviding basic psychosocial support, such as psychological first aid, or onward referral toappropriate services
Identifying and assessing people with specific vulnerabilities (such as age, gender ordisability) who may find it harder to access services or receive support
Rapid on-the-job training of rehabilitation colleagues in more specialised areas (such as
spinal cord injuries)
Rapid training of community workers, or other professionals or organisations, to identify
people with a disability and others in need of rehabilitation
In the absence of rehabilitation assistants – training healthcare workers to perform tasks
traditionally carried out by rehabilitation assistants
Advocating for quality rehabilitation provision and basic needs for those injured, atorganisation, local and national levels – including use of injury-specific data
Ensuring inclusion of injured people and people with disabilities in the emergency response
and recovery phases (specifically considering long-term service provision, education,
livelihood, shelter and accessibility)
Leadership and co-ordination in a response
Primary responsibility for coordinating national health sector disaster response lies withthe affected government, usually by means of the command and control centre, commonly

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CHAPTER 1 | INTRODUCTION

known as a Health Emergency Operations Centre (HEOC) or CICOM in the Americas. While
rehabilitation may fall under the responsibility of the ministry of health or another government
ministry, early rehabilitation is generally best coordinated via the same mechanism as theoverall health response. Where there are large numbers of trauma patients requiring ongoingcare, a rehabilitation working group (or sub cluster) may be required. National and international
rehabilitation actors alike engage with this leadership structure to support effective coordinationand ensure adherence to local guidelines, referral pathways and data collection.
There are certain situations where national coordination mechanisms are unable to cope
– due to the severity of the humanitarian situation, or where existing national response orcoordination capacity is unable to meet needs in a manner that respects humanitarian principles(see Chapter 2). This could include such scenarios as conflict or where there is no sovereignstate. In these situations, the Inter Agency Standing Committee (IASC) Cluster Approach may
be implemented. Clusters are groups of humanitarian organisations, both UN and non-UN, ineach of the main sectors of humanitarian action, e.g. water, health and logistics. WHO is thelead agency for the Health Cluster, and when activated, allows organisations to coordinate andpool information, such as shared needs assessments, gaps and priorities.
Diagram 6: Leadership and coordination actors in a response
UNHCR

WF
P&
FOO
FA
DS
O
EC
UR
ITY

O
WH
TH
AL
E
H

Informa
ti

HC
OCHA

ON
ITI
TR
NU
F
ICE
UN

LO
GIS
TI
WF CS
P

UNOP

ERC

EARLY RECOVERY
P
WE
NCY N
GE ATIOER UNIC
EM MM
CO
LE
TE

M
a

on

gementna

UNHCR & IFRCUN
HC
GENCY SHELTER
R
E
R&
CAM
EM
P
IO
& C MA
M
OO NA
RD GE
INA M
ITO ENN

TEDUC
Sa UN ATIO
ve IC
Nthe EF
Ch &ildre

PROTECTIONN E
TIO IENITA YGSAN R & H
E
F
WAT
ICE
UN

25 | EARLY REHABILITATION IN CONFLICTS AND DISASTERS INTRODUCTION

CHAPTER 1 | INTRODUCTION

Actors involved in early rehabilitation
The variety and quantity of rehabilitation actors involved in emergency response will be dependent
on the scale and severity of disaster, pre-existing level of health/rehabilitation infrastructure andthe ability of local and regional actors to cope in both the immediate and longer term. The initialstages of large-scale emergency response can often be chaotic, especially if there are no clear
preparedness plans in place and infrastructure has been damaged. In areas of chronic instability
and conflict, this disorder can persist. It is essential that the individuals responding understandtheir own role and that of the wider humanitarian response, in particular the Humanitarian
Principles. Further online learning is recommended around this subject, and a variety of multilingual courses can be found at www.disasterready.org.
Common actors in emergencies
National
It is well documented that, where they are present locally, it will be national rehabilitation staff
providing the significant bulk of early rehabilitation. Appropriate international assistance fromthe rehabilitation sector should only be deployed if it is required and requested from the hostcountry. Those considering travelling to other countries to offer assistance should consider
what national capacity there is first and also consult the document: ‘Responding internationallyto disasters: a do’s and don’ts guide for rehabilitation professionals.’
In-country rehabilitation responders may include:
Governmental health/rehabilitation services
Military health/rehabilitation services
Non-governmental organisations (NGOs) (that is national non-profit groups which are
independent from government)International non-governmental organisations (if already present in the area, pre-emergency)
Private providers
National associations (such as the relevant national physiotherapy association)
International
In large-scale emergencies, at the request of the host country, or in response to humanitarianneeds, a host of International Non-Governmental Organisations (INGOs) may respond to provide
assistance in many sectors, such as WASH (water, sanitation and hygiene), education, health,shelter etc. INGOs have different mandates, priorities and funding streams and can operate
across multiple sectors.
The following INGOs are examples of those that have recently supported rehabilitation responses
in emergencies:
CBM
Humanity and Inclusion
International Medical Corps
International Organization for Migration
Médecins du Monde
Médecins Sans Frontières
26 | EARLY REHABILITATION IN CONFLICTS AND DISASTERS INTRODUCTION

CHAPTER 1 | INTRODUCTION

Additionally, the International Committee of the Red Cross (ICRC) and The International Federationof Red Cross and Red Crescent Societies (IFRC) often have roles to play in rehabilitation.
In addition to organisations directly involved in health and rehabilitation, it may be necessary forrehabilitation providers to liaise with actors beyond their sector. Camp management, shelter,
protection, nutrition, water, sanitation and hygiene and education are all areas which interlink
with rehabilitation to provide a truly holistic response.
Emergency medical teams (EMTs)
EMT refers to groups of health professionals and supporting staff that aim to provide direct
clinical care to populations affected by disaster or outbreaks and emergencies by acting as surge
capacity to support the local health system. They include governmental (both civilian and military)and non-governmental teams and can be sub-classified as either national or international,
dependent on the area of response. EMTs can range from small group of healthcare workers toa fully functional field hospital.
They comply with the classification and minimum standards set by WHO (https://www.who.int/
hac/global_health_cluster/fmt_guidelines_september2013.pdf) and its partners, and arrive pretrained and self-sufficient, in order to avoid further burdening an often overwhelmed national
health system.
Any EMTs with surgical inpatient capacity (known as Type 2 and Type 3 EMTs) are required to include
rehabilitation professionals and equipment in their team, while there are also standards for teams thatwill just be delivering rehabilitation. Further explicit guidance exists in a separate set of standards:‘Minimum technical standards and recommendations for rehabilitation for EMTs’ (https://extranet.
who.int/emt/sites/default/files/MINIMUM%20TECHNICAL%20STANDARDS.pdf).
In emergencies where significant numbers of national or international EMTs are deployed,
an emergency medical team coordination cell (EMTCC) is likely to exist, either as part of the
HEOC or under the health cluster. The core purpose of the EMTCC is coordinating the surgeof responding EMTs, both national and international, to best meet excess healthcare needs
resulting from the current emergency. Rehabilitation professionals responding as part of an EMT
must ensure they are appropriately trained to deploy and engage fully in a coordinated responseby way of providing information, data collection and updates as to capabilities and activities.

27 | EARLY REHABILITATION IN CONFLICTS AND DISASTERS INTRODUCTION

CHAPTER 1 | INTRODUCTIONREFERENCES
UNISDR Terminology on Disaster Risk Reduction 2017 Available athttps://www.unisdr.org/we/inform/terminology

Natural Disasters 2018 2019 CRED. Brussels
Trends in Armed Conflict – 1946 – 2018 Oslo, Peace Research Institute, Oslo: PRIO 2018
The Sphere Handbook: Humanitarian Charter and Minimum Standards in Humanitarian Response
Association, Sphere. Geneva: s.n., 2018
Emergency medical teams: minimum technical standards and recommendations for rehabilitation
Organization, World Health. Geneva: s.n., 2016
WCPT report: The role of physical therapists in disaster management Therapy, World Confederation
for Physical. London: s.n., 2016
Implementation Guide for Man-made and Technological Hazards UN Office for Disaster Risk Reduction
s.l.: UNISDR, 2017
Lessons from the 2015 earthquake(s) in Nepal: implication for rehabilitation Sheppard P. S.,
Landrey M. D. 9, s.l.: Disabil Rehabil, 2016, Vol. 38, pp. 910-13
Natural Disasters and Injuries: What Does a Surgeon Need to Know? Bartholdson, Sofia and Schree,
Johan von. 2, 2018, Curr Trauma Rep, Vol. 4, pp. 103-108
The International Disaster Database Disasters, Centre for Research on the Epidemiology of. EMDAT. Available at: http://www.emdat.be/ [Cited: 20 06 2019]2017 Bangladesh landslides: physical rehabilitation perspective. Uddin T., Gosney J., Islam M. s.l.:Disability Rehabilitation, 2019, Vol. 28, pp. 1-8
The Human Impact of Volcanoes: A Historical Review of Events 1900-2009 and Systematic
Literature Review. Doocy S., Daniels A., Dooling S., Gorokhovich Y, PLOS Currents Disasters, 2013
Apr 16. Edition 1
Ebola virus disease Beeching N., Fenech M., Houlihan C. 2014, BMJ, pp. 7348-5
Management of limb injuries during disasters and conflict ICRC, WHO. Geneva: ICRC, 2016
Health Care in Danger ICRC, 2019. Available at: http://healthcareindanger.org/the-issue/
Stop Bombing Civilians Inclusion, Humanity and. 2018. Available at:https://humanity- inclusion.org.uk/en/campaign/stop-bombing- civilians?gclid=Cj0KCQjwkK_qBRD8ARIsAOteukAxadFUx- 6gZFuIX9766A_1ltQ7pHMHQ8yiPlVejvRvdho
JrUf4DMaAgnTEALw_wcB
Blast Injuries: The impact of explosive weapons on children in conflict s.l.: Save The Children, 2019
Aid worker security report: Figures at a glance Stoddard, A., Harmer, A. and Czwarno,
M s.l.: Humanitarian Outcomes, 201828 | EARLY REHABILITATION IN CONFLICTS AND DISASTERS INTRODUCTION

CHAPTER 2 | KEY CHALLENGES

CHAPTER 2
KEY CHALLENGES IN DELIVERING EARLYREHABILITATION IN CONFLICTS AND DISASTERS
AIMS:
By the end of this chapter you should be able to understand thechallenges faced in delivering early rehabilitation in conflicts and disasters,
including:Managing large numbers of patients with limited resources
Adhering to key professional and humanitarian standards
Knowing who might be more vulnerable in conflicts and disasters
Keeping yourself safe and well

29 | KEY CHALLENGES IN DELIVERING EARLY REHABILITATION IN CONFLICTS & DISASTERSCHAPTER 2 | KEY CHALLENGES

CHAPTER 2:
KEY CHALLENGES IN DELIVERING EARLY REHABILITATION
IN CONFLICTS AND DISASTERSINTRODUCTION
CASE STUDY
An earthquake has struck your city at 6am – your house and immediate family are OK, butmany properties in your surrounding area are damaged and the roads are blocked by debris.
Communication is down and you can’t contact the rest of your family and friends. The radio isreporting that thousands of people are expected to have been killed and all the main hospitals
are already overflowing. Already there is talk of search-and-rescue and medical teams arrivingfrom outside of the affected area, but you don’t know when. You also don’t yet know which ofyour rehabilitation services (and colleagues) have survived. You are pulled between supportingyour family, helping with the immediate needs in your local area and your role as a rehabilitation
professional.

Picture 1: Destruction following a 7.8 magnitude earthquake in Nepal, 2015

© ADH /Timm Schamberger

30 | KEY CHALLENGES IN DELIVERING EARLY REHABILITATION IN CONFLICTS & DISASTERSCHAPTER 2 | KEY CHALLENGES

Conflicts and disasters result in health services being overwhelmed. They create multiple challenges
to the delivery of safe and effective rehabilitation care, though the type and impact of these challenges
will vary according to the context, severity and acuity of the emergency. While high-income countries
may have more resilient health systems, they may be less familiar with managing the complexities ofmass casualty trauma, while low-income health systems may be more vulnerable but more familiar
with managing conflict or disaster-type injuries and practising with reduced resources.

Typical challenges for the rehabilitation professional include:
Overwhelming patient numbers and how to prioritise care
In the first days following mass casualty situations, there is usually an overwhelming surge ofpatients and it is important to be able to prioritise rehabilitation input. It will not be possible
to treat all patients with rehabilitation needs. This can be an enormous challenge, and means
treatment time with patients is also reduced. It is often best to focus initially on risk management,
and patient and caregiver education can maximise input and carryover. Priorities will vary widely
depending on the setting, resources available, individual presentations and your own skills, butsuggested priorities might include:
1.

Patients whose life may be at risk without rehabilitation input, e.g. new suspected spinal
injuries, or patients in need of urgent respiratory input (if within your scope of practice)2.

Patients who are likely to quickly develop complications without rehabilitation input, e.g.
patients with spinal injuries or burns

3.

Patients who may be facing early discharge or who can potentially be safely discharged
from acute care with rehabilitation input (therefore freeing up resources for others), suchas patients requiring assistive devices, education and a follow-up appointment (e.g.
patients with lower limb fractures following surgical management)

4.

Patients whose conditions will be quickly improved through rehabilitation input or
who might be at risk of slowly developing complications, such as patients with new
amputations, patients on traction and patients with brain injuries

Issues with prioritisation will carry on beyond the first days, and in conflicts and protracted
crises they can continue for the duration of a response, with a persistent challenge of balancing
the needs of new patients requiring early rehabilitation and those with ongoing needs. In thesesituations, patient and caregiver education and ’active’ treatment programmes (using exercise,functional activities and positioning) are key, with patients also taught to identify potential
complications and how to seek assistance if they develop. Passive treatment modalities carriedout by the therapist (whether passive movement, stretching or other modalities) are usually notindicated or are a low priority.

31 | KEY CHALLENGES IN DELIVERING EARLY REHABILITATION IN CONFLICTS & DISASTERSCHAPTER 2 | KEY CHALLENGES

Picture 2: HI Physiotherapist providing early rehabilitation in a busy hospital setting after Haiti earthquake, 2010
© William Daniels / Handicap International

When considering whom to treat (or where to provide care), it is essential to do so based onhumanitarian principles and considering basic medical ethics. Humanitarian principles provide
the fundamental foundations for humanitarian action which rehabilitation professionals working
as humanitarian responders in conflict and disaster settings should adhere to:
Humanity

Neutrality

Impartiality

Independence

Human sufferingmust be addressed
wherever it is found.
The purpose ofhumanitarian action
is to protect life andhealth and ensure
respect for humanbeingsHumanitarian actors
must not take sides inhostilities or engage
in controversies
of a political,
racial, religious or
ideological nature

Humanitarian action
must be carried out
on the basis of needalone, giving priority to
the most urgent casesof distress and making
no distinctions on thebasis of nationality,
race, gender, religious
belief, class or politicalopinions

Humanitarian action
must be autonomousfrom the political,
economic, military orother objectives thatany actor may holdwith regard to areas
where humanitarian
action is being
implemented(OCHA, 2012) https://www.unocha.org/sites/dms/Documents/OOM-humanitarianprinciples_
eng_June12.pdf

32 | KEY CHALLENGES IN DELIVERING EARLY REHABILITATION IN CONFLICTS & DISASTERSCHAPTER 2 | KEY CHALLENGES

Upholding and representing the humanitarian principles are important in supporting
acceptance by the local community whom you are serving, and thus contributing to a safe
operating environment for healthcare staff in emergency settings. Particularly in conflictsettings, both local and international healthcare professionals are particularly vulnerable
to being perceived as non-neutral actors, even when working as healthcare staff. Clear
signposting outside health facilities stating that all are welcome, weapons may not be
brought in and including a clear establishment of criteria for admission or services – so thatreceiving care is not perceived to be at the discretion of any individual health provider – canall help to reduce this risk and foster acceptance in the community. If you are an international
rehabilitation worker supporting national staff, be sensitive to local cultural norms and beaware that your behaviour will reflect upon your organisation and colleagues, often evenafter you have left.
Complexity of injuries
Though this guide presents clinical injuries in distinct chapters like ‘amputation’ and ’fracture’,in reality, many patients in both conflicts and disasters will present with complex poly-trauma,
meaning therapists need to be skilled in multiple clinical areas. The treatment of one injury will
require consideration of others. It is not unusual to treat a patient with multiple fractures, anamputation and significant burns, that all have to be managed concurrently.
A lack of staff with experience in major trauma
In high-income settings, many therapists quickly specialise in particular areas, while in lowincome settings, rehabilitation professionals are sometimes less likely to be integrated into
Picture 3: Patient with lower limb polytrauma© Davide Preti/HI

33 | KEY CHALLENGES IN DELIVERING EARLY REHABILITATION IN CONFLICTS & DISASTERSCHAPTER 2 | KEY CHALLENGES

acute medical teams. Staff with experience in major trauma are almost always in short supply.
Therapists working in trauma care need to be able to perform basic rehabilitation safely for all
patients, including those with orthopaedic, neurological, respiratory and soft-tissue injuries.
There are challenges in expecting generalist physiotherapists to work in major trauma without priorexperience – and so building trauma training into professional training and continuing professional
development is paramount. Therapists who are not appropriately trained need to be given
appropriate roles, or be rapidly trained up and supervised accordingly. In some recent disasters,
to address initial surge needs, physiotherapy and nursing students have been drafted in and given
more basic tasks to perform, while in Nepal the physiotherapy association played a key role incoordinating the mobilisation of additional physiotherapists for the 2015 earthquake response.
Adaptive medical and surgical practiceMedical teams also have to change the way they work in emergencies – access to specialist
services are likely to be limited (at least initially) and management choices are adapted dependingon the environment and pressure on services. For example, intensive care units, where available,
are likely to be overwhelmed. Anaesthesia practices have to be modified and patients without
life-threatening injuries may have to wait longer for definitive management. Infection risks mean
external fixation, delayed primary closure and recurrent debridement’s are often preferred, while
limited access to specialised imaging and surgery may mean that spinal cord and traumatic brain
injuries may need to be managed conservatively. Rehabilitation professionals need to be familiar
with such adaptive practices and adapt their own methods accordingly. Adaptive practices aredetailed in each clinical chapter.
Challenging rehabilitation work space
In large-scale disasters, it is not unusual to be treating acute patients outside of acute wards –whether in hospital corridors, overflow tents in car parks or tents in formal or informal camps;
patients are managed in a wide variety of places. This is magnified in situations that resultin the damage or destruction of healthcare facilities. Multi-disciplinary team (MDT) support is
likely to be more limited in these situations, and risks to patients are further magnified if they
face limited monitoring, or lack an appropriate bed. Patient treatment and education need to beadapted, in particular for patients being managed on the floor, and manual handling needs to beadapted to protect patients, caregivers and staff.
Limited access to equipment
A lack of essential equipment (including assistive devices) can limit rehabilitation; in many areas
it is not possible to scale up local manufacturer and importation timescales, which can cause
problems beyond just the first weeks of an emergency (and persist throughout a conflict). The
pre-positioning of assistive devices has been successful in high-risk areas (such as in Nepal
prior to the 2015 earthquake). For national and international emergency medical teams (EMTs),
the minimum standards for rehabilitation highlight equipment essential (and non-essential
but recommended) for initial deployment; however, these standards are minimum and aimed
at field hospitals and so not directly transferable to fixed trauma or rehabilitation facilities.
Offers of international donations are not uncommon in emergencies, but close examination ofequipment suitability, sustainability (especially for prosthetics) and cost (for example, shipment
or maintenance) is required. EMTs should come with their own equipment, but even then, it will
be limited and will need to be rationed.
34 | KEY CHALLENGES IN DELIVERING EARLY REHABILITATION IN CONFLICTS & DISASTERSCHAPTER 2 | KEY CHALLENGES

Depending on your role, one priority may be the provision of assistive devices to those withpre-existing conditions if their devices have been lost or destroyed and they will be unsafe
without them.
General examples of useful early rehabilitation equipment (which should include both paediatricand adult versions) include:
Elbow crutches
Gutter crutches
Walking frames
Wheelchairs (for inpatient and discharge
use – able to be fitted with pressure
cushion seating)

Stump boards
Pressure mattresses
Basic splints (ankle-foot orthosis andwrist splints)
Portable commodes (for discharge)
Exercise bands
Other equipment may be required depending on the role and competency of the therapist,
including:Pulse oximeter
Goniometer
Splinting kit
Stethoscope
Spinal braces
Blood pressure monitor
A lack of information from medical notes
It is often considered good practice in emergencies for patients to keep a copy of their medical
notes; however, in many situations, notes may be missing or limited. As a result, it can bedifficult to ascertain what treatment and investigations a patient has had. This can be particularly
problematic where there is a lack of documentation of post-operative or post-injury precautions,such as restricted weight-bearing status or limited range of movement. Unless within yourscope of practice, in the absence of documented guidance you must obtain guidance from aphysician regarding issues like fracture stability and ability to weight bear.
Barriers to safe discharge and follow-up
The coordination of inpatient discharge planning and follow-up is still one of the greatest
challenges in emergency settings, especially where patients have been transported fromremote areas, or if their homes have been destroyed. Due to hospitals being overwhelmed,
further anticipated surges or insecurity, patients may need to be moved from an acute setting
as soon as possible, therefore it is important to consider the following points:
1.

Early discharge of acute patients
A lack of bed spaces may lead to earlier than expected discharge; sometimes as soon as apatient is stable post-operatively. Short stays in hospital and limited possibilities for followup place increased pressure on initial rehabilitation sessions, and again emphasise thatpatient and caregiver education, maintaining a database and considering follow up plans
are all critical in the early stage, otherwise patients are lost to follow-up. Even for expected
longer-stay patients, it is still important to make discharge plans early, as emergency settings
can be unpredictable. Establishing rehabilitation criteria and emergency care pathways inadvance of an event can help to limit patients being discharged to an unsafe environment.
During an emergency rehabilitation professionals may have a role in advocating for patientsto remain in health facilities if they are being placed at risk by being discharged.

35 | KEY CHALLENGES IN DELIVERING EARLY REHABILITATION IN CONFLICTS & DISASTERSCHAPTER 2 | KEY CHALLENGES

Picture 4: Rohingya Camp, Bangladesh 2019
© Davide Preti/HI

2.

Challenging discharge destinations
Think about where your patient is being discharged to. This could be (amongst otherthings) their home, a displaced people’s camp or shelter, a step-down facility or to staywith friends or family. They could be travelling several days, or staying alongside thehospital. Examples of the challenges patients face on discharge in emergency settings
include sleeping on hard floors, camps being severely inaccessible, not being able toaccess aid distributions, a lack of caregivers, inaccessible toilet facilities and patientsnot being able to return for follow-up due to distance, cost or availability of transport. If
patients are commonly being discharged to camps, try to find out what the environment
is like. This will help you to problem-solve and set up appropriate treatment plans before
they are discharged.

3.

Family and/or community support
Be mindful that there may be a lack of family/community support, as those affected by
the conflict/sudden onset disaster may have also lost their own families, friends, homes
and livelihoods. Pay particular attention to unaccompanied children, people with existingdisabilities and older people (see the vulnerability section below).
36 | KEY CHALLENGES IN DELIVERING EARLY REHABILITATION IN CONFLICTS & DISASTERSCHAPTER 2 | KEY CHALLENGES

4.

Follow-up
Disasters often affect rural and isolated communities; transport infrastructure andterrain, which may make accessing medical care (and in particular follow-up care andrehabilitation) difficult. Critically injured patients may be evacuated to more central urban
centres for treatment, but wish to return home as soon as possible. Similarly, it is rare
to provide rehabilitation for civilians on the frontline in conflicts. More often, patients arestabilised and then transferred for further care, but their length of stay in facilities is often
short, and safety and security challenges can make follow-up a challenge. This is further
complicated in situations of displacement, where populations are on the move, creating
huge challenges in ensuring continuity of care. Ideally, a patient will be followed up by
the hospital that carried out their main treatment, but in emergencies this is not always
possible. In the early days, there will be uncertainty about what services and facilities
are available to patients needing long-term rehabilitation. Often, private services are
made available free of charge, but may later revert to being charged for. Do not makeassumptions or unqualified promises to patients about access to services in the future.
Community follow-up can also be a challenge, due to safety and security issues and thesheer volume of patients. For international teams, such as EMTs, follow-up can be evenmore challenging, especially if the length of stay of the team is limited or unknown.

5.

Onward referral to other rehabilitation services
Rehabilitation professionals should play a role in making sure that patients who haverehabilitation needs are identified, and referral mechanisms are established. This
would include linking emergency response services with hospital and communitybased rehabilitation facilities. Appropriate follow-up is key to successful patient
outcomes, therefore coordination should be done through existing mechanisms to
avoid duplication. In large emergencies, this may be done through the Health Clusteror the EMT coordination cell. Recently, the inclusion of rehabilitation specialists inoverall coordination (such as in Nepal in 2015 and Mosul in 2016) has included referral
pathways and hotlines being coordinated centrally, so it is critical for rehabilitation
actors to engage with coordination. Where local services are unable to meet demands,
INGOs are likely to be establishing services, and so being aware of all actors involvedin the response is important.

An example of a referral form is available on page 42 of the EMT Minimum Standards andRecommendations for Rehabilitation: https://extranet.who.int/emt/sites/default/files/MINIMUM%20
TECHNICAL%20STANDARDS.pdf
Where it is possible to refer patients, they should be given all the information about their referral
and treatment to date so that they can also follow up themselves (for example knowing wherea prosthetic service is and how to access it).
Dealing with non-emergency related rehabilitation needs
In populations where services have not been available or accessible, or where people aredisplaced or have lost essential equipment, those with disabilities and impairments unrelated tothe current emergency may also need to access the rehabilitation services. Balancing the needsof those with disabilities and chronic health conditions against those with new injuries can bea challenge, in particular where resources are limited. Prioritising based on clinical need (seeearlier prioritisation tool and the professional standards section overleaf) is vital.

37 | KEY CHALLENGES IN DELIVERING EARLY REHABILITATION IN CONFLICTS & DISASTERSCHAPTER 2 | KEY CHALLENGES

Integrating international support
Offers of international assistance can create challenges for local responders. Some international
assistance can be vital, whereas those that stay for short periods of time, or who are not equipped
for the challenges of humanitarian support, can draw time and resource away from a local response.
International rehabilitation responders who will be treating patients are still subject to the sameprofessional requirements as in a non-emergency, and must register with the national authorities.
Normally, unless registered as part of an EMT or INGO, rehabilitation professionals should not
travel to conflict or disaster zones to provide treatment. International responders should prepare interms of language and cultural competency as soon as they learn of their deployment. They should
also be sensitive to the position and experience of local colleagues, and be aware of differencesin remuneration, accommodation and security measures for international and national staff. To
mitigate the likely rapid turnover of international staff in early weeks, clear focal points for contacts
and referral mechanisms should be made and handed over. More information is available in:
Responding Internationally to Disasters: A Do’s and Don’ts Guide for Rehabilitation Professionals:
https://humanity-inclusion.org.uk/sn_uploads/uk/document/responding-disasters-dos-anddonts-guide-rehabilitation-professionals-april-2016.pdf
Maintaining standards of practice in conflicts and disasters
Despite facing overwhelming needs, it is vital that rehabilitation professionals maintainappropriate levels of practice. These include professional standards (such as those publishedby the World Confederation for Physical Therapy (WCPT) and the World Federation of
Occupational Therapists (WFOT)) and also wider humanitarian-specific standards, such as
humanitarian principles, Sphere Standards and the WHO Emergency Medical Team MinimumStandards and Recommendations.
Professional standards
Profession-specific ethical principles (either national or global) continue to apply in emergency
settings. Both WCPT https://www.wcpt.org/sites/wcpt.org/files/files/WCPT-DoP-Ethical_
Principles-Aug07.pdf and WFOT https://www.wfot.org/resources/code-of-ethics havepublished ethical principles for their professions.
Scope of practiceThe sheer volume and diversity of cases faced in emergencies can challenge our scope of practice.
Therapists should work within the boundaries of their professional scope of practice, as definedin the country in which they are working. Even in emergencies, rehabilitation professionals should
practise only in those areas where they are individually safe and competent to do so. It may bepossible to seek support from within the team, or from other responders, if something is outsideof your scope.

38 | KEY CHALLENGES IN DELIVERING EARLY REHABILITATION IN CONFLICTS & DISASTERSCHAPTER 2 | KEY CHALLENGES

Documentation
Informed consent and confidentiality
Principles of informed consent and patient confidentiality are vital during emergencies; both the WCPT
policy statement for informed consent and the EMT Minimum Standards apply in emergency settings.
Database
Keeping a central record of the patients you see is critical, both to ensure they can be followed
up, but also to inform the overall response patterns of need. Most services will already maintaina database, but in the midst of an emergency this can be disrupted or need adaptation. The
purpose of a database is to enable effective tracking and follow-up of patients, and to enable
overall reporting and contribution to a coordinated response. Suggested minimum items for arehabilitation database include:
Patient name
GenderDate of birth or age
Telephone number (or number for a family member or friend if they don’t have one)Type of injury/diagnosis (ideally as part of an agreed response-wide classification system)
Address or discharge destination (if known)
What type of follow-up is required (including any additional medical, equipment or
specialist rehabilitation input).
By recording and reporting on types of injury (normally via a central coordination mechanism,
such as the HEOC), rehabilitation professionals can help guide the overall response. For example,
rehabilitation professionals reporting on numbers of spinal cord injuries or amputations can help
ensure that adequate resources (bed spaces, prosthetic services etc.) are mobilised.
For established multi-disciplinary teams, more comprehensive examples of datasets areavailable, such as those included in the ICRC guide: Management of limb injuries during disasters
and conflicts https://icrc.aoeducation.org/files/downloads/A_Field_Guide_Low_res.pdf and for
EMTs, the EMT Minimum Data Set: https://www.mdsgateway.net/
Documentation of assessment and treatment
Effective documentation is essential where patients may encounter multiple professionals or
medical teams during the course of their treatment, and may consequently lack a thoroughunderstanding of their medical care to date. A lack of systematic record-keeping is detrimental toany coordinated response. Overall, documentation is frequently neglected during emergencies,
which could result in treatment duplication or error.
Maintaining a record of patient assessment, treatment and future treatment plan is vital. It can:Avoid duplication of questioning or treatment and save time
Ensure contraindications and precautions are known
Enable therapists to monitor progress and identify complications
Enable other individuals or teams to easily continue care
Simplify referrals
Ensure accountability to those we work with and work for
39 | KEY CHALLENGES IN DELIVERING EARLY REHABILITATION IN CONFLICTS & DISASTERSCHAPTER 2 | KEY CHALLENGES

Rehabilitation professionals should ensure that all interventions are documented; notes shouldbe legible, avoiding the use of acronyms and abbreviations. At present, specific guidelines foroccupational therapists do not exist; therefore the guidance set out by the WCPT should be adhered
to (WCPT Standards of Practice). https://www.wcpt.org/guidelines/records-management
More detailed information about what to include in your assessment and treatment can be foundin Chapter 3.
Record management
Where possible, rehabilitation notes should be integrated into the patient’s main clinical file. If
this is not possible, a separate record should be maintained.
Ownership of medical records in emergencies has been identified as a controversial area (seeManagement of limb injuries during disasters and conflicts - https://icrc.aoeducation.org/files/
downloads/A_Field_Guide_Low_res.pdf). However, where patients may receive treatment from
more than one team, it is vital that some kind of clinical record (either complete or summative)
remains with a patient so that other healthcare workers can see what treatment they have undergone.
Patients in conflict settings may be much safer if they are identified using a numerical identifier
rather than their name. Additionally, you should consider providing de-identified data to protect
patients if governments demand a record of the medical care provided. Regardless of thesetting, any data should be stored safely and securely, ensuring confidentiality.
Research in conflicts and disasters
Research into early rehabilitation in conflicts and disasters is required to improve preparedness
and response. It is important to collect data and gather evidence to guide future responses. It
is vital to protect patient confidentiality and data collection processes must always place patientcare and dignity prior to any research purposes. Additionally, all research should be conductedwithin this context, gain research ethics approval and, ideally, receive ethical approval from a
local research ethics committee or authority.
Protecting the most vulnerable
Conflict and disaster environments place people at an increased risk of discrimination and/or abuse, inparticular children, women, older people and those with existing disabilities or chronic health conditions(WHO, 2013). In some contexts, this may also include particular ethnic or religious minorities. We
need to be aware of (and act upon) factors that can make certain people more vulnerable.
Gender: Be aware that women, men, boys and girls are affected by conflicts and disasters
differently. Girls and women in particular face increased risks during and after conflict anddisasters: gender-based violence may increase at times of instability, while women and girls
may also face an increased burden of care-tasks (such as provision of food and water) and caring
for the sick and injured. Further information can be found from UNFPA at https://www.unfpa.
org/sites/default/files/pub-pdf/GBVIE.Minimum.Standards.Publication.FINAL_.ENG_.pdf
Age: While children may be particularly vulnerable during emergencies (see below), older people
are also disproportionately affected by conflicts and disasters. They may be more vulnerable to arisk, less able to flee and have reduced access to humanitarian aid. They often play keys roles infamilies and communities, which frequently become even more important in a crisis (e.g. caring
for grandchildren). Further reading from HelpAge can be found here: https://www.helpage.org/
what-we-do/emergencies/older-people-in-emergencies/
40 | KEY CHALLENGES IN DELIVERING EARLY REHABILITATION IN CONFLICTS & DISASTERSCHAPTER 2 | KEY CHALLENGES

Disability: People with disabilities may be disproportionately affected by disasters. They might
be more likely to be left behind in emergency responses, or fail to benefit from humanitarian
services due to a range of environmental, physical and social barriers. Rehabilitation
professionals should have an understanding of issues which may affect patients’ reintegration
into their communities, such as stigma around disability, as well as access to basic services
and environmental accessibility. Read more about disability-inclusive humanitarian action in
the WHO (2013) Guidance Note on Disability and Emergency Risk Management for Health:
https://apps.who.int/iris/bitstream/handle/10665/90369/9789241506243_eng.pdf
A focus on vulnerable childrenChildren are more vulnerable than adults to exploitation and abuse, due to their age, sizeand limited participation in decision-making. In emergencies, systems that protect children,
including family and community structures, often break down and children may be separated
from their families, placing them at risk. Unaccompanied and separated children are at increased
risk of injury, abuse and exploitation, including trafficking or being recruited by armed groups.

KEY pointS
1.

Make sure, first and foremost, that rehabilitation professionals do not pose a risk to
those with whom we are working by ensuring that, even in emergencies, new staff areappropriately screened and inducted2.

Never separate a child from their family or caregivers. Try to group children and theirfamilies together in child-friendly environments and protect them from distressing scenes

3.

Rehabilitation professionals should be aware of the protection focal point in theirorganisation, and know who, how, and when to escalate concerns; particularly aroundthe safeguarding of children

4.

Organisations and individuals should be familiar with the Minimum Standards for Child
Protection in Humanitarian Action

5.

Take time to understand the social norms and expected behaviours for girls and boysof different ages in the culture you are working in. This will help in identifying concerns,
as well as planning services and treatments.

A wealth of resources on protection in emergencies is available from the Global Protection
Cluster: http://www.globalprotectioncluster.org
Safety and security
Safety and security risks are heightened in situations which are insecure, so when working
during an emergency your personal safety and security must be a priority. These concerns arecontext-specific, but it is worth remembering that the usual personal safety fears which may
be encountered in more secure settings are still the most likely sources of danger – your own
underlying health conditions, petty crime and road traffic accidents in particular.
The guide Responding internationally to disasters: a do’s and don’ts guide for rehabilitation
professional is an essential read prior to travelling to a response and highlights the risks ofdeploying independently, or without the necessary attributes and experience.

41 | KEY CHALLENGES IN DELIVERING EARLY REHABILITATION IN CONFLICTS & DISASTERSCHAPTER 2 | KEY CHALLENGES

Prior to starting work, a safety and security briefing should be offered by your organisation. Generalissues which will normally be included are travel, communication (including social media), culturalsafety, community relationships and specifics around equitable provision of healthcare services.
Conflict and emergency situations change rapidly; it is essential to continually analyse thecontext and associated security risks (using multiple sources), and to be aware of and respectorganisational security procedures. The protection of aid workers is enshrined in international
humanitarian law and rules governing non-international armed conflict. However, with the decline
in international conflicts and corresponding increase in non-international conflicts involving nonstate armed groups, often driven by political, religious or ethnic ideologies, there has beenclear erosion in respect for the legal frameworks that protect aid workers. In 2017, 158 major
incidents of violence against humanitarian operations occurred in 22 countries, affecting 313 aid
workers – over 90% of whom were staff working within their own countries.
Additional training about working in insecure environments is available, such as BSAFE (available
in multiple languages) https://training.dss.un.org/course/category/6 or trainings available on
humanitarian training platforms, such as www.disasterready.org or www.kayaconnect.org

Healthcare in Danger
Safety and security for healthcare facilities can often be precarious and cause constraints forhealthcare delivery. Despite healthcare being protected by the Geneva Convention, there are
increasing attacks on health workers, facilities, vehicles and indeed, patients. Health Care in
Danger (HCID) is an initiative of the International Red Cross and Red Crescent Movement aimed
at addressing the issue of violence against patients, health workers, facilities and vehicles, andensuring safe access to and delivery of healthcare in armed conflict and other emergencies.
In 2016, in line with international human rights and humanitarian law, the United Nations
Security Council adopted a resolution condemning attacks and threats against the wounded
and sick, humanitarian and medical staff providing healthcare and their equipment,
transportation and facilities, including hospitals. Nevertheless, attacks on healthcare havecontinued, and in recent years, healthcare activities in Yemen, Syria, Democratic Republic of
the Congo (DRC) and South Sudan have been suspended due to attacks on staff, patients ordirectly on the facilities. Provision of healthcare in emergency situations may entail delivering
healthcare in countries where domestic law is used to criminalise health professionals
providing services to certain groups, or in situations of conflict where the provision ofhealthcare (or prevention thereof) has been manipulated by a party to the conflict. Healthcare
providers may also be harassed or targeted by non-state armed groups or warring militia
who are suspicious of the actions of INGOs or see an opportunity to leverage a ransom.
Looking after yourself
Ensuring the wellbeing and safety of those responding to emergencies is paramount. The
inherent nature of disasters and conflict settings means that there can be significant risk to yourown physical and mental health.
Long working hours, tough environmental conditions, restricted diet, increased stress and exposure
to both distressing events and (in some cases) communicable diseases may all affect your health.
You must take suitable rest periods from working, be aware of current disease outbreaks andtrends and ensure the use of appropriate PPE and adherence to vaccination regimes.
42 | KEY CHALLENGES IN DELIVERING EARLY REHABILITATION IN CONFLICTS & DISASTERSCHAPTER 2 | KEY CHALLENGES

Mental health issues, such as depression, anxiety and ‘burn-out’, are well-documented in humanitarian
workers and volunteers. It is known that national volunteers can be particularly affected. Not only
are they experiencing the same workload stressors, but they have come from affected communities
themselves. They are experiencing the same loss and grief as those they are working to support, but
without the same training, support and structure as professional workers.
It is not just individual traumatic events (such as a violent attack or earthquake), but also thestress of heavy workloads, disagreements with colleagues, long hours and a lack of time forself-care that are key contributors to stress.
Self-careSelf-care is vital to ensure you can continue to operate safely in austere environments. Ways inwhich this may be done include:
Ensuring adequate rest periods
Seeking peer/managerial support, access to psychosocial support and counselling (even if
only long-distance)
Being aware of warning signs in oneself and others, and seeking support around signs ofburn out and severe stress such as behaviour changes, sleep difficulties, risky behaviours
and experiencing withdrawal, outbursts or emotional distress
Negative coping strategies (such as drug or alcohol abuse or excessive working) commonly occur
and can be associated with mental health disorders in humanitarian workers. Stress and ‘burnout’ have an adverse effect on an organisation’s ability to provide services to people directly
affected by the emergency. It is therefore in everyone’s best interests to prioritise self-care andstress management where possible.
IFRC have published helpful field guides on self-care, including “managing stress in the field”
https://www.ifrc.org/Global/Publications/Health/managing-stress-en.pdf and Caring for Volunteers– a psychosocial support toolkit http://legacy.pscentre.org/wp-content/uploads/volunteers_EN.pdf

Picture 5: HI Team participating in a football tournament, Nepal 2015

© Claire Wissing / Handicap International

43 | KEY CHALLENGES IN DELIVERING EARLY REHABILITATION IN CONFLICTS & DISASTERSCHAPTER 2 | KEY CHALLENGES

KEY REFERENCES
Responding internationally to disasters: A do’s and don’ts guide for rehabilitation professionals
Humanity and Inclusion, 2016. Available at: https://humanity-inclusion.org.uk/sites/uk/files/
documents/files/responding-disasters-dos-and-donts-guide-rehabilitation-professionals-april-2016.pdf
Management of limb injuries during disasters and conflict. Geneva: ICRC, 2016 https://icrc.
aoeducation.org/files/downloads/A_Field_Guide_Low_res.pdf
The Role of Physical Therapists in Disaster Management WCPT, 2015 https://www.wcpt.org/sites/
wcpt.org/files/files/resources/reports/WCPT_DisasterManagementReport_FINAL_March2016.pdf
Guidance Note on Disability and Emergency Risk Management for Health WHO, 2013. Available at:https://apps.who.int/iris/bitstream/handle/10665/90369/9789241506243_eng.pdf
WHO Emergency Medical Team Minimum Technical Standards and Recommendations for
Rehabilitation WHO, 2016 https://extranet.who.int/emt/sites/default/files/MINIMUM%20
TECHNICAL%20STANDARDS.pdf?ua=1
Minimum Standards for Child Protection in Humanitarian Action, Child Protection Working
Group, 2019 https://spherestandards.org/resources/minimum-standards-for-child-protection-inhumanitarian-action-cpms/
Factors associated with common mental health problems of humanitarian workers in South Sudan.
Strohmeiher H., Scholte W. 10, s.l.: PLoS One, 2018, Vol. 13.
Mental health and psychosocial support: who cares for the volunteers? Dinesen C. s.l.: Humanitarian
Practice Network, 2018.
Thematic analysis of aid workers’ stressors and coping strategies: work, psychological, lifestyle andsocial dimensions. Young T. K., Pakenham K. I., Norwood M. F. 19, s.l.: Int J Humanitarian Action,
2018, Vol. 3.

44 | KEY CHALLENGES IN DELIVERING EARLY REHABILITATION IN CONFLICTS & DISASTERSCHAPTER 3 | PATIENT ASSESSMENT & TREATMENT - THE BASICS

CHAPTER 3
CHAPTER 3: EARLY REHABILITAITON PATIENTASSESSMENT AND TREATMENT - THE BASICS
AIMS:
By the end of this chapter, you should be able to:Understand the importance of infection prevention andcontrol in conflicts and disasters and the roleof a rehabilitation professional in thisHave the knowledge to undertake a generic earlyrehabilitation assessment
Understand why assessment and treatment approaches
may differ in conflict and disaster settings
Be aware of general key clinical management themes,
including pain management, wound infections and missed injuries

45 | EARLY REHABILITATION PATIENT ASSESSMENT AND TREATMENT - THE BASICS

CHAPTER 3 | PATIENT ASSESSMENT & TREATMENT - THE BASICS

CHAPTER 3:
EARLY REHABILITAITON PATIENT ASSESSMENT
AND TREATMENT - THE BASICS
INTRODUCTION
CASE STUDY
You are working in a hospital during a conflict, and in the past week there have been repeatedairstrikes in heavily populated areas. You have prioritised seeing a 24-year-old woman. She has
a new transfemoral amputation (unclosed – for delayed primary closure) to her right leg and an
external fixator with a large open wound to her left lower leg. She has also lost three fingers
from her right hand. She has a number of other minor shrapnel wounds. On handover from the
medical team, she is now medically stable. The team are concerned that she is not engaging
with them at all, and explain that when she came in, she was screaming about her two children.
She is unaccompanied. You don’t have a psychologist or social worker in your team, and thesurgeon has asked that you assess her.
As in any major trauma setting, those we work with have often experienced incredibly harrowing
events. In disaster and conflict settings though, this is often more profoundly felt, with theimpact not just being on the individual. Frequently, patients will have lost family members andfriends, homes and livelihoods. In some cases, their injuries may even be of secondary concern
to them when compared to the other losses they have experienced. In the early days of a
response, rehabilitation professionals are often among the few professionals to spend extended
time with patients and, as part of our assessments, will uncover often distressing realities
around a patient’s circumstances. This chapter introduces some of the challenges of assessing
and treating patients under such conditions.
As seen in Chapter 2, even when working in a disaster or conflict setting, it is essential tomaintain minimum standards of patient care and to be able to identify common complications.
While elements of this chapter may seem basic, it is the experience of the authors that inemergency contexts, it is often a failure to adhere to the basics that creates the greatest risk.
It is recognised that rehabilitation professionals will have received different levels of training indifferent contexts, and so the aim of this chapter is to create a common understanding about
what basic standards of rehabilitation assessment and treatment are in emergency settings. Thisis essential before progressing on to condition-specific management in the following six chapters.
Basic elements covered here will not be repeated in the clinical chapters.

Infection prevention and control (IPC)
Before seeing a patient, it is worth remembering the principles of infection prevention andcontrol (IPC) are of paramount importance in emergency settings. Limited resources, including
access to clear (potable) water and medical consumables, can create challenges, but IPC
remains essential to protect yourself and your patients. While the ‘open’ nature of traumatic
injuries increases the risks of infection, sub optimal surgical environments, as well as insanitaryconditions post disaster or in camps, can create a perfect storm for infection – both for infectious
diseases and wound infection.
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Basic IPC precautions for rehabilitation professionals include (but are not limited to)Hand hygiene
Use of personal protective equipment such as gloves, masks or aprons where indicatedSterilisation and medical device decontamination
Healthcare waste management
Patient placement (including isolation if required)
Respiratory hygiene and cough etiquette
Environmental cleaning
Prevention of injuries from sharp instruments and post-exposure prophylaxis
Transmission-based precautions
Aseptic technique and device management for clinical procedures (where within scope ofpractice)
Hand hygiene is the cornerstone of IPC. While some specific procedures or infectious diseases
require additional precautions and PPE, the basic principles continue to apply in emergencies(images and guidance from WHO https://www.who.int/gpsc/5may/Hand_Hygiene_Why_
How_and_When_Brochure.pdf )E
ORSE
EF EAN/A PTICL OCEDURE
R

2

P

C

B

When

1

3

4

AFTER
TOUCHING
APATIENT

DY
RE

BEFORETOUCHING
A PATIENT

AF
BO
FL T E R OSUU
R IS I D E X P
K

5

AFTER
TOUCHING PATIENT
SURROUNDINGSHow
If your hands are not visibly soiled, clean them by rubbing them with an alcohol-based
formulation (such as an alcohol gel)
Wash your hands with soap and water when hands are visibly dirty, visibly soiled withblood or other body fluids or after using the toilet
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Rub hands for hand hygiene! Wash hands when visibly soiled
Duration of the entire procedure: 20-30 seconds

1a1bApply a palmful of the product in a cupped hand, covering all surfaces;

3

4

Right palm over left dorsum withinterlaced fingers and vice versa;

6Palm to palm with fingers
interlaced;

7

Rotational rubbing of left thumbclasped in right palm and vice versa;

Rotational rubbing, backwards andforwards with clasped fingers ofright hand in left palm and vice versa;

2

Rub hands palm to palm;

5

Backs of fingers to opposing palms
with fingers interlocked;

8

Once dry, your hands are safe.

Use of gloves
Gloves are often used inappropriately in emergency settings. Even if in short supply,
gloves are single use and should be disposed of safely after patient contact and not bereused.
Examination gloves are only indicated in situations where there is a risk of direct exposure
to blood, body fluids, excretions or items that are soiled with such materials.
Gloves are not required for routine patient contact where there is no risk of contact withblood or body fluids, or a contaminated environment

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Note on IPC and infectious diseases
If you are working in an area where infectious diseases (e.g. cholera, diphtheria, Ebola, Middle
East respiratory syndrome (MERS)) are an identified risk, additional IPC precautions will be inplace. Make sure that you have had specific training and have been provided with additional PPE
as required.
PATIENT ASSESSMENT
While it can be challenging, making time to carry out a thorough assessment of a patient will behighly valuable to rehabilitation professionals in an emergency setting, can save time and avoid
duplication later. Whilst each profession (and in some cases each clinical condition) may havetheir own specific assessment protocols, there are several core elements to each:
Database
If not otherwise recorded by your team, be sure to document the patient’s name, date of birth (orage), telephone number, main diagnosis and address or likely discharge destination (if known).
Refer back to Chapter 2 for more information on maintaining a database. Do not document
information that may place a patient at risk.
Initial subjective assessment
Before seeing a patient, obtain as much information as you can from their medical file andfrom medical colleagues (if available) and document this. Family members can also provide
information where patients remain unwell. Remember that patients may have experienced
extremely traumatic events and already faced repeated questioning from medical staff. Avoid
asking unnecessary questions, but if a patient wants to talk about their experience, try to allow
them time and listen to them, even if you are under pressure. Take note of their mental state –signs of confusion, low mood, anxiety or delirium.
Don’t forget to introduce yourself and your role (in simple language) – some patients may notknow what a rehabilitation professional does. Initial introductions with patients should also
identify what their expectations of rehabilitation and their recovery are.

Note

Note: It is not unusual in emergency settings to find that patients have not had their diagnosis
or prognosis explained to them. For patients with life-changing injuries, if they are not awareof the implications of their injury, try to work with the wider medical team to determine thebest way to inform and educate the patient.
Key points to document
History of presenting condition (HPC) – Date and mechanism of injury, extraction
and pre-hospital care, medical and surgical management to date, including where themanagement took place, the results of investigations and any plans for further management
or precautions, such as weight-bearing status. Be wary in conflicts of documenting any
information that may place a patient at risk.

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Past medical history (PMH) – does the patient have any other known health conditions orprevious unrelated surgeries? Pay particular attention to anything that might impair theirrecovery.
Drug history (DH) – what medication is the patient using? Were they previously taking
anything that was disrupted by the emergency, and do they have any known allergies?
Social history (SH) – in conflicts and disasters, this can be particularly challenging. In somecontexts, sensitive information (for example, loss of family members, and destruction ofhomes) should be taken from the patient file or other sources. It may be important to confirm
languages spoken and literacy. Other factors to document include if anyone is accompanying
them, if they have to care for anyone (e.g. children or older relatives) or if they have people able
to care for them and if they know where they can go after leaving the hospital. Other standard
questions include: what the patient did for work or in their leisure time, their religion and if
appropriate any smoking/drug/alcohol use (as this may impact upon recovery times)
Picture 1: HI rehabilitation staff completingassessments in a disaster setting, Nepal 2015
© Dominique Pichard/Handicap International

Objective assessment
What you assess is determined by the clinical presentation of the patient, but also by yourtraining, role and the protocols of the organisation that you work for. Different organisations willtake different approaches to assessment. As such, we will not prescribe any one approach here,
but will introduce key components of assessment below. During the early stages of disasters,
it may not be realistic to use comprehensive assessment tools, and objective assessments
will need to be very focused. However, the basic findings of any assessment must be always
documented. Depending on your training, common objective assessments to use might include:
Objective

Simple measures used

Notes

Observation of patient,including: distress,
posture, deformities,
external fixation,
surgical sites orwounds and dressings

You can document injuries andobservations on a body chart ifavailable as part of your record

Try to coincide rehabilitation
with dressing checks. Do not
undress a wound yourself unless
you are trained to redress it or acolleague is available to do so.

Check x-rays or other imaging
if you are trained to interpret
results

Signs of wound infection: redness,
warmth, swelling, purulent
discharge, delayed healing, newor increasing pain, malodour

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Objective

Simple measures used

Notes

Neurological disability– consciousness/
pupils/neuro exam

Consciousness can be measured
using AVPU https://en.wikipedia.
org/wiki/AVPU or (more detailed)
Glasgow Coma Scale (GCS)
https://www.physio-pedia.com/
Glasgow_Coma_Scale

AVPU: is the patient Alert,
Verbally responsive, Pain
responsive or Unresponsive

Heart rate, blood pressure,respiratory rate (including workof breathing). Oxygen saturationlevels and temperature (seeranges in the vital signs box
below).

This should only be done if
trained and if you can interpretthe results. See the vital signs
box below for normal ranges.

Vital signs

This is a useful way to identify
changes in consciousness

Vital signs can also be checkedfrom the medical record if
present and regularly monitored.
Vital signs can be used to spot
complications and check whether
a patient is appropriate forrehabilitation
Note signs of sepsis (blood
infection): a fever above 101°F(38°C) or a temperature below
96.8°F (36°C), resting heart rate
higher than 90 beats per minute,
breathing rate higher than 20
breaths per minuteCognition

Quick check orientation to:person/place/time/situation

Orientation check: what’s yourname, do you know where youare, do you know what day (orseason) it is, do you know what
happened to you? More detailed
assessments are possible –see the brain injury chapter for
examplesRespiratory
assessment

Auscultation, palpation, chest
x-ray review

Only if competent to carry thisout and interpret it. This will
identify complications and guideany respiratory treatment

Pain: Type, intensity,
timing, severity, andirritability

Visual Analogue Scale (VAS)
https://www.physio-pedia.com/
Visual_Analogue_Scale

You can also indicate type anddistribution of pain on a body
chart (see below). This can help
identify the cause of pain, and if
it is improving or worsening

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Objective

Simple measures used

Notes

Passive/active rangeof motion in affectedjointsMeasure using a goniometer if
appropriate

If reduced range is a concern.
Always check active movements
first

Muscle strength

Oxford Scale (MRC Scale)https://physio-pedia.com/
Muscle_Strength

If weakness is a concern. This canform part of a neurological exam(see clinical chapters for moredetails)

Muscle tone andspasticity:

Modified Ashworth Scale
https://www.physio-pedia.com/
Spasticity

If neurological injury is suspected

Function: includingbalance, mobility andtransfers, and activities
of daily living (e.g.
toileting/washing/cooking)Functional Independence
Measure (FIM) https://www.
physio-pedia.com/Functional_
Independence_Measure_(FIM)

You can assess function without
using a formal measure. Start
with the simplest likely level ofmobility (e.g. bed mobility for apatient that has not yet sat up)
and work upwards. If time isshort, you can quickly document
key tasks that the patient can or
cannot perform

AIM-T
Berg Balance Score https://www.physio-pedia.com/Berg_
Balance_Scaleor
WHODAS https://www.
who.int/classifications/icf/
WHODAS2.0_12itemsSELF.pdf

Tissue viability status:
skin integrity, pressure
ulcersPressure ulcer classification
https://physio-pedia.com/
Guidelines_on_Prevention_and_Management_of_Pressure_Ulcers

Psychological status:
depression, anxiety,confusion, delirium

Nutritional status

Note that you are unlikely to havetime to use a formal functional
outcome measure in the earlyphase of a response, but thesecan be useful later
For patients with restricted bed
mobility or areas of diminishedsensation. Note that stage onepressure areas can be difficult tosee on dark skin
Always consider the wider
impact of the disaster on theindividual. A distressed, confusedor depressed patient is unlikely
to want to actively participate inrehabilitation.

Mid Upper Arm Circumference(MUAC) for malnutrition
https://www.unicef.org/
nutrition/training/3.1.3/1.html

Beware of the impact ofmalnutrition and micronutrient
deficiency. Talk to your team if
you have concerns.

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Normal vital signs:

Vital signs should only be checked and interpreted if you are trained to do so as part of your role.
Age

Heart Rate

Resp Rate

Systolic BP

Diastolic BP

Preterm

120-200

40-80

38-80

25-57

Full-term

100-200

30-60

60-90

30-60

1 year100-18025-40

70-13045-90

3 years

90-15020-30

90-14050-80

10 years

70-12016-24

90-14050-80adolescent60-10012-18

90-140

60-80

adult

60-10012-18

90-14060-80

Normal temperature: 97.7–99.5 °F (36.5°C to 37.5°C) A fever (a sign of infection) is typically atemperature of over 100.4°F (38°C).
Normal SpO2: 96-99%

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A basic example of a patient assessment form is below:
Patient Name _________________________________ Tel ___________________ Age/DOB _________
Address/Discharge Location: _______________________________________________________________
History of Presenting Condition:

Past Medical History:

Drug History (Medication/Allergies)

Social History (including home and family situation, likely discharge destination)

Precautions or Contra-indications(post-operative restrictions, metalwork, loss of sensation, open wound, infection etc.)

Right

Left

Left

Right

Clinician Name: ______________________________ Org Contact: ______________________________
Signature: ___________________________________ Date: _____________________________________

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GENERAL COMPLICATIONS YOU MIGHT ENCOUNTER
Patients may be at a higher risk of secondary complications in conflicts and disasters, due to factors
associated with disrupted health systems and issues of access. Many secondary complications
arise from inadequate follow-up in emergency situations. Being able to identify and mitigate risk
factors for these complications should be prioritised to prevent further impairment.
Wound infections

Picture 2: Infected wound following a median
nerve injury

Infected wounds can create problems in thefirst days of an emergency, but can continue
to prevent for months. Open injuries with highlevels of contamination (from crush or blast)or at high risk of infection. In situations suchas tsunami and flooding, where lacerations
come in to contact with untreated water,wound infection is also common. In manysettings, access to consumables to maintainadequate wound hygiene and to antibiotics
is often restricted, exacerbating risks. Open
fractures and prolonged external fixation can
all increase the risk of osteomyelitis.

The effects of wound infections can be devastating, creating risks to life and limb. In addition
to contaminated wounds, patients with minor burns/wounds and post-operative patients are at
risk in many emergency situations. Those who have been displaced from their homes or who areliving in insanitary environments with lack of clean water are at higher risk. Patients may havebeen discharged from overcrowded health facilities where wound care was being undertaken byfamily members in the absence of adequate community nursing, and may lack the resources orunderstanding to adhere to high standards of wound, graft or external fixation care.

KEY pointS
1.

Follow basic infection prevention and control procedures at all times – this includes
handwashing and equipment decontamination

2.

Therapists should be familiar with the seven overt signs of wound infection (redness,
warmth, swelling, purulent discharge, delayed healing, new or increasing pain,
malodour) and know what to do when they identify one

3.

Therapists should also be aware of warning signs of sepsis (a complication of severe infection)
including fever, confusion, slurred speech, a non-blanching rash, increased heart andrespiratory rate and diarrhoea. Should sepsis be suspected, seek urgent medical assistance.

4.

Discharged patients should be given clear instructions on wound care and signs ofinfection. Adequate supplies of dressings/cleaning materials must be available and aprocess established to seek medical attention for possible infections

5.

Follow-up of patients should be arranged, even if original care givers move on

6.

Access to clean water and adequate nutrition to promote healing should be advocatedfor these patients

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Missed injuries
Faced with overwhelming numbers of patients, and often with limited access to medical
assessment tools including laboratory, imaging and nerve conduction studies, it is to be
expected that some conditions will be missed by medical teams when providing lifesaving care.
As therapists may be one of the first members of a medical team to review patients following
stabilisation or surgery, they may also become aware of missed injuries or other conditions.
Commonly, these may include peripheral nerve injuries, non-displaced fractures or mildmoderate brain injuries. Sometimes these may be identified several days (or even weeks) after
the injury occurred. Therapists always need to report any unexplained symptoms to a supporting
medical team member, and to be aware of signs of deterioration in their patients.

KEY pointS
On initial assessment, it is always worth checking with patients (or their family members) if
they have any unexplained symptoms.
Poorly controlled pain
Pain management is frequently neglected in emergency settings. Rehabilitation professionals may be
involved in assessing pain, advising on needs for analgesia, as well as delivering non-pharmacological
pain treatments. Some therapy treatments (such as after burn injuries) should be timed to coincidewith optimum pain management and dressing changes to optimise pain management.
In the first days of a response, or in constrained conflict situations, adaptive approaches toanaesthesia and pain management may be used by the clinical team, as the type and quantityof medications available may be limited. Surgically, nerve blocks and ketamine are commonlyused instead of general anaesthesia in conflict and disaster settings. Paracetamol, non-steroidal
anti-inflammatories and opioid based analgesics are all on the WHO essential drugs list and soare more likely to be available than other pain medication, as is as amitriptyline, which can beused (if appropriately prescribed) for neuropathic pain.
For those responding as part of a classified EMT, your patients should have access to adequate
supplies of analgesia. EMT specialist rehabilitation cells are not required to provide medication soshould develop links with other local providers. Knowing what drugs are available locally, and if
patients need to pay for them, can be helpful. Even if medication is available over the counter in somecountries, rehabilitation professionals should not prescribe or advise on medication use beyond theirscope of practice. Note that, for extended scope rehabilitation prescribers, you may not be able toprescribe in another country if this is not within the defined scope of your profession in that country.
Visual pain charts can be used to assess pain:

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Visual analogue scale
No
Pain

Moderate
Pain

0

1

2

3

4

5

Worst
Pain
6

7

8

9

10

Visual analogue scale

0

2

4

6

8

10

General types of pain
Type

CausesCommon Descriptors (examples)

Acute nociceptive pain

Damage to tissues or organs,such as pain from a fracture or
wound or new infection

Sharp, aching, throbbing(inflammatory)

Acute neuropathic pain

Damage to the nervous
system, such as from aperipheral nerve injury or spinal
cord injury

Burning, freezing, shooting, prickly,
electrical, often in areas away fromthe injury and in response to stimuli
that would not normally be painful

Chronic pain

Pain that persists after an injury
has healed

Dull, aching, non-specific

KEY pointS
1.

Staff may be working in facilities where access to effective pain control may be limited.
Work with the team to find the best solutions for your patients

2.

Maintaining pain control on discharge or in a community setting can be difficult,especially if patients cannot access free/affordable medication. There may be problems
with accessing clinics and money for prescriptions, as well as adherence to treatment

3.

Cultural beliefs arounds origins of pain, expectations and acceptance of pain will also
impact treatment and response to rehabilitation.

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Pressure areas
Many traumatic injuries can increase the risk of pressure ulcers developing, in particular conditions
that combine reduced sensation (like spinal or peripheral nerve injuries) with reduced movement(like spinal injuries, brain injuries, or patients on traction). There is evidence of an increase inpressure ulcers in patients, particularly those with spinal cord injuries, in conflicts and disasters.
Inadequate pressure relief, staff shortages, lack of education for carers, poor nutrition andhydration, poor bladder and bowel care contributed to preventable pressure ulcers.
Picture 3: Patient with a pressure ulcer

following a spinal cord injury in the Rohingya Camps,
Bangladesh 2019
© Davide Preti/HI

KEY pointS
1.

Be aware of the risk factors for pressure ulcers, particularly in patients on bed rest, on
traction, or with reduced sensation.

2.

Promote safe positioning from the acute stage; involve volunteers, nursing staff andthe patient’s family/caregiver.

3.

Promote good bladder and bowel care, and ensure there are adequate supplies ofcontinence products

4.

Consider sourcing appropriate mattresses/seat cushions locally, in particular if
patients are being managed on the floor. Escalate equipment needs to coordination
mechanisms, such as the EMTCC

5.

Document pressure risks and pressure areas and seek support from the medical teamin their management

Respiratory complications
There are multiple ways in which conflicts and disasters can affect the respiratory system. There
are obvious direct causes, such as flooding and tsunami (aspiration pneumonia was a significant
issue following the 2004 Indian Ocean tsunami in Aceh), actual chest trauma, inhalation ofsmoke or volcanic smog. In situations of displacement, overcrowding and damp, insanitary living
conditions, acute respiratory infections are also a major cause of morbidity. Patients who areimmobile following injury or surgery are also at risk of respiratory complications, as are those
who have suffered neurological injury, such as a spinal cord injury or stroke. Disease outbreaks

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like measles can also lead to respiratory complications, such as pneumonias, particularly inchildren. Finally, recent re-emerging trends in conflicts have included the use of poisonous
gases, including chlorine, which can cause respiratory complications

KEY pointS
1.

Where possible, patients should be nursed in as upright a position as possible toreduce respiratory complications

2.

Sitting (medically stable) patients out of bed, early mobilisation, and, for bed-boundpatients, using the active cycle of breathing technique (ACBT) or bubble pep may all
help reduce post-operative respiratory complications.

3.

Where trained, rehabilitation professionals should be prepared to use core respiratory
skills for respiratory therapy in conflicts and disasters, including respiratory
assessment, positioning, suction (where available), manual techniques,
active chest clearance techniques and airway clearance games for children.
Acute paediatric respiratory physiotherapy skills are particularly important inoutbreaks such as measles (as seen in Samoa in 2019) and influenza.

BUBBLE PEP

Bubble PEP (Positive Expiratory Pressure):
A simple tool for respiratory therapy
Bubble PEP can be used to encourage air
movement through the lungs and to support
sputum clearance. See https://www.gosh.
nhs.uk/medical-information/procedures-andtreatments/bubble-pep for detailed instructions.
Example of easy to make Bubble PEP is below:
Basic instructions for bubble PEP:
I. Ask your patient to take a breath in and blowout through the tubing, into the water tocreate bubbles. The breath out should be as
long as possible. Aim to get the bubbles outof the top of the bottle each time.
II.

Picture 4: Demonstration of Bubble
PEP in a low resource setting© Davide Preti/HI

Repeat 6-12 times. This is one cycle.

III. Ask your patient to huff (1 or 2 times) (forced
expiration technique) and cough to clear thephlegm, as taught by your physiotherapist.
Encourage your patient to cough the phlegm
out rather than swallow it.
IV. Repeat this cycle (steps one to three) 6-12
times in total

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Malnutrition
The drivers of malnutrition in conflicts and disasters will vary depending on the level of food security,
feeding practices and pre-emergency health services, as well as how these structures are now
affected. Malnutrition (including micronutrient deficiency) in conflicts and disasters can increasemorbidity and mortality and impair recovery. Children under five suffering from severe acutemalnutrition are at high risk of suffering long-term cognitive and physical impairments. Stimulative
therapy and play involving caregivers are recommended once these children are medically stabilised.

KEY pointS
1.

Rehabilitation professionals should be aware of the importance of good nutrition post
injury, and should work with the team to ensure patients are appropriately nourished2.

Rehabilitation professionals should be able to identify patients suffering from severe
acute malnutrition (SAM), including the use (or referral to the medical team) of Mid
Upper Arm Circumference (MUAC) as a reference for this. These patients should bereferred to specialist centres for nutrition support

3.

Severe micronutrient deficiencies (most commonly iron and Vitamin A) can also impact
on recovery. It is good to be aware of common deficiencies in the areas where you areworking, and how to identify them4.

Malnutrition also includes obesity. In countries where the population has high obesity
levels, there are likely to be more patients affected by non-communicable diseases,
such as diabetes and cardiovascular disorders.

Pre-existing health conditions
Whilst conflicts and disasters cause injuries, they also disrupt existing systems and health services.
This can lead to exacerbation of chronic conditions (such as diabetes, cardiac and respiratory diseases).
Trauma patients may have pre-existing health conditions that can exacerbate, or be exacerbatedby, their injury. Diabetes is of particular concern for wound healing.
People with disability may be disproportionately affected by conflicts and disasters. Thisis well documented and there is currently more emphasis on the active inclusion of people
with disabilities in emergency response. Those with disabilities may be more likely to havebeen injured or their assistive devices may have been lost; environments may be lessaccessible and access to regular therapy, medications and care givers may have ceased.
Rehabilitation professionals should aim to actively identify these people and work withcolleagues, community-based groups or disabled people’s organisations to address their needs.

KEY pointS
1.

Take a full medical history for each patient; consider access to necessary medication ortherapy and equipment for chronic conditions

2.

Identify and/or collaborate with local healthcare providers to activate a referral pathway
for patients requiring follow-up for chronic health conditions

3.

Consider the need to replace lost or damaged assistive devices, as well as the need for
new devices for people with injuries
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Infectious diseases
Infectious disease outbreaks as secondary consequences of emergencies are often
exacerbations of endemic diseases caused by the impact of the emergency – whether damage
through contamination of water supplies, destruction of health services or displacement andconsequential overcrowding. Outbreaks can also occur in conflicts due to the above, as well as
longer-term disruption of vaccination and treatment programmes.
Common communicable diseases seen in emergencies include diarrhoeal diseases (including
cholera), acute respiratory infections, measles, and vector-borne diseases (such as dengue fever
and malaria). Pulmonary tuberculosis is also a concern. In some conflict affected areas, diseases
that were once close to eradication, such as polio, are now re-emerging. Access to safe drinking
water, vaccination programmes and rapid case identification and case management are vital topreventing outbreaks.

KEY pointS
1.

Rehabilitation professionals must be vigilant, firstly in respect to their own personal
health and immunisation status, but also in identifying and reporting suspected cases

2.

Be aware of the possible need to scale up rehabilitation services to treat survivors ofparticular outbreaks (see Chapter 1)

3.

Be prepared to help spread key public health messages and encourage good practices
with your patients

Paediatric considerations
Though in many countries paediatrics is considered a clinical speciality, in conflicts and disasters
all therapists are likely to encounter paediatric patients. Children must be considered as a distinct
population. Condition-specific considerations will be mentioned in each chapter, but below aresome general considerations:Children are typically injured alongside family members or friends. This has serious psychologicaland safeguarding implications, which must be addressed concurrently with medical care andrehabilitation. Managing an injured child’s distress should be a priority – don’t force rehabilitation.
Children have anatomical and physiological differences to adults. Specifics in relation to injuries
will be addressed in the coming chapters. From a respiratory perspective, up to the age of
3, ventilation/perfusion (VQ) matching in children is the opposite to adults: Due to chest wallcompliance, the dependent lung is poorly ventilated. To improve VQ matching, position the childwith their good lung UP. More information on respiratory therapy in children is contained in the
respiratory therapy cheat sheet.
Blast injuries in particular often result in poly-trauma, making early rehabilitation more complex.
Younger children in particular are more likely to present with associated head and thoracic
injuries, while the presence of certain explosive remnants of war (such as cluster munitions) can
increase the likelihood of upper limb injuries in children by being mistaken for toys or objectsof interest.
In some contexts, children with impairments may be socially disadvantaged as a result of theirinjury, resulting in them not attending school, being kept at home or being perceived as being

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unable to work or marry later in life. Early education with family members and links to peer
support can help mitigate this.
Injured children may have experienced destruction of their communities, deprivation, forced
displacement from their homes, schools and communities and separation from, or loss of,
loved ones, including parents. While specific agencies often take overall responsibility for childprotection and education, keeping children safe is everybody’s role in humanitarian response.
Refer back to Chapter 2 for information about protecting children in your care.

KEY pointS
1.

Children will require paediatric-sized assistive devices and other equipment. Access topaediatric-specific equipment (such as wheelchairs, crutches, orthotics and prosthetics)
is often limited. Where children require assistive devices over extended periods oftime, these need to be re-fitted regularly while the child is still growing

2.

Carry some child friendly treatment equipment. Carrying some basic toys as part ofa treatment bag (even if just bubbles, balloons, and a mobile phone with music orvideos) can be really helpful

3.

Treatment approaches need to be modified. Consider distraction, play and ageappropriate, activity-based approaches with younger children

4.

Where possible, involve family and caregivers in all aspects of the child’s care. This
reinforces stability to a child and protects them against further psychological distress.
Appreciate who should give consent in a family, according the specific context

5.

For continuity and to enhance feelings of protection and stability, try to keep the same
staff and translators involved in a child’s care. National staff members may be lessintimidating than unfamiliar international staff.

6.

Peer support can be invaluable. Children feel more relaxed in the presence of otheryoung people and can offer each other support. Try to group paediatric beds/treatment
sessions together and incorporate interactive group games.

Picture 5: HI rehabilitation staff providing
treatment to a 4 year old, victim of an airstrike,in Yemen© ISNA Agency / HI

Picture 6: HI rehabilitation staff providing
a treatment session to two young girls with
amputations after the earthquake in Nepal, 2015
© Lucas Veuve/Handicap International

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Rehabilitation-based age appropriate play activities
Type of play

ExampleIn rehab6-18 months

Exploratory

Pushing buttons,
making noise with
instruments.

Use toys that make sounds oractions to encourage movements.
Engage with things like bubbles ormusic.

18 months 3 years

ActiveRunning, jumping,building.

Build treatment around fun basic
fine and gross motor activities, likebuilding blocks or imitating actions.

3-6 years

Imaginative

Playing doctor,
dress up, doing art
activities.

Get the child to also play doctor or
nurse and help out, or build fine
motor activities around art or basic
puzzles.

6-9 years

Challenging

Puzzles and games
that challenge
motor skills.

Use local puzzles or popular sportsthat will challenge the child’s skills.
Use group activities.

9-14 years

Team and
individual

Team sports, butalso individualinterests or hobbies.

Use sports or other appropriate
play, based on the child’s interests.

Note that the above is just a guide – different children will respond differently to different typesof play.
REHAB WITH
DISTRACTION

A paediatric blast injury field manual is available and contains a chapter on rehabilitation, as
well as paediatric rehabilitation considerations for injuries, including spinal cord injuries,
burns and fractures: https://www.savethechildren.org.uk/content/dam/gb/reports/pbip_
blastinjurymanual_2019.pdf

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GENERAL TREATMENT APPROACHESThe following six clinical chapters will detail condition-specific approaches to rehabilitation.
However, there are some general approaches to treatment in conflicts and disasters that areworth emphasising:
Education and self-management
Your time with patients in emergencies is often severely constrained, and opportunities to regularly
follow patients up may be limited. Educating patients and caregivers and providing them with clear
guidance on any restrictions and signs of complications, advice and exercises, and explaining how
to progress (and what to do if they don’t make progress) is key. Where patients are awaiting
definitive management, pre-operative education can make post-operative care much easier.

KEY pointS
1.

Adapt your use of language to ensure your patient can understand you

2.

Check understanding by asking patients or carers to demonstrate or explain what you
have just taught them.

Promoting functional independence
Patients will often leave hospital to return to extremely challenging environments – streets may beblocked, access to essential services (including aid distributions) may be restricted or patients may
be living in tents, crowded conditions or remote locations. Promoting early functional independenceis, therefore, incredibly valuable. In some instances, you may need to use clinical reasoning
to take decisions that best protect a person on discharge in disaster or conflict environments,
rather than following what may normally be considered best practice. A good example of this isproviding crutches (rather than wheelchairs) for amputees who face early discharge to challenging
environments where a wheelchair would leave them stuck in a room or tent.
Though passive modalities are often not useful in acute settings, be aware that in some contexts,‘hands-on’ therapy or electrotherapy will be contraindicated or inappropriate, particularly if
working in conflict areas with victims of torture.
Working with family members or caregivers
In conflicts and disasters, it is often family members who provide routine daily patient assistance.
This can include support with positioning, dressing changes, mobilising, toileting, eating/drinking
and washing/dressing. Therefore, as your own time with patients is also likely to be limited, it isessential to support these care givers on how best to perform tasks safely, whilst also promoting
patient independence. Educating patients and caregivers in basic post-operative rehabilitation,
including positioning, range of motion exercises, transfers and mobility is often vital.

KEY pointS
1.

Consider pictorial aids for caregivers and staff, or positioning charts

2.

Develop guidance in local languages

3.

Remember caregivers may have unseen stressors in addition to the patient care andmay therefore need prompts/visual resources to remember instructions.
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Psychological support for patients
Psychological first aid (PFA)
While rehabilitation professionals may be present during the immediate days and weeks after aconflict or disaster, professional psychological support for patients is often limited in emergencies.
Rehabilitation professionals are often the healthcare specialist who spends the most time withpatients, in particular those with life-changing injuries. Often, they are in a position to support
people, and while many are already well equipped to do this, some may not know what to say or
how to help. It is useful to have a framework that advises what you can say that will be helpful,while keeping yourself and those you are helping safe and respecting people’s dignity, culture andabilities. PFA does just this; the official description of PFA is that it ‘involves humane, supportiveand practical help to fellow human beings suffering serious crisis events.’
Providing PFA means being able to:Provide practical care and support, which does not intrude
Assess needs and concerns
Help people to address their basic needs (for example, food and water, information)
Listen to people, but not pressure them to talkComfort people and help them to feel calm
Help people connect to information, services and social supports
Protect people from further harm (9)You can read more about PFA and download the official guide for humanitarian field workers
here: https://www.who.int/mental_health/publications/guide_field_workers/en/
Peer support
Peer support can be an excellent option for patients who may have experienced life-changing
injuries, such as amputations or spinal cord injuries. Peer support simply means ‘offering
assistance to someone who is at the same level as the supporter’. In conflict and disastersettings this may mean recruiting volunteers who have a pre-disaster impairment as peer
supporters. These volunteers, once trained, are able to offer reassurance of life after injury, as
well as practical and emotional support. At other times, patients with similar level of injuries canbe brought together in an in-patient or clinic setting.
Whilst the aim of peer support is not to replace professional help, it does encourage sharingof emotions, problems and coping strategies in the face of new injuries, whilst alleviating theburden of psychological support from staff.
Psychosocial support
Psychosocial support helps individuals and communities to heal psychological wounds andrebuild social structures after an emergency or a critical event. It can help change people into
active survivors rather than passive victims.
The term ‘psychosocial support’ indicates the strong link between problems of a social andpsychological nature. People affected by the same conflicts and disasters will experience
very different psychosocial impacts. They may have pre-emergency concerns, such as being
marginalised, having previous disabilities or experiencing mental health issues. Other problems
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can arise as a direct result of the emergency, e.g. family separation, destruction of social
networks and livelihoods, grief, depression and anxiety disorders. Finally, the aid response itself
can pose psychosocial problems due to lack of privacy, aid dependency or anxieties around the
distribution of aid.
A short video explaining psychosocial support is available from Save the Children here: https://www.youtube.com/watch?v=_h0L6u68tbI
Consider the following points when providing early rehabilitation in such settings:
1.

Ensure marginalised groups are catered for and can access rehabilitation services

2.

Link with agencies to reunite any separated family members of patients

3.

Link with agencies providing psychosocial support, community groups and livelihood
projects

4.

Consider past and future livelihood as soon as possible and integrate into rehabilitation
goals (access to work is essential not only for economic security, but also for personal
wellbeing and sense of belonging)

REFERENCESManagement of limb injuries during disasters and conflict. Geneva: ICRC, 2016.
Pain Control in disaster settings: a role for ultrasound-guided nerve blocks. Lippert SC, Nagdev A.,
Stone M. B., Herring A., Norris R. 6, s.l.: Annals of emergency medicine, Jun 2013, Vol. 61,
pp. 690- 96.
Medical Rehabilitation after natural disasters: why, when and how? Rathore F. A., Gosney J. E.,
Reinhardt J. D., Haig A. J., Li J., DeLisa J. A. 10, s.l.: Arch Phys Med Rehabil, 2012, Vol. 93,
pp. 1875-81.
Disability inclusion and disaster risk reduction: Overcoming barriers to progress. Twigg, Kett andLovell. London: ODI, 2018, ODI Briefing Paper.
Risk factors for mortality and injury post Tsunami, epidemiological findings from Tamil Nadu.
Guhar-Sapir, Debarati, Parry and Degomme. s.l.: PJJSA, 2006.
Pressure ulcer occurrence Following the great east Japan earthquake: observations from a disastermedical assistance team. Sato T, Ichioka S. 4, s.l.: Ostomy Wound Management, 2012, Vol. 58,
pp. 70-75.
Lessons from the 2015 earthquake(s) in Nepal: implication for rehabilitation. Sheppard P. S.,
Landrey M. D. 9, s.l.: Disabil Rehabil, 2016, Vol. 38, pp. 910-13.
Natural Disasters and the Lung. Robinson B., Alatas MF, Robertson A., Steer H. s.l.: Respirology,
2011, pp. 386-95.
WHO, War Trauma Foundation and World Vision International. Psychological First Aid: Guide for field
workers. 2011.

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CHAPTER 4 | EARLY REHABILITATION OF FRACTURES

CHAPTER 4
CHAPTER 4: EARLY REHABILITAITON OF
FRACTURES
AIMS:
By the end of this chapter, you should be able to:Understand fracture pathology, fracture classification,and implications for early rehabilitation
Complete an assessment of an acute fracture,including identifying complications
Plan and deliver early rehabilitation of fractures
Provide education and advice regarding recovery andsecondary complications of fractures

4

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CHAPTER 4:
EARLY REHABILITAITON OF FRACTURESINTRODUCTION
While fracture rehabilitation is often straightforward, in acute conflict and disaster settings
your rehabilitation work may be complicated by a number of factors related to the context.
In conflicts and disasters, patients often present with multiple injuries, which can complicate
your rehabilitation plan. Rehabilitation professionals working in conflicts and disasters should
be familiar with complex fractures, and adapted surgical management techniques in disasters.
Fractures are among the most common injuries seen in conflict and disaster settings, witharound half of all patients seen in conflict settings presenting with at least one fracture. Be
aware that, due to the sudden surge of demand for health services and inpatient beds during anacute emergency, patients who present with non-life threatening fractures may be discharged
very quickly or may have to wait for definitive management. Patients may be immediately
discharged after the application of Plaster of Paris (POP), thermoplastic orthoses, or even shortly
after orthopaedic surgery. You will need to maintain close contact with the nursing or medical
team in order to be alerted to any cases presenting with fracture, so that you can assess them
before inpatient discharge.
There is a higher risk of wound infection in conflict and disaster settings, as field managementof conflict wounds may be carried out by untrained individuals or with unclean materials, andslow extrication in the case of emergencies like earthquakes or typhoons results in prolonged
exposure to potential sources of infection, such as dirty water. The mechanism of injury is also
relevant as a blast mechanism is likely to force dirt, debris and other contaminants into an open
wound, which may require extensive or multiple debridements. The presence of wounds orother injuries may significantly impact the rehabilitation plan for a patient with a fracture. Medical
notes may be missing, and post-operative instructions may not be relayed by the medical or
surgical team. If there is any uncertainty about safety considerations, such as weight-bearing
status or treatment progression, rehabilitation professionals should use their clinical judgement
and only work within their scope of practice and experience.

ANATOMY
It is necessary to have a basic understanding of anatomy and bone physiology to understandthe implications of a fracture for function and rehabilitation; of weight-bearing versus nonweight-bearing, or fracture through the epiphysis or joint capsule. Below is a basic outlineof fracture types, recovery time and implications for medical and surgical management. For
more detailed information on fracture types, see the Fracture and Dislocation Compendium
https://ota.org/research/fracture-and-dislocation-compendium. For fracture management
in emergency settings, see WHO Disaster Management Guidelines https://www.who.int/
surgery/publications/EmergencySurgicalCareinDisasterSituations.pdf

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Common types of fractures
Different classification systems for fractures exist; however, in an acute conflict and disastersetting it is not necessary to know all these classifications in detail in order to deliver safe andeffective care. At a minimum, you should be aware of some common features to understand
implications for rehabilitation and recovery.
It is important to check the following:
Ensure you have information about the location of the fracture; is it through the bone
shaft, into a joint or are there multiple fractures along the bone?
Assess for deformity; is the bone in alignment, does it have continuity or did the bone
emerge from the skin/soft tissues?
Are there any associated injuries? Is the fracture open or closed and what is thecondition of the surrounding soft tissues? Check the surgical notes and enquire with the
medical team for damage to blood vessels or nerves, as they may impact rehabilitation
What was medical or surgical management? Are they any precautions or restrictions
following management?
Basic fracture descriptions:
Stable (or non displaced) fracture: the broken ends of the bone line up
Displaced: Fractured portions of bone are separated or misaligned.
Closed fracture: the bone has not pierced the skinOpen (or compound) fracture: the skin may be pierced by the bone or by a blow thatbreaks the skin at the time of the fracture. The bone may or may not be visible in the wound
Greenstick: a fracture in a young, soft bone in which the bone bends and breaks
Transverse: the break is in a straight line across the bone
Spiral: the break spirals around the bone; common in a twisting injury
Stress/hairline: small crack or severe bruising within a bone
Oblique: diagonal break across the bone
Compression: the bone is crushed causing the broken bone to be wider or flatter inappearanceComminuted: the break is in three or more pieces and fragments are present at thefracture site
Segmental: the same bone is fractured in two places so there is ‘floating’ segment of bone
Be aware that certain fractures (such as pelvic fractures) are associated with high-energy trauma,such as crush or blast injuries, and are more complex to manage. High-energy trauma injuries
are also often associated with significant blood loss and poly-trauma. In conflicts and disasters,
these patients may be less likely to survive. If they do survive, they are likely to have substantial
associated injuries, such as spinal cord injury or severe soft tissue and organ damage. This
may limit early rehabilitation, or your involvement for rehabilitation may be delayed. If you are
unsure about assessment or treatment of these patients, first seek out the medical team for
information about relevant precautions and always remain within your own scope of practice.
For more information about scope of practice, please refer to Chapter 2.
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Fracture healing and timeline of recovery
When dealing with simple fractures, generally; paediatric fractures will heal most quickly(approximately 3-6 weeks) and adults upper limb fractures will heal faster (approximately six
weeks) than lower limb fractures (approximately 8-12 weeks). After the initial bleeding andinflammation phases, which take around 4-6 days, new cells will begin to proliferate. Remodellingand strengthening of this new bony material will occur over the coming weeks and months.
Remember that, while it is helpful to understand approximate timescales of recovery for different
fracture types, every patient will be different. In conflict and disaster settings, patients may be more
likely to heal slowly. This may be due to multiple injuries, late or suboptimal fracture management,
the patient’s past medical history (conditions such as diabetes, which affect vascular supply, willslow or limit healing) and nutritional and smoking status. Vascular injuries and infections are also
likely to impair fracture healing. Fractures caused by gunshot wounds or blast mechanism, and whichleave behind shrapnel close to the bone, may be more likely to suffer delayed or non-union. Blast or
crush injuries which cause huge soft tissue damage are likely, (if the limb is salvaged) to heal slowly,
due to impaired blood flow, and there is a high likelihood of long-term peripheral nerve injury (PNI).
Diagram 1: Bone healing

Bone strengthens in response to the load it experiences, therefore once safe limits are set by the
medical team regarding weight bearing; your rehabilitation treatment should include progressive
weight bearing. As this guide is focused on the acute phase of rehabilitation, you should prioritise
guiding the patient on the safe limits of weight bearing for the initial phase of their recovery and offer
them basic advice on when and how they can start to increase their weight bearing at home (see thepatient information leaflet).

PAEDIATRIC FRACTURES
When paediatric patients fracture their bones, their bones heal differently to adults. As theligaments of children are stronger than their bones, they are more likely to experience sprains or
greenstick (where the bone bends but does not break) fractures. However, as paediatric bones
are still growing, fractures which cross the growth plate (epiphysis) can cause deformity byimpacting the growth of the bone.
Nevertheless, children may heal more quickly than adults (as fast as about four weeks for somefractures) and they have better opportunity to remodel any deformity. As with adults, healing may
be delayed or impaired by poor nutrition, the physiological load of multiple injuries or health issues.
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Medical and surgical intervention
In an ideal situation, fracture patients will have seen the medical or surgical team who will haverecorded precautions and contraindications for rehabilitation before the patients is examined by
the rehabilitation professional. However, in conflicts and disasters, this may not be the case andpost-operative/medical notes may be limited or not available at all. Wherever possible, always
try to get as much information from the medical team as you can before you see the patient.
If you are unsure about anything, ask, and never do anything in your assessment or treatment
which has been contraindicated by the team. Below is a brief explanation of some of the mostcommon fracture management strategies. Keep in mind that during surgical management,
delicate structures such as nerves or tendons can be damaged, or pins can be accidentallyplaced into these soft tissues. A loss of movement or sensation post-operatively is an indicationthat this may have occurred and the patient should be reviewed by the surgical team.
1.

Plaster of Paris (POP) cast:Frequently referred to as POP casts,
these are normally cheap and readily
available and are used to immobilise andprotect a fractured bone while it heals.
They consist of cotton bandages coatedin wet gypsum, which can be mouldedto the shape of the person’s limb,
before drying into a hard, protective
shell. The patient should avoid getting
the POP wet or putting anything insideit, which patients sometimes do to try
and relieve itching. Itching could cause asore and lead to infection. The fit should
not be too tight to eliminate blood-flow
and you should only apply, or assist in
applying a POP cast if this is within yourscope of practice.

Picture 1: POP cast used in conflict anddisaster settings© Davide Preti/HI

What to watch out for in conflict and disaster settings:
compartment syndrome (refer to the complications table below), open fractures or wounds
inappropriately managed by POP, undiagnosed nerve injuries (refer to the PNI chapter).

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2.

Internal fixation:
Metal plates are surgically inserted andused to hold the bone in place while
it heals. The surgeon may or may notremove the rods once the bone is healed.
Internal fixation may be contraindicatedin conflicts and disasters, due to therisk of infection, suboptimal operating
conditions and challenges with long-term
follow-up. These surgeries should only
take place in fixed facilities; therefore, you
are less likely to encounter them in a field
hospital/tented facility.

What to watch out for in conflict anddisaster settings:
infection, failure of fixation,
undiagnosed nerve injury.
3.

Picture 2: Internal fixation of humerus© Davide Preti/HI

External fixation:
Metal pins or K-wires are surgically inserted through the skin to hold the brokenbone in a corrected position for healing and are attached to an external rod or frame
which holds them in place. The external fixator should be removed once the bone ishealed. They may be used on fractured bone which has fragmented into multiple
pieces, or used to temporarily stabilise a patient with multiple injuries until theyreceive definitive orthopaedic surgery. External fixators may also enable earlier weightbearing compared to a cast; however, you should always check with the surgical team.

What to watch out for in conflict and disaster settings:
pin site or wound infection, insufficient stability from the fixation, undiagnosed nerve
injury, pins inappropriately placed through tendon or nerves.

Pictures 3 & 4: Examples of external fixators used in conflict and disaster settings© Davide Preti/HI

72 | EARLY REHABILITATION OF FRACTURESCHAPTER 4 | FRACTURES

4.

Traction (skin and skeletal):
Traction is widely used for the management of fractures and dislocations (including neckof femur fractures, femoral shaft fractures, displaced acetabular fractures and some pelvic
fractures) in conflicts and disasters. It is usually used because the fracture/dislocation
cannot be treated with POP casting, or as a temporary measure until definitive treatment
is provided. Skin traction may be used as a short-term measure for adults with a femoral
fracture, or may be the definitive treatment for paediatric patients. Skeletal traction is lesseffective for adults as a definitive treatment, but is effectively used for children with hip
fractures.

What to watch out for in conflict and disaster settings:
the development of pressure areas, urinary tract infections, chest infections, footdrop contractures (if the foot is positioned in equinus), peroneal nerve palsy, pin
tract infection and thromboembolic events (e.g. deep venous thrombosis [DVT] or
pulmonary embolism). These complications stem from a lack of patient mobility,
muscle atrophy, weakness and stiffness that result from a fracture. Therefore, bed
exercises and basic respiratory treatment (refer to Chapter 3) can help to minimise
these complications; all within the limitations of the fracture and traction.

Pictures 5 & 6: Examples of traction used in conflict and disaster settings© Davide Preti/HI

ASSESSMENT AND MONITORINGYour assessment for a patient with a fracture in a conflict and disaster setting should follow thesame format as a standard rehabilitation assessment. When the patient has other injuries or isaffected by post- operative medications or pain, it may be difficult to complete a full assessment
in one session. If this is the case it is acceptable to only complete the parts of the assessmentthat it is possible to do, and limit your treatment plan to what can safely be done until you gather
more information. Only assess the components you feel competent to complete, and which fallwithin your scope of practice.
At the end of the assessment you want to be able to produce a list of problems, develop a treatment
73 | EARLY REHABILITATION OF FRACTURESCHAPTER 4 | FRACTURES

plan that focuses on your problem list; and set goals with your patient or their family/caregiver.
General assessment guidance is provided in Chapter 3 of this handbook; however, specificconsiderations that might impact your fracture assessment (and treatment plan) within conflictor disaster setting may include:
Lack of medical history/complete background information such as weight-bearing status
or post-operative notes, due to the emergency transfer of patient, disrupted services andthe potential that the patient has been separated from their family
Increased risk of infection i.e. the mechanism or context of the injury (blast or prolonged
exposure to dirty water) could increase the risk of contamination. Poor theatre conditions
and a contaminated hospital environment, e.g. an emergency camp with limited sanitation
services, can also increase the risk of infection. Disrupted care will make continuity oftreatment difficult, leading to extensive or hard to treat infections
SUBJECTIVE ASSESSMENT
In addition to your standard subjective patient history (refer to Chapter 3), some information isespecially important for prioritising the patient’s problem list and creating a safe and effective
treatment plan. Important fracture specific information to consider for each section is listed below.
History of Presenting Condition (HPC):
A timeline of the injury and treatment to date
The mechanism of injury; was it high- or low-energy? Was there any twisting? These
answers will indicate the extent of the associated soft-tissue injuries, any possible
additional injuries and the risk of complications
Is the treatment definitive or is further surgery required? Note any post-operative
instructions (such as weight-bearing status) from the operation notes or the orthopedic
teamPrevious Medical History (PMH):
Co-morbidities that will negatively impact fracture healing include diabetes, any vasculardisease, prolonged use of steroids or conditions affecting bone integrity (such as
osteoporosis)
The use of non-steroidal inflammatory drugs may impact the inflammatory phase inacute fracture healing. Smoking and poor nutrition will impair healing overall
Special consideration should be given to frail, older patients and others with baseline
co-morbidities that increase their risk of complications, e.g. baseline respiratory or
cardiovascular disease, malnutrition, fragile skin or pre-existing pressure ulcers, falls
history or cognitive impairment
Social History (SH):
Daily activities that the patient needs to complete for independence; i.e. will the patientneed to manage with one hand? Will the patient have to use stairs? Will the patient beable to self-propel a wheelchair (considering environmental and personal factors)? What
will the patient sleep on?
74 | EARLY REHABILITATION OF FRACTURESCHAPTER 4 | FRACTURESPain:
Is the pain controlled to allow the patient to move and mobilise (as allowed by theweight-bearing status)?
Is the pain proportionate to the injury and in the expected location?
Is the pain coming from an undiagnosed injury or might it indicate a serious
complication?
Sensation:
High-energy injuries are more likely to cause nerve (and vascular) injuries, especiallyfracture dislocations. Pressure from splints and surgical repair can also cause nerve
injuries. Note that surgical procedures, such as application of an external fixator, maycause nerve injuries and you should assess your patient’s sensation and movement
post-operatively (for more information on assessment and treatment, refer to the PNI
chapter). Below are some of the most common fracture types which can result in nerve
injuries.
Table 1: Injuries resulting in nerve injuries
Injury type

Nerve commonly affected

Clinical signs

Shoulder fracture
dislocation

Axillary

Deltoid weakness (reduced
shoulder abduction and flexion) andloss of sensation over lateral aspectof upper arm (sargeant’s patch)

Humeral fracture:proximal or shaft

RadialWrist drop and loss of sensation in
first web-space

Humerus fracture supracondylar (morecommon in paediatrics)

Median – anterior
interosseus branch

Loss of thumb IP flexion, i.e. Unable
to perform ‘OK’ sign.

Radial head dislocation +/-Radial – posterior
interosseus branch

Loss of wrist and MCP joint
extension all digits

Fibular head fracture knee
dislocation

Common peroneal

Foot drop

Hip/acetabulum/pelvis
fracture

Sciatic nerve (posterior)Femoral nerve (anterior)Foot drop

ulna/radial fracture‘Monteggia’

Decreased hip flexion/knee
extension power

OBJECTIVE ASSESSMENT
The first role as rehabilitation professionals is to identify any current or potential complications.
A quick neurovascular screen is a good starting point. It can be done very quickly if there are noworrying findings.
75 | EARLY REHABILITATION OF FRACTURESCHAPTER 4 | FRACTURES

Remember the 5P’s
1.

Pain – is there unexpected pain to light touch and/or with passive stretching of theassociated muscles? Is there tenderness surrounding a wound or pin site?

2.

Paraesthesia – any unexplained sensation changes? If so, assess the peripheral nerve
fields distal to the fracture (see nerve injury chapter)3.

Paralysis – any unexplained weakness? Assess movement/muscle activity of the limb

4.

Pallor – is the colour of the limb equal to the other side? Is it grey and dusky or bright
red around a wound? Assess capillary refill (normal = refill in less than two seconds)

5.

Perishing cold – is the temperature equal to the opposite limb? Assess the pulses

Diagram 2: Acute fracture complications:

Impaired
vascularsupplyCrushsyndrome

Compartment
syndrome

Nerve
injuryIncreased
morbidity or
mortality

Fat Embolism

DVT

PE

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Table 2: Acute fracture complications, red flags, and actions to takeComplication

Signs and symptoms(red flags)

Action to take

Rhabdomyolysis (or crush
syndrome)

Significant muscle pain/
swelling

Requires immediate action
from the medical team

Risk factors:
Crush injury (resulting in muscle
damage with byproducts
damaging the kidneys

feverManagement includes
fluid resuscitation and the
management of associatedrenal failure

Timeframe:
usually occurs in the very
acute phase (around 1-3days) post-injury

vomiting
confusion
tea-colored urine
irregular heartbeat

Compartment syndrome(acute)Risk factors:
Tibial or forearm fractures,
high-energy wrist fractures
crush injuries

Pain out of proportion to theassociated injury and painon passive movement of
the muscles of the involved
compartments

Requires immediate
action. Inform the surgeon
immediately.

Timeframe:
usually occurs in the very
acute phase, post-injury

Neurovascular changes –5P’sRemove any cast, splint ofcircumferential dressing andelevate limb to heart level.
May require emergency
fasciotomy

Fat embolism or Pulmonary
Embolism (PE)Increased respiratory
rate, shortness of breath,
confusion, lethargy, rash onchest/neck (fat embolism),chest pain (PE)Inform the medical teamurgently. Check observations;administer oxygen if required
and if this is within yourscope of practice

A swollen, hard, painfullimb that is tender to touch.
Heat and discoloration(usually red but can beblueish-grey)

Inform the medical team.
Check whether the teamis happy for the patient tomobilise

New or increasing pain,
heat, redness, swelling,green or cloudy oozing/
discharge or tenderness

Inform the medical teamTimeframe:
occurs in very acute phasepost-injury
Deep Vein Thrombosis (DVT)
Usually in the calf but canalso occur in upper limbs.
This can progress to a PE(see above)

Severe swelling

Timeframe:
Patient is most at risk in theacute phase and first threemonths post-injury
Infection
This can be from a surgicalwound, open fracture or pin
sites

77 | EARLY REHABILITATION OF FRACTURESCHAPTER 4 | FRACTURES

Picture 7: Left, infected metal implant

Picture 8: Right, post fasciotomy to relieve
compartment syndrome

COMPARTMENT SYNDROME
Compartment syndrome is a MEDICAL EMERGENCY. Pressure builds up within muscles,
which can decrease blood flow and prevent nourishment and oxygen from reaching nerve
and muscle cells. If compartment syndrome is not treated immediately, it can cause
permanent muscle damage, tissue death and infection. If compartment syndrome issuspected (see table above for signs), all tight bandaging and casts should be removed, andan emergency fasciotomy (skin and fascia incisions to relieve compartment pressure) may
need to be performed.
After completing the basic neurovascular assessment and ruling out any red flags, assess thefollowing (observing any instructions/limitations, post-operative or otherwise):
Range of movement (ROM) – assess active ROM and passive ROM unless otherwise indicated.
For example, for a post tendon repair, start with active ROM so that the patient is in control andpain can be monitored. If the patient lacks full active ROM that is not due to pain, then passive
ROM can be gently assessed, taking into consideration any soft-tissue structures that will beaffected.
Strength –Assess the strength of the affected body parts using Oxford Muscle Grading Scale/
Manual Muscle Testing (see Chapter 3 and Chapter 5), starting with isometric testing andprogressing to movement against gravity if permitted. Resisted movements should be avoided
in an acute fracture.

78 | EARLY REHABILITATION OF FRACTURESCHAPTER 4 | FRACTURES

Function – consider how the patient will manage transfers, e.g. lying to standing, and consider
whether they will need any mobility aids for this. Plan how the patient will perform daily activities
while adhering to weight-bearing restrictions. Other functional considerations may include thepatient’s use of a latrine, bed pan and positioning to relieve skin pressure if they are on bedrest(see positioning guidelines in ABI chapter and guidelines on avoiding respiratory complications).
Other considerations for objective assessment
Cast/splint/dressing – check that these are not too loose or too tight due to swelling during theacute phase of a fracture. Ensure that joints (fingers and toes!) aren’t immobilised unnecessarily.
Unless there is an emergency, do not remove a dressing unless you can safely (and competently)
re-apply one. If you suspect an infection, seek support from the nursing or medical team.
External fixator – check all pin sites for signs of infection. Check that all wires and pins are solidand secure. Check that each nut and bolt is tight. Do this systematically, i.e. from top to bottom,
left to right and do it/teach the patient to do it the same way each time, using clean hands. In
addition to potential infections and neurovascular complications, pin sites can impale tendons ormuscle bellies, causing reduced and painful movement.
Use of x-rays – x-rays (and other imaging) if available can be useful as part of an assessment
if it is within your scope of practice as a rehabilitation professional to read them. If not, ask aqualified colleague and do not attempt to interpret them yourself.
Fracture blisters – these usually occur in areas with little subcutaneous tissue such as, the ankle,
tibia and elbow. Blisters are either clear (filled with serous fluid) or haemorrhagic (filled with blood).
Leave the blisters alone, elevate the limb to reduce swelling and inform the medical team.
Outcome measures –outcome measures in this setting should be quick and simple to administer.
Outcome measures frequently used in the acute phase of fracture rehabilitation include manualmuscle testing, ROM and functional goals.
TREATMENTThe treatment section in this chapter relates to upper and lower limb fractures. For spinal
fracture management, please refer to Chapter 8 for more information, for information regarding
pelvic fractures, see the box below. At all stages, consider any spinal precaution instructions
before commencing rehabilitation. If the patient is allowed to mobilise in a spinal brace, ensure
correct fit of the brace (educate family/caregiver) before moving them.
Acute fracture rehabilitation aims to safely maximise function and support fracture healing
while maintaining function and decreasing complications. Rehabilitation treatment should startwith gaining the patient’s trust, providing basic education and advice and adding exercises for
movement and function, as allowed by the medical team and tolerated by the patient.
For specific considerations that might impact your treatment in conflicts and disasters, pleaserefer to Chapter 2.

79 | EARLY REHABILITATION OF FRACTURESCHAPTER 4 | FRACTURESPELVIC FRACTURES
Pelvic fractures may be stable or unstable, and their presence is usually confirmed by theuse of imaging. Unstable fractures in particular are usually associated with high-energy
trauma, such as crush or blast injuries, and are likely to be accompanied by other injuries,
including to the abdomen and urinary systems, and significant blood loss. The medical
team may apply a binder, which you should not remove during treatment or without first
discussing with them. Patients with stable pelvic fracture and limited other injuries may betreated with bed rest.
Rehabilitation may be slow but follows the usual principles; avoiding complications such aspressure sores, minimising weakness and muscle shortening, gradually building strength and
ROM through gradual increase in functional tasks and weight bearing (in accordance with the
instructions from the medical team). Consider implications of other injuries for the use of assistive
devices (e.g. upper limb injury, limiting use of crutches) and include caregivers to maximise
independence in daily tasks, such as toileting, that will be impacted by limited mobility.
Priority list
Priority for treatment of the fracture depends on meeting standards of basic wound and fracture
care revolving around the following surgical objectives:
Adequate wound debridement
Soft tissue coverage
Stabilisation of the bone to allow satisfactory bone healing
Rehabilitation treatment goals
Early active mobilisation of trauma patients has been shown to improve patient function andoutcome. All rehabilitation should include written information and family/carer education in orderto maximise treatment carryover. The use of a diary for patients to record their daily exercises
and mobility/sitting out time has been shown to improve adherence to their rehabilitation
programme.
Your treatment plan should focus on:
Early patient mobilisation
Maintenance of joint range of motion
Maintenance of strength
Return to optimal function
Discharge planning (including outpatient/community follow-up)
For simple fractures without affected ROM, and where a patient can mobilise safely, you
can provide patients or caregivers with basic information to maintain strength and ROM, andminimise pain during the fracture healing period (see the patient information leaflet). Advise
patients to seek rehabilitation services once their fracture has healed (usually when the cast or
external fixator is removed) if they have any ongoing problems, as this may not be automaticallyoffered. Do not undertake wound or pin site care if this is not part of your normal practice (see80 | EARLY REHABILITATION OF FRACTURESCHAPTER 4 | FRACTURES

information on scope of practice in Chapter 2 for more information), but make sure that thepatient knows what to do and has the resources to do this, e.g. their own dressings, access tosoap and clean water and knowledge of where to seek help with this if they need to.
REHABILITATION TREATMENT
Every injury is different, and in conflict and disaster settings you are likely to see complex patientswith many injuries. It can be best to focus on the joints and muscles that are required for initial
functional movements and getting out of bed. Consider what the most important movementthat the patient needs to be able to do is. Ensure that pain is controlled prior to starting any
rehabilitation treatment; please refer to Chapter 3 for more information on pain management.
Beware of potential complications and red flags, which may not become clinically apparent until
the patient begins to move.
Oedema management
Protect, Rest, Ice, Compress and Elevate (PRICE) principles are a good way to minimise acute phaseoedema, use an elasticated bandage if available. Slings for upper limb fractures should be alternatedwith PRICE and gentle exercises to reduce swelling. Oedema management is important in fracturesof the hand and wrist. If oedema is not minimised it can result in stiffness, decreased ROM, increased
pain and long-term deformity/impairment. Elevated positioning and regular mobilisation (avoiding
disruption of the fracture healing) are essential and can be taught to the patient.
ROM and resistance exercises
Active ROM and/or resistance exercises for uninjured limb(s) should be taught, in order tomaintain and increase the patient’s strength, avoid stiffness and reduce the risk of pressure
ulcers. For example, if a patient is immobilised in a below-the-elbow cast for a wrist fracture,
you should provide exercises for the shoulder, elbow and fingers. Overall, for the joints aboveand below an immobilised joint, active or passive ROM should be encouraged.
The patient should progressively improve their strength, moving from isometric to anti-gravity toresisted-range exercises. In the acute stages, however, weight bearing may be contraindicatedand only isometric exercises may be allowed; always confirm with the medical team.

EXERCISES

Bed mobility
The first priority (once safe to do so) is for the patient to sit fully upright in the bed, and toteach caregivers the manual-handling techniques to facilitate this. This will help reduce the riskof pressure ulcers, postural hypotension and improve respiratory function, especially for thosepatients on traction and bed rest. Encourage the patient to assist with this as much as they areable to. Use available tools, such as a rope tied to the end of the bed, to allow the patient toassist and to promote independence with bed mobility.

81 | EARLY REHABILITATION OF FRACTURESCHAPTER 4 | FRACTURES

Weight bearing
Always check the weight-bearing status with the medical team. If you cannot obtain thisinformation in the acute phases it is safer to assume the patient is non-weight-bearing until thiscan be clarified. If some weight bearing is allowed, always consider whether the patient has
the capacity to understand instructions, and to comply with them. If the patient is non-weightbearing, check the patients understanding and compliance with this. Focus on teaching goodtransfer and manual handling techniques that enable the patient and family to continue nonweight bearing when transferring without your help, or once discharged.
Transfers

WEIGHT-BEARING

Progression for transfers can be done in this order:
Sitting balance to sliding board transfer (if available)
Sit to standPivot transfer using a mobility aid (walking or gutter frame)
Ambulation (with/without walking aid) whilst respecting the weight-bearing status ofeach limb
Sliding boards are short in length, made of smooth wood and allow a person to transfer toand from a wheelchair. In conflict and disaster settings, you are unlikely to have sliding boards
available but these can be manufactured locally. When planning transfer practices during
rehabilitation treatment, remember that the patient may be transferring to the floor at home,
especially if they are living in a tent, or sit on the floor for meals. Therefore, it is important topractice transfers according to the patient’s home set-up.
Assistive devices for walking aids could include gutter/walking frames or elbow crutches/
walking sticks. If these are not available, choose the device that best protects the patient’s
weight-bearing status, even if it restricts their mobility. In the early rehabilitation stage, it may
be beneficial to use several people to assist with manual handling and mobility; this will ensure
safe transfers, limit the duration of bed rest and reduce potential complications. Progressive
standing exercises (e.g. weight transfer, stepping, gait and balance (static and dynamic) can also
be performed during transfers.
A sling can be a helpful reminder for the patient to keep the upper limb non-weight-bearing
while doing transfers. (see video of bilaterally non-weight-bearing slide board transfer – edge ofbed, on board and in chair with staff member in front and behind).
TRANSFERS AND
MOBILITY82 | EARLY REHABILITATION OF FRACTURESCHAPTER 4 | FRACTURES

Cardiovascular fitness and strength
Cardiovascular fitness and strengthening is important to avoid overall deconditioning. It canbe achieved by: increasing sets and/or repetitions of sit to stand practice, sitting out of bed
duration, and mobility practice. Pacing during this process is important as it can cause fatigue,
therefore several short walks and sitting out more often for shorter durations to start with arerecommended. Sitting out of bed for meals/dressing changes should also be encouraged.
Electrotherapy
Electrotherapy is contraindicated in the presence of metal implants and practical challenges, suchas limited electricity or single-use pads. A focus on active, functional rehabilitation and education
to help the patient to self-manage at home is preferable. If there is a strong expectation thatelectrotherapy may form part of rehabilitation treatment in your setting, work with your patientto evaluate the limited benefits versus a more active treatment approach and jointly agree aplan.
Multidisciplinary team (MDT) communication
MDT communication is important for the management of fracture patients, therefore consider
the following for your rehabilitation treatment:
Join daily ward rounds and handovers with the orthopaedic team/nursing staff if theyoccur
Give feedback to the orthopaedic team and ward staff after treatment sessions
Plan the timing of rehabilitation sessions when the patient has received their pain
medication, not during meals!
Give feedback to the ward staff if pain medication seems too high or low for yourrehabilitation activities
Speak with family/caregivers present to increase carryover and adherence
If possible, combine rehabilitation sessions with MDT duties, such as dressing changes,
and encourage other team members to support the patient’s rehabilitation treatment
plan (e.g. encourage completion of exercises)
Psychological considerations
It is important in conflicts and disasters to gather information on the mechanism of injury,
including information about self-harm attempts, whether the incident involved fatalities andany signs of post-traumatic distress. In patients displaying or reporting emotional distress or
psychological difficulties, consider onward referral to inpatient or outpatient mental healthservices, if available. Please refer to Chapter 3 for more information about psychological first aid.

83 | EARLY REHABILITATION OF FRACTURESCHAPTER 4 | FRACTURES
ub-acute or delayed presentation complications

Diagram 3: Sub-acute or delayed presentation complications

Delayed,mal- or nonunion
Nerve
injuryPressure
ulcer

Increased
morbidity or
mortality

Avascular
necrosis

Osteo myelitis

CRPS

Wound
infectionNote

ote: You should always be aware of conditions in your patient that can masquerade as fracture
Note: You should always be aware of conditions in your patient that can masquerade as
omplications
regardless of the context, such as tuberculosis or cancer.
fracture complications regardless of the context, such as tuberculosis or cancer.

able 3: Sub-acute or delayed presentation complications
Complication
Osteomyelitis (infection of thebone)

Signs and symptoms (red flags)






Action to take

Inform the medical team of yourFeverconcerns.
Lethargy, malaise (orirritability in children)
pain, swelling, redness and awarm sensation over an areaof boneloss of range of movement

84 | EARLY REHABILITATION OF FRACTURESCHAPTER 4 | FRACTURES

Table 3: Sub-acute or delayed presentation complications
Complication
Osteomyelitis (infectionof the bone)Signs and symptoms (red flags)
Fever
Lethargy, malaise (or irritability inchildren)

Action to take
Inform the medical teamof your concerns.

pain, swelling, redness and a warm
sensation over an area of boneloss of range of movement
Malunion (the bone heals
out of alignment)

Deformity
Reduced functioning in the affectedarea
Discomfort
Pain
Swelling

Non- union (the fracture
does not heal)Continued movement at thefracture site beyond expectedhealing times
Reduced functioning in the affectedarea
Discomfort
Pain

In cases where surgicalpatients are not followed
up by surgical teams(which can occur inmany conflicts anddisasters) then arrange
for orthopaedic review ofthe patient
In cases where surgicalpatients are not followed
up by surgical teams(which can occur inmany conflicts anddisasters) then arrange
for orthopaedic review ofthe patient

Swelling
Complex Regional Pain
Syndrome (CRPS):
abnormally severe pain
and reduced function thatdevelops following injury.
Type 1 (following injury
or immobilisation without
nerve injury) or type 2(injury with nerve injury)

Continuing pain, allodynia, or
hyperalgesia in which the pain isdisproportionate to any known
inciting event

Consult the medical
team and develop a joint
treatment planoedema, changes in skin blood
flow, or abnormal sudomotor
activity (sweating, abnormal hairor nail growth) or reduced range ofmovement in the region of pain
The exclusion of other conditions
that would otherwise account forthe degree of pain and dysfunction

Avascular necrosis – thedeath of bone due to lossof blood supply. Most
commonly seen in sub
capital hip, neck of talus
and waist of scaphoid
fractures.

Gradually worsening pain, inparticular on weight bearing
Reduced range of movement in theaffected joint

85 | EARLY REHABILITATION OF FRACTURES

Arrange urgent
orthopaedic review

CHAPTER 4 | FRACTURES

Discharge planning or ongoing rehabilitation
While a complete discharge plan is unlikely to make up part of your acute rehabilitation of a fracture
patient, it is still something to plan for from your very first assessment. Will the patient need onward
referral, or assistive devices? These can take longer to organise and obtain in conflicts and disasters,so plan ahead. Consider the need for:
Mobility aids, including wheelchairs (if appropriate to provide in the terrain you areworking in)
Home exercise programmes
Family education and support
Follow-up rehabilitation and orthopaedic outpatient appointments
If a patient needs to use crutches or a walking frame, ensure they are safely able to mobilise withthem at the prescribed level of weight-bearing. If upper limb injuries are also present, be sure tocheck weight-bearing status before using walking aids. If the injuries are at the wrist or hand, modified
gutter crutches may be suitable. Ensure the patient can safely stand up and sit down with crutches,
can turn and can climb up and down at least three steps (more if appropriate). Keep in mind that not
all assistive devices and walking aids are helpful in the environments you will be working in. If a splint
is being used, check the section on splinting in the PNI chapter for relevant care and precautions.

CASE STUDY
Past Medical History
Mr Abukhair is a 34-year-old male who presented to the emergency room (ER) following an
explosion, where he was thrown around 100m from the blast site. He was semi-conscious
when he was brought to the ER after three hours of injury, with massive blood loss. He wasimmediately admitted to the intensive care unit (ICU) following initial conservative management.
On investigation, a CT head scan revealed no abnormal findings, but AP, lateral and oblique x-rays
confirmed multiple fractures: displaced pelvic fracture, bilateral femoral fractures and left tibial
fracture. The patient’s neurovascular exam was normal.
While in ICU, his treatment included:
blood transfusions
intrameduallary (IM) nails of both femurs
left tibia external fixationconservative management of pelvic fractures
After 18 days in the ICU, Mr Abukhair was transferred to the orthopedic ward. Bed rest wasadvised for six weeks, due to the pelvic fracture, with no movement at the hip joint permitted.
He did not receive any rehabilitation treatment during his stay in the ICU.
Social History: Chronic smoker for 12 years and chews khat (a local stimulant).
Family History: 6 children. His brother is his main carer while he is in hospital.
Physical examination
Pain assessment
Numeric Pain Rating Scale: 7/10 (in rest), 9/10 with slight movement
Aggravating factor: any movement in lower limb

86 | EARLY REHABILITATION OF FRACTURESCHAPTER 4 | FRACTURES

Relieving factor: rest in supine position with slight abduction and external rotation of hip andmedication
Location of pain: at the hip joint, knee and over the buttock areas
Observations
Lying in supine position with head slightly elevated, IV cannula and urinary catheter in-situ
Long scar running along lateral site of bilateral thighs, bilateral quadriceps muscles wasting
Bilateral lower limb swelling (from toes to knees), external fixator left tibia
Obvious pain on movement of toes and ankles
Dry, broken, pale skin over foot and ankle
On examination
Slight limitation in passive ROM in bilateral ankle and toes due to pain
Dorsi flexors 3+/5 plantar flexors 4/5
Active ROM, complains of pain but can attempt slight movement, not full range
Unable to perform isometric quadriceps contraction due to pain 1/5
Knee flexion; right 20 degrees, left 35 degrees

Picture 10: X-ray to show nails through bilateral femurs

Picture 9: Patient with an external fixation
87 | EARLY REHABILITATION OF FRACTURESCHAPTER 4 | FRACTURES

KEY pointS of the chapter
Fracture rehabilitation in conflicts and disasters are frequently complicated by acomplex ploy-trauma presentation
It is important to be aware of complications and red flags, which can arise alongsideeven simple fractures
A thorough assessment, which includes a social history and joint goal setting with thepatient, will enable you to prioritise your rehabilitation plan appropriately
During immobilisation, whether because of traction, external fixation, POP or
thermoplastic orthoses, the focus should be on maintaining strength, ROM and asmuch independent function as possible
Provide advice to your patient regarding their return to activity and using the affected
limb within the weight-bearing limits set by the medical/surgical team. These are likely
to be conservative in the acute phase
Core recommended text

AO/OTA Fracture and Dislocation Classification Compendium AO Foundation and Orthopaedic
Trauma Association 2018. Available at: https://www2.aofoundation.org/AOFileServerSurgery/
MyPortalFiles?FilePath=/Surgery/en/_docs/A OOTA%20Classification%20Compendium%20
2018.pdf
Management of Limb Injuries in Conflict and Disaster. ICRC 2016. https://icrc.aoeducation.org/

REFERENCES
Physical agent modalities (2nd ed.) Bracciano, A. 2008 Thorofare, NJ: SLACK Incorporated
British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST)(including diagnosis and management of compartment syndrome of the limb)
Available at: https://www.boa.ac.uk/standards-guidance/boasts.html
Fundamental of hand therapy: Clinical reasoning and treatment guidelines for common diagnoses of
the upper extremity (2nd ed.) Cooper, C. 2014 St. Louis, MO: Mosby
Introduction to orthotics: A clinical reasoning and problem-solving approach (5th ed.)Coppard, B. M. and Lohman, H. L. 2020 St. Louis, MO: Elsevier
Fractures due to gunshot wounds: do retained bullet fragments affect union? Riehl, J.T., Connolly,
K., Haidukewych, G. and Koval, K., 2015. The Iowa orthopaedic journal, 35, p.55.

88 | EARLY REHABILITATION OF FRACTURESCHAPTER 5 | PERIPHERAL NERVE INJURIESCHAPTER 5
EARLY REHABILITATION OFPERIPHERAL NERVE INJURIES

AIMS:
By the end of this chapter you should be able to:
Demonstrate a basic understanding of peripheral nerve injury (PNI)
pathology and classification
Perform an assessment for a patient with a PNIDevelop a problem list and a treatment plan for a patient with a PNIDevelop a realistic timeline of recovery and avoid secondary
complications for a patient with a PNI

5

89 | EARLY REHABILITATION OF PERIPHERAL NERVE INJURIESCHAPTER 5 | PERIPHERAL NERVE INJURIESCHAPTER 5
EARLY REHABILITATION OF PERIPHERAL NERVE INJURIESINTRODUCTIONPNIs are a very common presentation in situations of disaster or conflict and are one of theleading causes of long-term impairment. However, in conflicts and disasters, PNIs may be
missed by the medical or surgical team as they prioritise working to save limb or life. Therefore,
rehabilitation professionals may be the first to notice a PNI and should always look for this in
their assessment of a patient injured in conflicts and disasters.
Patients with complex multi-trauma often present with PNIs as part of their injuries. Nerves can be
injured in a variety of ways and to different levels of severity. In conflict and disaster settings, nerves
may be compressed when a person is trapped under rubble, sliced by a knife wound or flying debris,or damaged by a blast. Note that a PNI can also be caused by viral infections, and as they require
similar rehabilitation management, they will not be described separately in this chapter.

AnatomyNerves can be motor nerves supplying muscles, or sensory nerves providing an area of skinwith sensation, or mixed and doing both jobs. Injuries to peripheral nerves, therefore, will cause
problems with power and sensation in the muscles and in the area supplied by that nerve.
For example, injury to the nerves of the hand may make feeling and gripping delicate objects
difficult, while injury to nerves in the leg may weaken or disable the dorsiflexion needed to lift
one’s foot off the ground when walking.
In conflicts and disasters, patients rarely present with only a PNI, and often have multiple
injuries, most frequently fractures. Bony or vascular injuries must be treated and stabilised, e.g.
immobilising a fracture, before the PNI is treated. Specific nerve repair or grafting surgery may
be unavailable in conflict and disaster settings, but early rehabilitation management and advice
to the patient can minimise complications and maximise their independent function.
A nerve consists of the axons of peripheral neurons, bundled into groups called fascicles. Each axon iscovered in a protective layer called the endoneurium, and each fascicle, or bundle of axons, is covered
in a further protective layer called the perineurium. The entire nerve is like a cable consisting ofmultiple fascicles and is covered by an outer layer of connective tissue called the epineurium. Nerves
are also bundled along with protective fluid, and blood vessels which provide energy and nutrientsto the nerve. It is worth noting that sensory information is transported in the outer layer of the nerve
tissue, and so in compression injuries sensation is often more impacted than power or motor function.
Spinal nerve
Epineurium
Axon
Fasciculus
Perineurium

Blood vessels

Edoneurium

Diagram 1: Peripheral nerve anatomy
90 | EARLY REHABILITATION OF PERIPHERAL NERVE INJURIESCHAPTER 5 | PERIPHERAL NERVE INJURIES

Table 1: Common methods of injury to a peripheral nerve
Compression

Laceration/cut

Traction/stretch

Compression injury may occur
to the nerve when a person ora limb is crushed, e.g. trapped
under debris in a collapsedbuilding, or in compartment
syndrome(see
Fractures
chapter), e.g. compression of
the radial nerve with crushed/swollen arm

A laceration or cut (either fully or
partially) to the nerve may occur
if the person is injured by flying
debris or a gunshot, or stabwound.

The nerve may be injured bybeing stretched beyond its
limit if a person is pulled by
the limb through rubble or anarrow space after a building
collapse. E.g. brachial plexus
during a difficult birth

Nerves may also be accidentally
cut during surgery, e.g. amisplaced fixator pin cutting theperoneal nerve

Classification of a PNI
Having some understanding of the level of injury to the nerve is necessary to predict the durationand extent of healing. There are two main systems of classification. Seddon’s system divides
nerve injuries into three broad categories, according to the level of damage, starting with injury
to the ‘lining’ of the nerve tissue, progressing through to the nerve being completely severed.

Neurapraxia(Conduction block)Axonotmesis(Axon divided)

Neurotmesis(Nerve divided)

Diagram 2: Grades of Nerve Injury (Seddon 1942)
Sunderland developed a classification system which added more detail. However, in conflicts
and disasters it is unlikely that you will have the tests available to obtain enough information to
apply Sunderland’s classification.

91 | EARLY REHABILITATION OF PERIPHERAL NERVE INJURIESCHAPTER 5 | PERIPHERAL NERVE INJURIES

Table 2: Sunderland’s classification
SeddonSunderland

Nerve

Potential for recovery

Neuropraxia

1st degree

Usually caused by compression, thenerve is not permanently damaged.
Patient presents with incomplete
paralysis

Good likelihood of fullrecovery within eightweeks

Axonotmesis

2nd degree

The nerve has been partially damaged,
with a larger portion of nerve fibres stillworking and a portion not working

Good likelihood of fullrecoveryAxonotmesis

3rd degree

Around half of the fibres of the nerve
have been damaged and around half
are still working

Potential for recovery,
but will likely be slow,
with less than 100%
recovery. Surgery may
be required

Axonotmesis

4th degree

The nerve has been partially permanently
damaged, with the majority of nerve
fibres not working and a small number
still working

Requires surgicalintervention

Neurotmesis

5th degree

Usually caused by laceration. Nerve
is completely severed, and patient
experiences complete paralysis and lossof sensation

Requires surgicalintervention

Nerve Recovery
For first-degree/neuropraxic injuries, the nerve has good potential to recover and conduct
normally again with restoration of movement and sensation. With second-degree injuries,
healing may be possible but slower, as the damaged nerve fibres need to repair and new nerve
fibres must grow before movement and sensation can return to normal. For injuries of third
degree and higher, surgery is required for recovery of sensation and motor function.

Surgical intervention

Note

Note: Surgery to repair damaged nerves is highly specialised and may not be available inconflicts and disasters, or the available, limited surgical resources may be prioritised for lifesaving interventions
Primary repair (end to end) This approach connects the two ends of a severed nerve and is theideal surgical option; however, this should be completed within the first few days of injury andwithout any stretch or tension through the repair site.

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Nerve grafting (to bridge gaps in nerves) This approach can also be used. Autografts, whereby
healthy nerve tissue is transplanted from elsewhere in the patient’s own body, come in several
forms, such as cable (several sections of small nerve grafts bundle into parallel lines), trunk (mixed
motor and sensory nerves, often of larger diameter) and vascularised (sensory nerve donor, suchas sural). Allografts (commercially processed scaffold) may also be used. Grafting can occur at alater date than primary repair, but must still take place within two years of the initial injury.
Timeline of recovery
For neuropraxic injuries, (e.g. first degree) recovery will take place within six weeks on onset,
or once the source of compression is removed. For example, in a limb with extensive swelling,
once the swelling is resolved and this pressure on the nerve is released, the nerve should
function normally again. For more significant injuries, such as second degree or higher, once
the affected nerve is in continuity it will regenerate at roughly 0.5mm to 2mm per day. This
regeneration will occur from the site of injury and moves distally. It will continue for roughly amaximum of two years, no matter what level of injury. This is important when planning how
often you should reassess the patient, and when telling patients what to expect after discharge.
Diagram 3: Lower Limb Nerves

Diagram 4: Upper Limb Nerves
Axillary(circumflex)
nerve

Radialnerve

lateral femoral
cutaneous nerve

Radial nerve
behindhumerusMediannerve
Radialnerve

sciatic nerve

Mediannerve

commonperoneal nerve

Radial
nerve
Ulnar
nerve

Ulnar
nerve

Branchof radial
nerve
Ulnar
nerve

Anterior view

tibial nerve

the tibial nerve
wraps aroundthe back of theankle where it
becomes theposterior tibial
nerve as it
passes throughthe tarsal tunnel
to the inner footdeepperoneal nerve

superficial
peroneal nerve

93 | EARLY REHABILITATION OF PERIPHERAL NERVE INJURIES

Radialnerve

Posterior view

CHAPTER 5 | PERIPHERAL NERVE INJURIES

Secondary complications
Secondary complications of PNIs are also a significant issue, some of which are discussed in greater
detail in the opening chapters. Before discharge, or as a key part of treatment, the patient and theircaregiver should be made aware of the following potential complications and how to avoid or minimise
them:
Loss of function – PNIs can reduce the patient’s ability to complete basic daily activities, such as
washing, dressing, cooking etc. Use of equipment, such as splints, or compensation strategies
can help
Swelling – Due to reduced blood-flow and lymphatic drainage, limbs can become swollen andtake a long time to resolve, leading to potential further neuropraxias and pain. Keeping the limb in
a comfortable, elevated position and regular passive range of motion (ROM) and/or active ROM,
as able, will help
Contracture – Due to muscle imbalance around a joint, contractures or fixed muscle shortening can occur
within days. Keeping the limb in a neutral resting position through the use of a prefabricated or custom
thermoplastic orthosis, and regularly moving the joints through their full ROM will help
Burns/lacerations – Patients with decreased sensation can easily burn or injure themselves throughcontact with hot surfaces or water or not using protective clothing, e.g. shoes. Test water with the
opposite, or sensate limb, and always wear covered, supportive shoes if foot sensation is reduced
Pressure ulcer – Patients with limited sensation as a result of a PNI are at risk of pressure ulcers,which are harder to see on dark skin. Keeping skin dry, regular position changes and regular skinchecks (use a mirror if necessary) will help
Neuroma – A non-cancerous thickening of nerve fibres made of non-conducting tissue which
stops the signal from being sent along the nerve. Neuromas are a potential, limiting complicationof nerve recovery which can cause pain or hypersensitivity; they usually do not develop until atleast six weeks post-injury.
Pain and hypersensitivity – Can be bothersome and potentially lead to complex regional pain
syndrome (CRPS) (see references below). Starting re-sensitisation training will help reduce therisk of this complication
Slow healing wounds – PNIs slows down the healing of skin; extra care must be taken with anyother injuries in the affected area
Mental health impact – Depending on the severity of the nerve injury, the very slow healing or
permanent loss of function can significantly impact your patient’s mental health as they adjust
to life post-injury. Refer your patient to local mental health services if available and appropriate.
Factors affecting recovery
You should be aware and inform the patient of certain factors or behaviours which can negatively
affect the healing of a PNI.
Diabetes – Will significantly slow the recovery of a nerve. Consider this when planning reevaluations and timelines of recovery
Excessive pain reaction to a gentle stimulus (allodynia) – Re-sensitisation training using materials
the patient can access at home should be started early to try to minimise this complication,
which limits rehabilitation
Burns/fragile skin – Creates difficulty in handling and moving the affected area and carrying out
manual techniques, as well as increasing the risk of infection. Keep clean hands and be guided
by the medical team94 | EARLY REHABILITATION OF PERIPHERAL NERVE INJURIESCHAPTER 5 | PERIPHERAL NERVE INJURIES

Smoking – Will significantly reduce blood flow and potential healing of the nerve
Nutrition – The patient should try to maintain a healthy diet and hydration with sufficient protein.
This may be difficult in conflict and disaster settings.

ASSESSMENT
The assessment of a patient with a PNI following a sudden onset disaster should follow thesame format as a standard rehabilitation assessment. Part of the assessment specific to theperipheral nerve is to ascertain whether a muscle or area of skin is neurally intact, i.e. has anormal nerve supply to it, or neurally affected, i.e. the nerve supply to it is damaged. Due topossible multiple injuries, it may be difficult to complete a full assessment. If this is the case itis acceptable to complete only the parts of the assessment that are possible to do and which fallwithin your scope of practice.
At the end of the assessment you want to be able to produce a list of problems that yourtreatment will focus on, develop a treatment plan and be able to set some goals with yourpatient or their family, if possible.
More details for what should be included in your general subjective and objective assessment
can be found in Chapter 3; the information below is specific to PNIs.
Subjective assessment
History of Presenting Condition (HPC): If possible, find out how the injury was sustained, themechanism of injury and previous treatments obtained, including any surgery
Past Medical History (PMH): Try to find out if the patient has had any previous surgery or medical
conditions and any ongoing medical conditions; this may influence the rehabilitation outcome
Social History (SH): This is vital for a comprehensive rehabilitation plan. Consider:
Who is their main caregiver or the most appropriate family member to involve?
What was the patient’s previous lifestyle, including work, housing and leisure?
Do they have somewhere to be discharged to?
Pain
Pain level assessment and treatment is essential, in order to make treatment more comfortable
and meaningful. Medications for pain generated directly by the nerve include amitriptyline,
gabapentin and pregabalin. You should be aware that these medications can take time to have apain-relieving effect. Using a Visual Analogue Scale, where the patient rates their pain out of ten,is easy and repeatable, although it may be difficult to isolate pain related only to the nerve injury
in a patient with multiple complex injuries. More information about general pain management
can be found in Chapter 3.
Specific things to ask a patient with a PNI also include
Function: Ask the patient how their function is affected, e.g. dressing, washing, working andcaring for dependents. Hand dominance is important in hand and arm injuries and will influence
the impact of any upper limb injury
Sleep: Ask the patient whether their sleep is affected by pain or their ability to get into a
comfortable position at night. If sleep is impacted, finding a comfortable sleeping position
should be an early treatment goal
Sensation: Ask about the presence of pins and needles, numbness and reduced sensation/feeling95 | EARLY REHABILITATION OF PERIPHERAL NERVE INJURIESCHAPTER 5 | PERIPHERAL NERVE INJURIES

Table 3: Common Nerve Injuries and Their Clinical Presentation
Common nerve injuries and their clinical presentation
Nerve

Muscle/action affected

Test/positive sign

Spinal accessory
nerve

Affects
trapezius

Posture – scapula drops
down and away fromspine. Assess abduction.
Test: hand behind backand lift hand away fromback. (Can still shoulder
shrug as levator scapulae
is still operational)

Long thoracic
nerve

Affects
serratusanterior

Scapula moves towards
spine at rest. Scapula
wings on movement

Axillary nerve

Deltoid

Unable to maintain/create
resisted abduction at 90
degrees

Affects
infraspinatus
andsupraspinatus

Assess glenohumeral joint
external rotation

Commonly injured
with shoulder
fracture dislocation

Suprascapularnerve

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Common nerve injuries and their clinical presentation
Musculocutaneous
nerve

BicepsInability to produce elbow
flexionUlnar nerve

High level –Ulnar flexor
digitorum
profundus,
flexor carpi
ulnarisInability to cross second
and third finger and poor
grasp and release

Wrist level –hypothenar,interossei,
adductor
pollicis
Radial nerve
Commonly injured
with humeral
fractureMedian nerve
Commonly injured
with supracondylar
humeral fractureHigh level –TricepsWrist drop is present

Wrist and digit
extensors

High level –flexor pollicis
longus, flexor
digitorumsuperficialis
Wrist level– thenarmuscles‘OK’ and pinch test

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Common nerve injuries and their clinical presentation
Gluteal nerve

GluteusmediusFemoral nerve

Quadriceps

Difficulty straightening
knee, or climbing stairs if
subtleTibial nerve

Weakgastrocnemius

Inability to walk on toes

Peroneal nerve

Weak tibialis
anterior

Inability to walk on heels

Commonly injured
with hip, pelvic,
acetabular fracture

Commonly
injured withknee dislocationor fibular headfracture

NormalTrendelenburg
Sign

Trendelenburg sign

98 | EARLY REHABILITATION OF PERIPHERAL NERVE INJURIESCHAPTER 5 | PERIPHERAL NERVE INJURIESPNI SPECIAL TEST

Objective assessment
The primary aim of the objective assessment is to determine which structures are neurally
affected and which are neurally intact, as well as identifying any secondary problems.
Sensory testing: As sensory information is carried on the outer, and therefore most vulnerable,
circumference of the nerve, it is often the first area to be injured. A sensory test can serve as aquick check for nerve damage, in a setting where a full examination is difficult, e.g. in the presenceof multiple fractures and an external fixator. See this video of a therapist examining a patient’s
ability to differentiate different sensations: https://www.youtube.com/watch?v=JijbJqTppyg
Testing by dermatome, that is, the area of skin sensation supplied by a particular nerve root or
nerve, can give you specific information about which nerve is damaged. Note that there is someindividual variance in dermatome and nerve supply across individuals.
Diagram 5: Lower limb dermatomes

Femroal nerve

Commonperoneal
nerve

Saphenous
nerve

Lateraldorsalcutaneous nerve(sural nerve)Superficial peroneal
nerve
Deep peroneal
nerve
Deep peroneal nerve

Medial sural cutaneous nerve(tibial nerve)
Lateral sural cutaneous nerve(common peroneal nerve)Intermediate dorsal cutaneous
nerve(superficial peroneal nerve)
Lateral dorsal cutaneous nerve(sural nerve)

Diagram 6: Ulnar, median and radial nerve
distribution in the hand
UlnarMedianRadial99 | EARLY REHABILITATION OF PERIPHERAL NERVE INJURIESCHAPTER 5 | PERIPHERAL NERVE INJURIES

Motor testing
Major peripheral nerve injuries usually lead to severe muscle weakness and consequential
atrophy, which can start 72 hours after injury. The neuromuscular junction undergoes significant
changes after nerve injury and is the most critical point for functional recovery, even after proper
nerve regeneration.
Beside the manual muscle testing examination, there are motor nerve function tests that can
detect muscle weakness of upper and lower limb peripheral nerve injuries. Pick one muscle
for each peripheral nerve, e.g., infraspinatus for suprascapular nerve. Use the Oxford Muscle
Grading Scale to record strength. If the motor nerve is not conducting, the muscle will not
activate properly, affecting the active movement, muscle tone and posture of limb. Check ROM
in the joints above and below the affected area, as well as at the affected joint.
Choose at least one functional movement for the affected area, such as putting on a piece ofouter clothing, brushing hair, sit to stand, getting in and out of bed. For lower limb nerve injuries,
a timed walk test or Berg balance test are both quick and reliable. Videoing the gait on yourphone or the patient’s phone can be very useful for reviewing and referring back to at a later
date. In an area with absent or reduced active movement, also assess the passive movement.
If movement is present but weak, repeat a movement up to ten times to assess for fatigue.
Lack of co-contraction at a joint causes instability and reduced eccentric control, e.g., reduced
plantarflexion control with a drop foot.
Neural mobility, i.e. how much the peripheral
nerve moves within the tissues, can beassessed by considering the path of thenerve and what limb movement will put it
under stretch. The important factor is that thenerve glides backwards and forwards during
a limb movement, and there are no sticking
or tension points which can cause pain or
restricted recovery. These sticking points areusually at a joint or when the nerve passes
through soft tissue. Be careful to avoid overstretching or tensioning the nerve (pins andneedles will appear).

Diagram 7: Peripheral Pulse Sites

Assess the soft tissue through your handlingof the area – palpate the tissues, feeling fortighter parts, spasm, shortening or flaccidity.
Palpate all the soft tissues in the area, not justthe neurally affected tissue.
Remember other structures may be involved,
and be aware of any contraindications tomovement when doing these tests.

Carotid

Brachial
RadialUlnar
FemoralPopliteal

Posterial tibial
Dorsalis pedis

Peripheral Pulses
Peripheral pulses can be used as a valuable clinical tool for a suspected PNI, the diagram above
illustrates the peripheral pulse sites:

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Table 5: Red Flags for PNIs

Red flags: The following red flags are specific to PNIs only. You should always be aware of noncondition-specific red flags in your patient, such as infection. Refer to Chapter 3 for more information.
Signs or symptoms

Possible underlying
condition

Action to take

Red, hot swollen limb, patientcomplains of severe pain which
is worsened with passive
movement

Compartment syndrome

Stop treatment, alert the
medical teamRed, hot, swollen limb
with lack of pulses. Patientcomplains of pain andshortness of breath at rest

Deep venous thrombosisor pulmonary embolism

Stop treatment, alert the
medical team

Patient complains of severe
pain; you may notice
malalignment at the joint or
abnormal bony movement or
shape

Unstable fracture which
has not been diagnosed, or
immobilised

Stop treatment, alert the
medical teamBilateral pins and needles
and numbness, weakness
bilaterally in hands/feet,headaches and numbness
around the head, severely
reduced neck ROM. Fatigue
inability to maintain headposture. Multisegmental
weakness and multisegmental
sensory changes

Unstable cervical spine

Stop treatment, alert the
medical team

Facial nerve damage
The facial nerve supplies the facial muscles, allowing for facial expression and movement.
It does not supply sensation to the face. The facial nerve can be damaged by an injury to
the face, head or neck. The facial nerve is the VII cranial nerve. It arises from the pons of
the brainstem and exits the brain behind the ear. It lies next to the VI cranial nerve, which
supplies the abductor muscles of the eye and the VIII cranial nerve, whose function is hearing
and balance.
The facial nerve has four branches which supply the face; these are the forehead, eye, cheekand chin branches. If the facial nerve is damaged, one whole side of the face will droop. This isdifferent to a stroke when only the lower half of the face drops. The facial nerve also supplies
sensation to part of the tongue and the small bones of the ear.

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If you suspect damage to the facial nerve, you can test the function by assessing the facial
movements by asking the patient to:1.

Raise the eyebrows – if damaged the forehead will not raise/wrinkle

2.

Close the eyes –if damaged the eye will not close or only partially close

3.

Smile – if damaged the affected cheek will not lift

4.

Push the lower lip forwards – the affected side will not move

Picture 1: Patient with a facial nerve injury,
unable to lift the affected cheek when smiling© Davide Preti/HI

Picture 2: Patient with a facial nerve injury,
unable to fully close the eye on the affected side
© Davide Preti/HI

The patient with facial nerve damage will have difficulty in eating, drinking, talking, closing theeye to blink and sleep and showing facial expression.
Treatment in the early stages should include:1.

Eye care – teach the patient to tape the eye shut and use eye gel to protect it and prevent
drying out

2.

Support the cheek for talking drinking and eating, to assist the necessary muscle function,
prevent drooling or slurring of speech3.

Avoid over activity in the unaffected side to decrease imbalance4.

As recovery occurs, gentle graded facial exercise to encourage normal movement tomaintain muscle strength and ROM

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Rehabilitation treatment has two main aims in PNIs: restoring as much independence as possible
and educating the patients and their caregivers about realistic expectations and management
strategies. The process of rehabilitation should start from basic activities, such as ROM
exercises, and then progress, e.g. applying a splint, re-sensitisation exercises. As long-term
rehabilitation may not be possible in conflicts and disasters an important principle of effective
PNI rehabilitation is supporting the patient with knowledge and exercises to independently
continue their rehabilitation, after discharge.
Aims of treatment
Maintain active ROM and passive ROM of affected and surrounding soft tissues (agonist
and antagonist) and joints
Avoid movements or positions that could overstretch and traction the affected nerve
Minimise neuropathic pain
Minimise compensatory and abnormal movements, but allow function
Minimise internal scar tissue
Restoration of sensory and motor function
Appropriate advice and education are essential for both patient and caregiver
Prevent secondary complications
Treatment
Mobilise affected area frequently (4-6 times a day) with active and passive movements,
with appropriate analgesia to reduce risk of contracture. Avoid this if there are injuryrelated contraindications, e.g. recent reconstructive surgery or unstabilised fracture
Protect neurally affected area with splint, support or stick – to avoid further damage andreduce pain and maintain joint alignment
Find comfortable position for rest and sleep
Neural mobilisation – nerves are mobile tissue but should not be stretched to the point of
inducing paresthesia (feeling a tingle). When mobilising the limb, think about gliding thenerve in a smooth movement
Weight bearing – once fractures are stable, fixed or immobilised, weight bearing should bestarted as soon as possible for both arm and leg, to stimulate motor control and neural pathways
Teach patient or caregiver to take over some elements of treatment if they can safely
repeat it without your supervision (always check first). Patients should repeat treatment
multiple times per day, in order to be effective, and be able to continue post-discharge
Electrical stimulation/electrotherapy may be used in the treatment of a PNI, but only if
it sits within your scope of practice, units specific to the treatment of a PNI are available
and the patient can continue this treatment regularly, and under supervision. It is also notrecommended for use in the acute phase of rehabilitation in conflicts and disasters

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Advice for caregivers
Do not ignore the area; stimulate and support the affected limb or area, but take care to
avoid doing too much as stretching and overuse can cause pain and further damage
Remember a PNI includes potential sensory loss, creating a risk for burns and pressure
sores, which can appear within hours after the initial injury. Check the skin regularly
Do not pull/drag on an affected limb, the traction can further damage a nerve
Maintain passive ROM to avoid joint contractures and/or tissue shortening. It is importantto find a comfortable resting position for the limb for sleep
In the case of shoulder nerve damage, support the arm proximally, i.e. close to the body
Take particular care of areas with swelling
When using splinting, ensure they are safe and competent with donning, doffing and skincare
When washing, avoid water that is too hot and dry the skin area thoroughly afterwards,
paying extra attention to skin folds between the fingers and toes
Temperature and skin care in general: the person should always wear a shoe, avoid heat/cold (e.g. ice packs) in insensate/decreased sensation areas
Be careful of small scratches which may not be felt or noticed, e.g. scratches from pets/thorns, which can develop into bigger wounds/infections if not noticed and quickly cleaned
and protected
The role and importance of splinting
Using splinting to treat a peripheral nerve injury is important, but often challenging. All injuries
to peripheral nerves result in possible motor loss and subsequent muscle imbalance creating thepotential for further loss of function as surrounding tissues contract.
The objectives of splinting include protection of injured tissues, enhancement of a healing
environment, prevention or minimisation of contracture formation, compensation for lost motor
function and facilitation and enhancement of functional daily activities.
The prescription, fabrication, and fitting of a custom orthosis requires:
1.

A strong understanding of the basic mechanical principles of splinting2.

Knowledge of the mechanical properties of splinting materials

3.

Knowledge of deep and surface anatomy

4.

Knowledge of the impact of compressive, tensile, and shear forces on the tissues

5.

A thorough understanding of the pathophysiology, diagnostics, and treatment of a PNI

Therapists who use splinting should strive to practice with a ’minimalistic’ approach, withemphasis on simplicity, cost accountability, flexibility and sustainability in the attainment of splint
effectiveness. This method of practice promotes patient satisfaction and compliance. Splinting
can be applied in many situations: while external fixation or traction is still used after primary
surgery; while awaiting nerve suture/healing or recuperation after repair and as a compensatory
measure for a permanent injury.

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You may be required to provide splinting in both phases of recovery, acute repair and protection,and prevention or contracture and aiding function.
Splints for acute repair and protection phase should be simple.
In the acute phase, a severe nerve injury should be immobilised with easily available material,
such as:A well-padded Plaster of Paris (POP) slab to prevent wrist drop for radial nerve palsy
Arm sling in case of a brachial plexus injury to prevent subluxation
A small improvised aluminium finger splints to prevent clawing of the fingers in ulnar
nerve lesions
Adhesive tape to hold the thumb in apposition during the night for median nerve lesions
Night splints to hold the foot at right angles in sciatic and lateral peroneal nerve lesions.

Note

Note: in certain settings, prefabricated wrists splints or ankle-foot orthoses (AFO) areavailable, such as:\POP volar wrist splint
Prefabricated hand orthosis
POP posterior foot slab or prefabricated ankle foot orthosis
Splint for preventing contracture and aiding function
If at a later stage, an orthosis or cuff-shoulder sling is needed, where possible, patients should
be referred to an existing centre, which can assess them and provide them with a custom-madeorthosis and follow-up. Orthoses should be comfortable, fabricated from lightweight materials,
easy to don and doff, aesthetically pleasing and convenient to use while remaining functional
and applying the guiding principle of ‘less is more’.

AFO FITTING

Picture 3: Example of a splint in neutral wrist position,and first web abduction to prevent contracture

Although orthoses for PNIs can be made anywhere with any available material, the process isextremely time-consuming, and the results may be poor. If a physical rehabilitation centre exists
in the area, both dynamic and static splints should be manufactured there.

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How to care for a splint
The below information can help you in reviewing the patient and their splint, but educating thepatient on the below principles of care must form part of your treatment.
Checking: When removing a splint, check for any red marks. If the marks fade within half an hour
this is fine, but if they persist, the splint will need adjusting. If the hands are stiff after removing
the splint, exercise each joint for a few minutes. Exercising the hand in warm water may also help.
Washing: If the splint is made of heat-sensitive materials, don’t put it in hot water or leave itnear heat sources, such as a radiator or on a sunny windowsill, because it will change shape. It is
important to clean the splint using cold or lukewarm water with washing-up liquid or gentle soap.
Adjusting: If there are any problems with a splint you did not make yourself, then do not try
to alter or adjust it. Contact the therapist or centre that delivered the splint. For children andteenagers, the orthosis needs to be adapted to their growth and patients should be followed up
every three months.
When a patient receives a splint or an orthosis, you must advise them on a wear schedule(i.e. when and for how long to wear it). This is related to the severity of the nerve lesion andespecially to the muscular activity. Although the aim of a splint is to support function, therapists
need to be aware that often, splinting does not encourage active movement of the affected part.
Instructional video for application of POP wrist splint:
https://icrc.aoeducation.org/videos/foot-and-anklefractures-and-sprains-lower-leg-backslabsplint.html
Instructional video for lower leg POP posterior slab:
https://icrc.aoeducation.org/videos/metacarpal-and-phalanx-thumb-spica.html
REHABILITATION TREATMENT OUTCOMES
Recovery after a PNI can be difficult to predict. Particularly in the first 7-10 days, it may bedifficult to know the exact level of damage to the nerve, making it impossible to give exact
timescales of recovery or non-recovery. The table in the classification section provides basic
guidance on the likelihood of nerve recovery in an ideal situation. This does not take into accountother factors which may reduce the recovery potential of a peripheral nerve. These additional
factors should be kept in mind when you are assessing and advising your patient. Factors which
may limit, or slow potential nerve recovery are often very similar to any other health factor
which will affect tissue healing, particularly diabetes, vascular conditions, advanced age, reduced
immunity and poor nutrition or smoking. In addition to these factors, recovery following a PNI
will also be affected by delayed treatment, poor patient understanding of the injury and poor
adherence or access to an ongoing rehabilitation plan. To provide the best possible chance for
maximum recovery, early identification of a PNI (first 7-10 days) and, if possible, re-assessment
every six weeks should be planned to ensure early identification of injury, early patient educationand effective monitoring of progress or complications.

106 | EARLY REHABILITATION OF PERIPHERAL NERVE INJURIESCHAPTER 5 | PERIPHERAL NERVE INJURIESCASE STUDY: LOWER LIMB
Background
Ahmed, 22 years old, presents with a gunshot injury to his right lower limb from an exploding
sniper bullet from a distance of about 200m. He has an open wound with a displaced, comminuted,
medial shaft tibia and fibular fracture and there was no information about possible nerve or
vascular injury. Ahmed came to the emergency department with temporary immobilisation andprimary wound care was administered. The initial medical plan was to maintain immobilisation
until surgical wound debridement and application of external fixator is possible.
Rehabilitation assessment
Subjective assessment: Ahmed is married and a father of three children; his wife is currently
seven months pregnant. He arrived at the hospital unaccompanied by any family member orfriends. Ahmed lost his job as a first-aid provider four months ago and has now been given theopportunity to start a part-time job as a health assistant in two weeks’ time. He lives with hisfamily and parents-in-law, both older and partially dependent on him. He lives in a fourth-floor
flat of a roughly finished building (shared shower on the ground floor, plastic sheets on thewindows, no stairs, and handrail). Ahmed regularly helps his brother-in-law to cultivate a small
piece of earth, where the family grows vegetables to support their difficult economic situation.
Objective assessment in emergency room: Ahmed is lying in bed with no mobility aid available;
he is conscious and alert and consents to assessment. Noted open wound on the back of the rightleg. Swelling (toes, dorsal aspect and malleolus and skin area surrounding the wound) and paleskin colour of the toes are also noted. There is a lower temperature of the toes and dorsal part of
the foot, as compared to the other side.
Sensation: loss of light touch sensation on the sole and lateral part of the foot, decreased
sensation on the top part of the footToes active flexion: M0, toes active extension: M2, ankle dorsal flexors and plantar flexors
unable to test due to fracture immobilisation
PROM toes: complete, but with pain. ROM ankle and knee unable to test due to fracture
immobilisation
VAS of injured site: 7/10
Possible vascular compromise, further investigation needed once stabilised
Objective assessment 24 hours later, after surgery with wound debridement and tibial
external fixator application: Ahmed lying in bed, no mobility aid available. Conscious and alert,consents to assessment. Noted increased oedema throughout right lower leg and pale skincolour of the toes ( no change after 24 hours)
Sensation: loss of light touch sensation on the sole of the foot, strong sensation of pinsand needles on the lateral part of the footToes active flexion: M0, toes active extension: M2, ankle dorsal flexors: M2, ankle plantar
flexors: M0, foot inversion: M0, foot eversion M2
Pedal pulses and capillary normal bilateral lower limbs.

107 | EARLY REHABILITATION OF PERIPHERAL NERVE INJURIESCHAPTER 5 | PERIPHERAL NERVE INJURIESPROM toes: full range but with pain. PROM ankle and knee: full ROM
VAS of injured site: 5/10
Red flag: vascular injury excluded after surgical evaluation
Clinical impression
22-year-old patient with comminuted rightside tibia/fibula fracture treated with external
fixator. Suspected partial tibial nerve injury
and potential partial peroneal injury, withmore severe involvement of the tibial nerve.
(Complete nerve injury not suspected due
to maintenance of at least some sensation).
Nerve damage resulting in lack of ability toheel raise/push-off when walking. Lack ofplantar flexion and inversion affecting stabilityof the ankle, resulting in risk of further softtissue injury. Ankle movement allowed withposition of external fixator. Wife and caregiverwill help with facilitating treatment and followup/care at home.

Picture 4: Patient with External fixation right tibia/
fibula; right ankle swollen and patient unable toplantar flex right toes

Treatment goals* Do not use electrical stimulation in the presence of an unhealed fracture or metal work
Make the patient aware of implications of the ongoing loss of sensation on the footBegin to normalise the hyperesthesia (tingling) on the lateral part of the foot and toes (maytake up to the next eight weeks)
Prevent ROM limitation in ankle and toes, prevent muscle weakness of leg (immediately)
Decrease pain and adequate pain management
Being able to walk with two elbow crutches in and outside with weight bearing (as per
post-op instructions) for at least 300m independently within seven days in order to safely
discharge home
To be able to climb up and down stairs with elbow crutches twice daily in order to safely
discharge homeLong-term goals (within six months)
Regain significant improvement to full power in plantarflexion, inversion and toe flexion,
plus normal sensation
Return to walking independently without aids
Return to work as a health assistant
To be able to care for new baby, help brother with food provision and take care of family duties
Reassessment of injury to determine severity of nerve injury, i.e. neuropraxia or neurotmesis

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Treatment approach
Desensitisation and re-sensitisation techniques with different materials
Adapt shoe (padding or foam) to wear on the affected footPassive ROM and active ROM exercises, including strengthening glute and core exercises,
e.g. bridging
Transfers training and progressive safe gait training ensuring heel-toe walking pattern andretraining on different surfaces, e.g. uneven gravel, grass etc., practising stairs
Intrinsic foot exercises, e.g. picking up a tissue with toes
Education
Explanation of recovery timing of a neuropraxia or axonotmesis: good possibilities torecover but not 100% assured. Re-evaluation of the symptoms after eight weeks will givea better picture of the final outcome and degree of lesion
Positioning of the foot during lying (no heel contact, use pillow) and sitting position (ankle
90 degrees) with foot on the ground and padded shoe
Importance of foot ground contact while walking, respecting medical prescriptions on
weight bearing
Regularly check the skin of the foot on the top and plantar part, with special attention to the heel
Wash the foot in lukewarm, clean water daily and drying it well. Keep pin sites dry andclean, monitor for signs of infection (heat, swelling, redness, pain)
Continue three times daily with active and passive ROM and neural mobilisation exercises,
as per instruction received
OutcomeOn discharge (after seven hospitalisationdays), Ahmed has good active ankle mobility
in dorsiflexion (M3+) but needs to improve
his active plantar-flexion (M1+), for which
he received a home programme. He is also
following the instruction on daily exercisesfor passive ROM to maintain ankle and toes
mobility with the help of his wife, who has been
trained accordingly. Ahmed is independently
mobilising with two crutches, but from time
to time he walks barefoot, which he has been
told is a dangerous habit. He knows that hehas decreased sensation on the sole of his footPicture 5: Patient completing strengthening exercises
and because of this, he is very susceptible towith external fixator in situ
injuries, especially when he goes to the fieldwith his brother-in-law. He has been informedthat improvement/normalisation of sensationand muscle activity might take a long time and encouraged to continue to adhere to the advices
and the home programme. He is able to climb stairs independently and safely, which allows him
to be independent in reaching the shower and to go out of his house (see pictures)
109 | EARLY REHABILITATION OF PERIPHERAL NERVE INJURIESCHAPTER 5 | PERIPHERAL NERVE INJURIESCASE STUDY: UPPER LIMB
BackgroundTen days ago, twenty-six-year-old Mahmoud sustained a penetrating wound to the back of hisright arm when he was hit by a piece of metal roofing during storm-force winds in a cyclone
which hit his island community. He was able to access initial medical treatment at the central
hospital where the wound was cleaned and an external fixator was applied to stabilise a
multi-fragmentary, midshaft humeral fracture. As he was otherwise medically stable, he wasdischarged and asked to attend rehabilitation as an outpatient the following week for woundassessment and rehabilitation.
Rehabilitation assessment
Subjective assessment: Subjective assessment is difficult, as Mahmoud is in severe pain anddistressed that he has been unable to locate his wife or two children since the cyclone. He iscurrently living in a temporary shelter set up by an international NGO and attends the clinic
alone. Prior to the cyclone, he supported his small family by providing a taxi service in the local
area. Mahmoud is left-handed with no past medical history or mobility issues. Mahmoud reports
severe pain (VAS 10/10) along the back of his arm, combined with numbness to the top of hishand, around the thumb area. The pain is particularly bad at night and he experiences difficulty
sleeping. Since his injury, he has experienced difficulty moving the right arm but reports that
this has become more isolated to extending the wrist and digits since the surgery. Although it
is difficult, Mahmoud reports he has been using only his left arm as he has been worried about
the symptoms and thinks something has gone wrong with his right arm.
Objective assessment: Patient seated with right arm supported by left across his body(protective posture). External fixator to right humerus with clean pin sites and healed woundwith no evidence of infection. Slight swelling present to right hand but normal temperature andcolour to skin throughout right arm
Sensation: Total loss of sensation to top of right thumb. All other areas sensate but hyperalgesia
present active movement: full movement of neck and unaffected left upper limb. Right shoulder
movement limited by stiffness and pain but motor function intact. Elbow extension, forearm
supination, wrist extension, finger and thumb extension M0. All other muscles throughout theright upper limb M4 limited by pain
Passive movement: Stiff end ROM of elbow, wrist, finger and thumb extension
Function: Unable to position right hand to grip any item with pressure
Clinical impression
26-year-old, right-hand dominant patient with multi-fragmentary, open, midshaft humeral fracture
managed with external fixator. Suspected radial nerve injury potentially sustained at time of initial
injury or intra-operatively. Neurotmesis suspected due to location and mechanism of injury, total
numbness and motor loss in radial nerve distribution. High pain levels limiting rehabilitation options
currently with ongoing potential to significantly impact function and mental health. Lack of active
wrist, finger and thumb extension limiting ability to position hand to grasp objects, despite ability toflex digits. Significant risk for secondary joint contracture, allodynia and long-term reduced function.

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Picture 6: Patient with external fixator to right humerus
Treatment goals
Short-term: Decrease pain and adequate pain management to aid sleep, improve ability to accurately
assess patient and improve patient’s ability to follow a treatment plan. Improve patient’s understandingof peripheral nerve function and why he is experiencing his current symptoms to improve trust andallow him to participate in his rehabilitation without fear of further harm. Make the patient aware of
the safety implications of the loss of sensation to the back of the hand. Regain full passive ROM at all
joints in the right arm. Provide a splint to improve wrist position and allow functional grip. Encourage
patient to use right hand/arm without fear of harm. Organise re-assessment in the next six weeks toreview any evidence of radial nerve recovery; i.e. neuropraxia or neurotmesis.
Long-term: Resolve or manage nerve pain effectively if this pain has continued. Prevent flexion
contractures at the elbow, wrist, fingers and thumb to maintain any function and improveoutcome if secondary surgery is available within the next two years, as neurotmesis suspected.
Maintain splint to assist in function.
Treatment approach
Advice on positioning for comfort with arm supported and hand elevated to reduce
potential for swelling. Patient not to sustain this protected position for long periods, as
flexion contracture is a risk
Advice to take nerve pain medications as prescribed, to improve ability to sleep, manage
rehabilitation and use his hand and arm
Desensitisation techniques, once nerve pain medication started
Wrist extension splint with advice to remove regularly to prevent loss of wrist flexion
ROM and power. Teach functional grips with splint on and encourage use of right arm
Passive ROM and active ROM exercises to treat initial stiffness, prevent contracture andbuild strength in unaffected muscles. Link with medical team to communicate evidence ofradial nerve injury
Establish plans for timescales for removal of external fixator
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Education:
Explanation of radial nerve injury and nerve pain as patient only aware of fracture. Re-evaluationin 6-8 weeks important to determine neuropraxia or neurotmesis, but patient should be awarethat the chances of long-term injury are high. Accessing nerve pain medication extremely
important to manage sleep and ability to comply with rehabilitation. This medication may notwork immediately but the effects will build up over time.
Regaining passive movement and preventing flexion contracture at elbow, wrist, fingers andthumb. Maintaining full ROM and power of unaffected muscles will not cause harm. Use ofa wrist splint to assist with function and help prevent contracture. Advice regarding regularremoval of splint to monitor any pressure areas (particularly at numb base of thumb) and to allow
full active wrist flexion. Continue exercises at least three times daily.
OutcomeAfter the rehabilitation session, Mahmoud understands the two parts of his injury; the humeral
fracture and the radial nerve injury. He understands the nerve pain he is experiencing and has
a plan of how to source specific nerve-pain medication with the medical team. Mahmoud will
work on his ROM himself, now he is no longer worried about causing more damage and wants
to prevent any further complications. He is able to put his wrist splint on himself and can seethat he is now able to make a fist and grasp objects. He understands he needs to return to theclinic for another assessment to see if his nerve is showing any signs of recovery, but he isaware there is a significant chance he will be unable to actively extend his elbow, wrist, fingers
and thumb long-term.

KEY pointS
Investigations to diagnose the severity or type of PNI are often unavailable in conflictand disaster settings and education and treatment to preserve function should
be started immediately in all nerve injuries. Reassessment at six weeks will show
improvement in the case of neuropraxia, otherwise regeneration of nerve healing isslow (max 2mm per day) while lacerations require surgical repair
PNI’s may be missed in the case of poly-trauma, and as the rehabilitation professional,
you may be the first to assess and treat a PNITreatment of a PNI should include information and education to the caregiver andpatient about potential risks arising from impaired power and especially sensation
Core recommended text
Further information related to CRPS is available at: https://www.mayoclinic.org/diseasesconditions/complex-regional-pain- syndrome/symptoms-causes/syc-20371151

112 | EARLY REHABILITATION OF PERIPHERAL NERVE INJURIESCHAPTER 5 | PERIPHERAL NERVE INJURIESKEY REFERENCES
British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) (including
diagnosis and management of compartment syndrome of the limb) Available at:https://www.boa.ac.uk/standards-guidance/boasts.html
Fundamental of hand therapy: Clinical reasoning and treatment guidelines for common diagnoses of
the upper extremity (2nd ed.) Cooper, C. 2014 St. Louis, MO: Mosby
Peripheral Nerve Injury. An Anatomical and Physiological Approach for Physical Therapy Intervention
Stephen J Carp, 2015. F.A. Davis Company
Occupational therapy for physical dysfunction (7th ed.) Radomski, M. V. and Trombly Latham, C. A.,
2014. Philadelphia, PA: Wolters Kluwer/Lippincott Williams and Wilkins
War surgery. Working with limited resources in armed conflicts and other situation of violence
Giannou G., Baldan M., Molde A. Vol. 2

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114 | EARLY REHABILITATION OF PERIPHERAL NERVE INJURIESCHAPTER 6 | AMPUTEES

CHAPTER 6
CHAPTER 6: EARLY REHABILITAITON OF
AMPUTEES
AIMS:
By the end of this chapter, you should be able to:Gain an understanding of an amputation
Carry out an assessment of a patient with an amputation(pre- and post-amputation phase)
Understand the complications associated with amputations
Provide early rehabilitation for a patient with an amputation

6

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CHAPTER 6:
EARLY REHABILITATION OF AMPUTEESINTRODUCTION
In conflicts and disasters, limb amputations are usually performed due to conflict-related
trauma (i.e. weapon-related injuries) or disasters (i.e. crush injuries). The decision to amputate,
as opposed to attempt salvage, will be based on person-related factors (i.e. the affected limb’s
vascular, neurological, soft tissue and bone condition, the person’s general health, etc.) and on
environment-related factors (the facility, level of post-operative and rehabilitative care, accessibilityof prostheses and/or wheelchair services, etc.). General indications for amputation include
severe tissue damage, vascular injuries (in the absence of vascular reconstruction capabilities)
and overwhelming infection. Of note, non-communicable diseases, including diabetes, are justas much of an issue in conflicts and disasters as in other contexts – and continue to contributedirectly to amputations.
Lower and upper limb amputations are defined by the level at which they occur.
Diagram 1: Lower and Upper Limb Amputations

UPPER LIMB
SD/Shoulder
Disarticulation

Forequarter(Amputation of the arm,
scapula and clavical)

ED/ElbowDisarticulation

AE/Above Elbow(Transhumeral)

PH/Partial Hand
(transcarpal)

LOWER LIMB
HD/Hip Disarticulation
KD/Knee Disarticulation

AD/Ankle Disarticulation

BE/Below Elbow(Transradial)
Hand and Wrist
Disarticulation

Hemipelvectomy(Amputation of theleg and pelvis)
AK/Above Knee
(Transfemoral)
BK/Below Knee
(Transtibial)

PF/Partial Foot(e.g. Chopart)
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Syme’sCHAPTER 6 | AMPUTEES

Factors that are considered when selecting the level of amputation:
The potential for healing of the stump
Patient’s general condition
The risk of additional surgeries
The fitting of the prosthesis (if the patient is likely to be a candidate for prosthetic rehabilitation)
The probable functional outcome
Length of viable tissue and bone
The age of the patient
For an optimal use of a prosthesis, it is important that the stump is:
Sturdy and well-padded with ample muscular soft tissue to distribute the shearing
stresses of weight bearing evenly
Muscularly balanced, so that agonist and antagonist muscle groups counteract each otherto prevent joint deformity or contracture
Not affected by any deformity or contracture
Free of pain
In conflict and disaster settings, the incidence of lower limb amputations is typically higher thanthat of upper limb amputations. Of lower limb amputations, transtibial amputation is the mostcommon procedure performed, followed by transfemoral amputation. For upper limb amputation,transradial amputation is most commonly performed, followed by transhumeral amputation. In
general, the level of amputation should be at the lowest possible level of viable tissue. For lower
limb amputations, for each joint and muscle lost through amputation and subsequently replacedby prosthetic components, there will be a greater loss of function, a greater degree of impairment
and the energy expenditure and oxygen consumption required to mobilise will increase. Although alonger stump is better for the patient’s prosthetic gait, length should not be gained at the expense ofcompromising stump healing. In the case of paediatric patients, knee disarticulation is preferable totransfemoral amputation wherever possible, as this will preserve the growth plate at the distal endof the femur, allowing for more proportional bone growth and preventing terminal bony overgrowth.

Picture 1: Transtibial amputation (long flap)

Picture 2: The residual limb (stump)

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In conflicts and disasters, wounds tend to be contaminated by a variety of environmentalorganisms and foreign matter, with crushed and devitalised tissue providing a medium forbacterial growth and infection. When amputation is needed, the most successful surgical
technique is often based on a staged approach that includes repeated debridement and delayed
primary closure (DPC) of the wound, in order to minimise infection and sepsis. In such cases,
DPC and concurrent injuries (very often, patients sustaining amputation will also sustain otherinjuries), will have a major influence on the treatment plan and timescale for rehabilitation.
In conflicts and disasters, guillotine amputations are still occasionally seen. The guillotine
amputation is a procedure in which all the tissues are cut at the same level. This type of
amputation eventually requires a closed amputation performed at a higher level. Further
management will depend on timing and the state of the wound. Guillotine amputation is notrecommended, due to the need for further surgical revision in order to achieve wound closure,which inevitably requires further shortening of the limb. Exceptional circumstances which may
demand a guillotine amputation include when the procedure is required for extraction (i.e. toenable a person to be removed from underneath collapsed structures).

MYOPLASTY AND MYODESIS
It is important that the rehabilitation professional is aware of which surgical technique has
been used in reference to the muscles, as this will also affect early rehabilitation priorities.
Myoplasty: The agonist and antagonist muscles are sutured together to maintain some of
the muscle function.
Myodesis: Muscle fascia is sutured to bone through drill holes, which provides a very stablestump. From a rehabilitation perspective, myodesis is far better for improved control andless redundant soft tissue in the adductor region. It is the preferred surgical technique, but alengthier procedure.
Providing rehabilitation for amputees in conflicts and disasters is challenging. Therapists will
face issues including limited clinical experience, limited multi-disciplinary team (MDT) input or
support, a lack of equipment, and, in many cases, a lack of access to specialist services, suchas prosthetic services. Physical therapists (PTs) and occupational therapists (OTs) can, however,greatly influence the patient’s independence and safety on discharge, and prepare them forpotential prosthesis use.
Rehabilitation for patients with amputations
Rehabilitation is focussed on preventing complications and optimising functional independence
and mobility. For patients sustaining amputation, the rehabilitation process is divided into fourphases:Pre-amputation phase
Early rehabilitation phase (divided in post-amputation and pre-prosthetic stages)
Prosthetic rehabilitation phase
Post-rehabilitation phase.
This chapter will focus on the first two phases. However, some basic information will be given at
the end of the chapter on the prosthetic rehabilitation and post-rehabilitation phases.
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Rehabilitation after an amputation is a complex task, and to ensure the best outcome it isimportant to:
Adopt aperson-centredcare approach

Patients and caregivers should be equal participants in the rehabilitation
process in order to ensure rehabilitation services are responsive to theindividual’s needs, environment and preferences

Adopt a MDT
approach

Team members should share goals and overlap practice. The ideal core teamwould include the surgeon, physical therapist, occupational therapist, mental
health professional, prosthetist, a nurse and the patient and their family/
caregiver. In conflicts and disasters such MDT work is a challenge. Input fromall professionals may be limited – but there are often particular shortages ofprofessions, such as mental health professionals and occupational therapists.
Where possible, therapists should seek out such support, but should be awareof some basic skills and strategies they can utilise in their absence

Make thecorrect decision
about longterm prosthetic
use, based on
the individual’s
circumstances

The decision of whether or not a prosthesis is suitable for the patient should
be made at the correct time (not too soon), with all available informationand the consent of the patient. If the patient is not ready for prosthetic gait
training as soon as the amputation has healed, for whatever reason, then the
pre-prosthetic phase continues until a definitive decision is made. Availabilityof prosthetics in conflicts and disasters may be limited or unclear in the firstweeks and months of the emergency, with backlogs for fitting (where they
are available) being common. Note that service provision can change following
an emergency, with organisations such as HI and ICRC being skilled in rapidly
expanding services

Facilitate andemphasise selfmanagement

Provide the patient with the rehabilitation education and self-management
skills needed for optimal long-term functional outcomes and to minimise
complications. This is particularly important in conflicts and disasters, where
professional input can be limited. It should be focused on self-management
in conflicts and disasters.

Ensure propercare of thestump

The principal function of the stump is to serve as the lever to control theprosthesis. Therefore, it is critically important to ensure proper care of thestump and to prevent any contractures that may prevent the use of a prosthetic

Manage theemotional
response

An amputation drastically alters an individual’s life and causes permanent
physiological change, as well as psychological and emotional distress. The
psychological impact of a traumatic amputation can cause the victim todisplay some, or all, of the stages of grieving: denial, anger, bargaining,
depression and acceptanceAt times, therapists involved in early rehabilitation will only see patients with amputations until thetime of their discharge from acute surgical wards, meaning they may not be involved in the later
rehabilitation phases. Rehabilitation follow-up may be uncertain. Despite these challenges, PTs
and OTs have a critical role in these settings and can significantly influence patient outcomes, even
if a dedicated rehabilitation unit or prosthetic service is unavailable. By focussing on safe mobility,
preparing the stump for prosthesis use and minimising complications, PTs and OTs can influence
the patient’s independence and safety on discharge, and prepare them for potential prosthesis
use. This chapter is therefore structured to support therapists through the early phases of therehabilitation process, regardless of where their interventions with patients might end.
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Pre-amputation phase
It is now recognised that, in conflict and disaster settings, the decision to amputate following
severe limb injury, where there is no immediate threat to life, can be delayed. Delaying amputation can save vital theatre time in the midst of an emergency and allows time to ensure theright decision is taken, that the procedure is planned appropriately using all available environmental and contextual information (including availability of local prosthetic and rehabilitation
services) and completed with the patient’s and family/caregiver’s informed consent. PTs and
OTs must be actively involved in the pre-amputation phase wherever possible. The objectivesof the pre-amputation phase are:1.

To contribute to the MDT surgical planning process2.

To complete a holistic baseline assessment of patient3.

To prepare the patient for what they can expect and help to alleviate anxieties about postoperative treatment and long-term rehabilitation

4.

Observe the patient’s psychological/emotional status and refer for support if required

5.

Ensure familiarity with locally available services which the patient (or family and caregivers)
will require (prosthetic, wheelchair, psychological, psychosocial, etc.)

Completing a comprehensive initial assessment will support goal setting, aid early identificationof potential barriers to use of a prosthesis and provide an insight into the patient’s acute stressresponse and coping style. Discharge planning should, if possible, commence pre-amputation,in order to ascertain if the patient will face significant environmental obstacles upon leaving the
hospital or health facility.

ASSESSMENT
Refer to Chapter 3 for details of a generic assessment. Amputation specifics are as follows:
Subjective assessment
History of Presenting Condition: mechanism and date of injury, other injuries, surgicalprocedures or surgical plans and any restrictions or precautions
Past Medical History: pre-injury function, pay attention to diabetes and other factors that
may impair healing, and physical ability/fitness, as this will have an impact on ability to use
prosthetics
Social History: pre-injury occupations and responsibilities (i.e. work, leisure activities,
family roles), hand dominance (i.e. right- or left-handed) for upper limb amputees,discharge destination and details regarding accessibility/supports available/proximity tohealth and disability services
Medication History: it is important to establish effective pain control as early as possible
and to check that the patient has access to medication needed for other health conditions
Other specific things to consider:- Psychological/emotional response to current situation, understanding of amputation
procedure and what will happen to them
- Attitudes and beliefs (cultural considerations), particularly regarding amputation anddisability- Patient’s own priorities for their recovery and rehabilitation
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Objective assessment
The following must be considered:
Age of the patient (i.e. potential for further physical growth and considerations for level ofamputation, need for frequent prosthetic reviews)
Medically stable and psychologically ready to begin active rehabilitation
Other injuries (i.e. soft-tissue injuries, fractures, traumatic brain injury)
Status of remaining limbs (i.e. strength, ROM, sensation)
Pressure injury risk, compartment syndrome (see fractures chapter)
Psychological status (i.e. evidence of acute stress response, coping style)
Nutritional status (i.e. risk of malnutrition, need for dietary support)
If time and the clinical setting permits, clinical progress and outcomes can be measured
through the use of functional outcome measures (see Chapter 3) and a combination of objective
measures, including range of movement, manual muscle testing, circumferential measurementsof stump size/oedema and visual analogue scales for pain. These measures should not interferewith focussing on observations of functional ability and goals, however, as achieving optimalfunctional independence must take priority in early rehabilitation in conflicts and disasters.
Other key pre-operative aims include:
Aim

Achieved by:Contribute to
the MDT surgicalplanning process

Considering the following factors that may influence amputation level
decision-making:Co-morbidities that would make the patient unable to tolerate prosthesis
Age: (including the considerations of knee disarticulation versus
trans-femoral amputation)
Cognitive impairments that preclude learning to use a prosthesis
Impaired sensation, chronic pain or arthritic conditions affecting
remaining joints
Upper limb impairment
Types and availability of prosthetic technology and/or wheelchair
services nearby

Address preand postamputation pain
management
plan

Understanding, through discussion with the surgical team, how the patient’s
pre- and post-operative pain will be managed – this will inform planning andtiming of the initial post-operative review and treatment sessions

Address surgicalclosure/wound
management
plan

Requesting clear instructions (ideally documented in the patient’s casenotes) about what the patient is and is not allowed to do in the first days
following amputation

Remember the patient’s pain might be both wound pain and neuropathic(nerve) pain and may also include pain from other injuries

The patient’s wounds may restrict mobility post-operatively, DPC, wounddrains or a difficult closure can preclude certain types of mobilisation, as canother injuries sustained

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Aim

Achieved by:

Begin to map
locally available
services as soon
as possible

Mapping (including contacts and referral information) of:

Ensure theavailabilityof required
post-operative
materials andequipment

Ensuring the following materials and equipment are available:

Provide detailed
education to
the patient andfamily/caregiver

Providing detailed education about:

At this stage,
it is importantto judge theamount of new
information thatthe patient isable to accept
and absorb

Rehabilitation and mobility device services
Community-based rehabilitation (CBR)
Psychological and psychosocial support
Local amputee/disability support services and organisations for thepatient and their family/caregiver, where available
Elastic bandages for compression bandaging
Walking aids/wheelchair
Stump board (for wheelchairs)
Positioning devices for elevation of residual limbs where appropriate(i.e. pillows, foam pieces, towels) – though note not to use under
the knee). Assistive devices to facilitate locally appropriate bathing
and toileting (e.g. commodes, shower chairs – though these are notappropriate/available in many settings)
Post-operative pain management plan and importance of the patientcommunicating when pain is not well managed
Phantom sensation and phantom pain
Post-operative mobility plan and reasons why it is important the patient tomobilise quickly after surgery (or adhere any mobility restrictions)Phases of amputee rehabilitation and how rehabilitation may progress,
what could be the functional outcome of the amputation and how
mobility devices may be used to optimise the patient’s functional ability
Potential onwards destinations (if known) and referrals
Members and roles of the MDT
Demonstration of mobility devices; this can support education andallow the patient and their family to ask any questions they may haveabout these devices
Role of nutrition in wound healing; consider a high protein diet if possible
Be careful not to promise a patient a prosthesis, as this can create
expectations that may not be met if a prosthesis is not suitable for thepatient post-operatively, or if there are difficulties procuring one

Early rehabilitation phase (post-operative)
The objectives of the post-operative phase are:
1.
2.
3.
4.
5.
6.

To promote recovery from surgery
To promote healing of amputation
To treat concurrent injuries
To provide a wheelchair or crutches
To conduct on-going assessment for prosthetic provision
To ensure the patient is already known by the closest national prosthetic services provider

7.

To continue treatment started in pre-operative phase (if possible)
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Post-operatively, there can be a number of complications that you should be aware of:Wound infection: discoloured or foul-smelling discharge, pus, increased warmth (comparewith contralateral limb), oedema, increased erythema (redness to skin) around wound,increased pain
Deep vein thrombosis (DVT): will most commonly occur in the calf, however can develop in
any limb. Signs include: significant pain, swelling, warmth, redness, cramping, worsening
pain on movement, bluish or whitish skin discolouration to affected limb, a heavy achingsensation in affected limb. DVT can also occur with minimal or no signs or symptoms
Delayed healing: wounds should demonstrate signs of progressive healing (discharge andoedema reduces, wound pain settles, wound edges close together to eventually form ascar). In delayed healing, wounds will remain moist, oedema will persist and wound edges
may not close, or may reopen (referred to as dehiscence). Infection or poorly controlled
oedema are common causes of delayed healing
Pain: wound pain, neuropathic (nerve) pain and/or phantom limb pain or sensation andmay also include pain from other injuries. Consider using a simple visual analogue scale tosupport standardised monitoring of pain across treatment sessions
Heterotrophic ossification (HO): HO is the development of bone inside soft tissues
where bone should not exist. The first sign of HO is usually loss of joint range or mobility,
which can limit limb function. Swelling, reddened skin, warmth, localised pain, a palpablemass and development of contracture can also indicate the formation of HO. Differential
diagnosis is important as these symptoms may also indicate multiple other complications,
including infection and DVT. HO mostly commonly, but not always, forms in joints closest
to the site of trauma
Bone spur: also called osteophytes; these are bony prominences that form at the distal
end of the residual bone. Bone spurs can be painful on palpation or when pressure isapplied over the area, which can make prosthesis use uncomfortable or intolerable. In
severe cases, the bone spur can cause skin breakdown or ulcers
Picture 3: Heterotrophic ossification following atransfemoral amputation, seen on x-ray

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Neuroma: neuromas are bundles or masses of sensitive nerve endings that form when
the nerve is cut during amputation. Localised sharp or shooting pain or tingling reproducedby palpation over the stump can indicate the presence of a neuroma
Pressure areas: check skin over bony prominences, including sacrum, buttocks, heels,
elbows, spine and scapulae for reddened areas. Redness should resolve within 20 minutesof relieving contact/pressure. Areas that do not blanch on touch, or where skin is broken
are indicative of developing pressure sores and immediate action must be taken to avoid
further progression
Compartment syndrome: observe entire limb for the ‘5Ps’; pain, pallor (pale skin), paraesthesia(numbness), pulse (no or weak pulse) and paralysis (weak muscle movement)
Post-operatively, it is also important to monitor for respiratory complications, with signs including
a productive cough, ‘wet’ chest sounds, shortness of breath and increased temperature. If you
are concerned, liaise with the medical team.
Post-operative assessment
Following surgery, the patient is assessed, or the pre-amputation assessment is revised, todevelop a treatment plan, establish outcome measures and set user goals. The post-operative
assessment also provides information that will help inform the decision on prosthetic use. As
many patients are likely to be seen for the first time post operatively, we have reproduced thepre-operative subjective assessment, with additions for post-operative care, below:
Subjective assessment
History of Presenting Condition: mechanism and date of injury, other injuries, timefrom injury to amputation, surgical procedure including DPC, planned date of closure (ifnot closed), management of any concurrent injuries, wound care plans, post-operative
precautions or restrictions, management plan and expected discharge date. Is the patient
stable/appropriate for early rehabilitation?
Past Medical History and pre-injury function – pay attention to diabetes and other factorsthat may impair healing and physical ability/fitness, as this will have an impact on earlyrehabilitation and ability to use prosthetics
Social History: pre-injury occupations and responsibilities (i.e. work, leisure activities,
family roles), hand dominance (i.e. right- or left-handed) for upper limb amputees,discharge destination and details regarding accessibility/supports available/proximity tohealth and disability services upon discharge
Medication History: is the patient on medication for nociceptive and neuropathic pain, antinausea, antibiotics? It is important to establish effective pain control as early as possible
and to check that they have access to medication needed for other health conditions
Other specific things to consider:- Contact details of all MDT local health staff involved with patient’s care

124 | EARLY REHABILITATION OF AMPUTEESCHAPTER 6 | AMPUTEESPSYCHOLOGICAL STATUS
Before rushing into assessment and treatment, check your patient’s psychological/emotional
response to their current situation. The loss of limb process is similar to the stages of grief,
and patients may have been affected in other ways by the conflict/disaster. Be prepared
to discuss prosthetics by ensuring you are aware of the status of local provision. Do notmake any promises you cannot keep. Check the patient’s understanding of their amputation
procedure and why it was carried out, as well as their cognitive status (ability to receive new
information and act on it), motivations, depression, anxiety, etc. Ask what are their priorities
for their recovery and rehabilitation, as these may be different from your own. Be sure to beaware of local cultural considerations (including attitudes and beliefs), particularly regarding
amputation and disability. Ask yourself: Is your patient ready to engage in rehabilitation? Ifthey are struggling, are there local counselling or peer support services available?
For the basics on supporting people in crisis, please refer to the WHO ‘Psychological First
Aid’ manual.
Objective Assessment:
Check the residual limb
Any residual limb/wound checks should be done in collaboration with other members of theclinical team. Do not undress a wound unless you are qualified and equipped to redress it.
Residual limb length: There needs to be enough room for prosthetic componentry
Soft tissue: Ideally no ‘dog ears’, adequate cushioning and coverage of bone end
Bone ends: Bevelled bone edge, no bony spurs, fibula cut 2cm shorter than tibia. Palpation
or x-ray determined
No neuromas: Nerves should be retracted deep inside the soft tissue during surgery sothey can’t get aggravated near the surface, causing a neuroma (see complications, above)
Shape of stump: Ideal transfemoral shape is conical, ideal transtibial shape is cylindrical.
You do not want a bulbous shape as it is very hard to fit a prosthesis

Pictures 4 & 5 above: poor stump shape (L) with short levers, excess soft tissue and scar line across bone.
Good shape (R) with cylindrical shape, good muscle coverage, skew flap and healthy tissue

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Scar line: This should not be over the end of the bone, check whether you have an adheredscar or mobile one, and whether scar tissue is palpable or tender
Wound: Be aware for any signs of infection (slough, smell, discharge, red, hot, necrotic skinmargins), check whether stitches are in/out and be aware that some wounds will be open
Vascular supply: There should be adequate supply for wound healing. Stump should be
warm, have sensation, good colour and pulse, etc.
Pain/tenderness: Along scar line, neuroma, soft tissue injury
Muscle cover: Evidence of myodesis and myoplasty with optimal shape. Sufficient muscle
cover over the cut end of bone
Skin condition: Be aware of scars, skin grafts, blisters, unhealed skin and dermatologicalproblems, such as eczema
Sensation: You will need to test and check sensation is intact especially over the prosthetic
weight-bearing areas, as well at the end of the stump
For more information on wounds with amputation please see the video from HI and BACPAR-Pain
Not just in the residual limb but more generally. Document type (including phantom pain,)severity and distribution. See pain section below for more details.
Range of movement (ROM) and muscle power
Including above the level of amputation and in residual limbs. Consider other injuries. In patients withlower limb amputations, pay particular attention to the risk of flexion contracture in the hip and knee.

Function
Bed mobility: In conflicts and disasters, this may even include patients being managed from thefloor, so adapt as required.
Sitting balance/tolerance: Relevant with transfemoral amputations, especially bilateral. They
have short levers and therefore a shift of centre of gravity backwards.
Transfers: To/from relevant surfaces. See the BACPAR/HI video on transfers for practicalguidance on this.

Mobility: For patients who have sustained lower limb amputations, this includes the use of awheelchair or crutches.
Seating/pressure/chair requirements: Especially for people with a bilateral amputation. Don’t
forget stump boards for patients who have sustained transtibial amputations for sitting.

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For cases of lower limb amputation, the post-operative objective assessment must include:
Contralateral leg, range of movement, strength, concurrent injuries, condition of footArm strength (i.e. ability to transfer, use wheelchair and walking aids)
Hand dexterity and grip, which may influence type of suspension of prosthesis
For cases of upper limb amputation, the objective assessment must also include, in addition
to the above:
Contralateral arm (i.e. strength, ability to transfer, hand dexterity and grip, which may
influence type of suspension of prosthesis)

EARLY REHABILITATION: TREATMENTManagement of oedema
Oedema management can be achieved through a combination of approaches, including active
exercise, stump elevation and stump compression. See the Guidance for the MDT on the
management of post-operative residuum oedema in lower limb amputees for more information
and a review of the available evidence: https://bacpar.csp.org.uk/system/files/guidance_v.8_0.pdf
For more information on oedema management please see the video from HI and BACPARStump compression

Description
No dressing

Rigid dressing(A rigid or semirigid dressing
applied toa transtibial
residuum tocontain andfurther prevent
formation of
post-operative
oedema)Pros

Cons
No risk of dressing being put
on incorrectly

No oedema control

Easy to monitor surgical wound

Increased risk of wound
infection

Reduction in oedema
Reduced healing time
Reduced time to prosthetic
casting
Reduced incidence of fixed
flexion deformities at the knee
Physically protects the stumpfrom external trauma
Removable rigid dressings
permits regular residuum
inspection
Able to apply earlier thanother modalities, such as
stump shrinkers

127 | EARLY REHABILITATION OF AMPUTEES

Prolonged wound healing

Require significant
expertise to apply
Non-removable versions
not suitable in conflicts
and disasters, due tohigher risk of infection

CHAPTER 6 | AMPUTEES

Description

Pros

Compression
sock (stumpshrinker)

Cons
Reduced oedema

Expensive/not available

Improve vascularity to thestump, increasing speed ofwound recovery

Requires measurement
and fitting
May require re-fitting/replacement as stump
shape changes

Can reduce phantom pain
Easy to put on/remove
Compression
dressing (stumpbandaging)

Reduced oedema

If donned incorrectly, canlead to poor healing andpoor stump shape

Improve vascularity to thestump, increasing speed ofwound recovery

Wound needs to bechecked regularly,
therefore bandage donned
and doffed regularly

Can reduce phantom pain
Patient/caregiver can apply
independently once taught

Clean bandaging notalways widely available

Cheaper/more widely available

Stump compression is frequently seen in conflicts and disasters, due to its availability and easeof application.
For more information on oedema management, including a demonstration of how to apply astump bandage, watch the videos from BACPAR and HI:

Avoid using clip or pins to fasten a bandage – use tape used for dressings instead.
Diagram 2: Bandaging for a below knee amputation
1.

2.

3.

4.

5.
Always bandage
up to the knee andabove

Diagram 3: Bandaging for an above knee amputation
1.

2.

3.

Always bandage up to the groin.
Include all of the skin and tissue ofthe inner thigh and groin

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Picture 6: Bandaging for a below knee

Picture 7: Bandaging for an above knee amputation

amputation© Davide Preti/HI© Davide Preti/HI

Diagram 4: Bandaging for a below elbow
amputation
1.
2.

3.

4.

5.

Picture 8: Bandaging for a below
Always bandage above the elbow

elbow amputation© Davide Preti/HI

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Diagram 5: Bandaging for an above elbow amputation
1.

2.

3.

5.

4.

6.

Always bandage above the elbow

Positioning
Positioning aims to prevent contractures and reduce oedema, as well as reduce the risk of othercomplications, such as pressure ulcers and respiratory problems. Teach the patient and caregiver
positions in both sitting and lying to help prevent contractures in the joints above the amputation level.
Do...

Do Not...

Do...

Do Not...

keep the knee positioned
in extension while in bed

place a pillow under theknee while in bed

keep the knee positioned
in extension when sitting

keep the knee in a flexed
position when sitting

NEVER PUT A PILLOW DIRECTLY UNDER THE KNEE JOINT
For patients with a transtibial amputation, it is crucial to prevent knee flexion
contractures
For patients who have sustained a transfemoral amputation, it is important toprevent hip flexion and abduction contractures
Avoid prolonged flexion/abduction/external rotation

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For lower limb amputation, prone lying can be useful to achieve sustained full knee extension
and to achieve neutral hip extension (to prevent flexion contractures in either joint). You willneed to consider how to accommodate concurrent injuries.
Pain management
Pain is an inevitable consequence of amputation and for many, pain will not just result fromthe trauma of the surgery, but may also include a neuropathic presentation known as phantom
limb pain. Pain can also be complicated by additional injury to the same limb or other parts ofthe body. For the rehabilitation professional involved in the early stages of rehabilitation, thechallenge is determining the nociceptive and neuropathic causes of pain (see Chapter 3) which
require attention, in order to manage the patient and so enable effective rehabilitation to occur.
Effective pain management requires a collaborative, multi-disciplinary approach.
Post-amputation pain: Nociceptive post-amputation pain at the wound site. This is normal
following surgery; however, if this persists or increases it can be a sign of infection, therefore
medical advice should be sought. Pain at the wound site should be distinguished from pain in
the residual limb and phantom limb pain. After amputation, all three may occur together.
Residual limb pain (RLP): Pain or sensation in the areas near to the amputated body part. Thisis known as residual limb or stump pain and its intensity is often positively correlated withphantom limb pain.
Phantom limb sensation: This is a normal experience for the majority of amputees, but it is nota noxious sensation, nor is it described by the patient as painful or unpleasant. It can include
feeling that the limb is still there, following sensations like itching. In such cases, education (preand post-operatively) and re-assurance are key.
Phantom limb pain (PLP): Classified as neuropathic pain, whereas RLP and post-amputation
pain are classified as nociceptive pain. PLP is often more intense in the distal portion of thephantom limb and can be exacerbated or elicited by physical factors (pressure on the residual
limb, time of day, weather) and psychological factors, such as emotional stress. Commonlyused descriptors include sharp, cramping, burning, electric, jumping, crushing and cramping.
PLP assessment should seek to establish the principle drivers. These may be centrally driven
adaptations, peripheral sensitisation, psychological/social factors and musculoskeletal factors.
Treatment can then target these drivers.

Note

Note: Graded motor imagery (GMI) should only be carried out by a therapist with relevant
experience. Details can found on this website: http://www.gradedmotorimagery.com/

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Pain

Residual Limb Pain

Phantom Limb Pain

rule out / manage

exclude phantom limb sensation (normal)- infection- oedema- ischaemia- post op pain

exclude causes related to residual limb pain

manage withlocal tenderness?
noyesCheck for- neuroma- bone spur
- HO
- sharp bone end

psychosocial
supportmedicationneuropathic agents

therapy- psychologist- peer counselling- education- family/ social
support- amitriptyline- pregabalin- NSAIDS- compression- handling- exercise- functional
activities- TNS- graded motor
imagery- heat / ice- trigger point
release- imagining moving
the amputatedlimb- rubbing thesound limb where
the pain is on theamputated side
- gentle massageof the scar once
healedsigns of autonomic
dysfunctionnoyesreferred pain fromhip, back , spine?

CRPS

For more information on pain in amputation,
watch this short video from HI and BACPAR:

Refer to the UKEMT oedema and pain leaflet
for more guidance for patients132 | EARLY REHABILITATION OF AMPUTEESCHAPTER 6 | AMPUTEES

Teach stump care
Promote healing through good hygiene, scar massage, desensitisation and handling of thestump. Massage can be helpful in reducing hypersensitivity; from day one, gentle touch of theresidual limb is advised and can gradually increase as healing takes place. This is also useful toimprove awareness and acceptance of limb loss.
Refer back to the section on complications to identify common issues with the residual limb.
Promote healing by
Liaising with nurse regarding dressing change
Oedema control
Ensuring adequate nutrition
Prevention of falls by education, safe transfers and safe use of wheelchair
Correct positioning
Checking for infection, additional tissue damage
Scar management, including donor sites for skin grafts
Encouraging psychological wellbeing of patient.
Teach care of the remaining limb
This is particularly important for patients where diabetes has been a contributing factor in thedecision to amputate. Discuss the importance of caring for the remaining limb by preventing
falls, ensuring good skin care and wearing appropriate footwear.
Treat concurrent injuries and/or co-morbidities
Severe limb injuries that require amputation are considered ‘distracting injuries’, which meansother, less obvious injuries, such as head injuries, fractures to small bones or soft-tissue injuries,
may only be properly identified after some delay. Persistent pain or weakness should be
investigated as a potential indicator of a missed injury. All identified concurrent injuries should
be reviewed and managed appropriately alongside an amputation. Prioritise treatments asappropriate, identifying those likely to delay or prevent prosthetic rehabilitation.

CASE STUDY
A six-year-old child presented to an EMT for closure of a below-knee guillotine amputation, wearing
a full leg cast on their other leg. On further investigation, it was revealed that this cast was hiding
an open tibial fracture, with an associated peroneal nerve injury. The management of injuries to the
non-amputated side was vital for the child to able to walk using a prosthetic. To complicate matters,
the child was distressed by their injury and terrified of health staff. They were accompanied by arelative (not their parents). Managing their distress and educating them and their caregiver became
an essential part of early rehabilitation – building trust before any physical rehabilitation could begin.
Active exercise
Active exercise aims to improve muscle strength and mobility, reduce oedema, reduce muscle
atrophy, aid transfers and functional independence and aid psychological adjustment. Start active
exercises for residual limb and whole body as soon as possible, taking appropriate precautions
with any other injuries.
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For detailed information on exercise and amputation, watch the video from BACPAR and HI:

Core exercisesCore stability exercises are especially important with multiple limb injuries/patients with higher
level amputations
These exercises can start early, even on bed rest. Postural awareness is key, and continues
its importance through to prosthetic gait education. Kneeling is especially good for bilateraltranstibial amputations, including four-point kneeling in later stages. Hip extension and trunk
stability exercise can also be helpful in earlier stages.
Lower limb amputation exercises
It is important that the patient maintains their strength and range of movement, post-amputation.
The patient and their caregivers should be advised to keep all remaining joints moving throughout
their full available range, especially the joints above the amputated site (hip and knee) to prevent
contractures.
The following exercises are good basic strengthening and ROM.
Straight leg raise
Put your legs out in front of you
Tighten your thigh
Lift your leg off the bed
Hold for ten seconds
Slowly lower
Repeat ten times
Repeat the above with the other leg
Hip flexor stretch
Lie on your back, preferably without apillow
Bring your thigh towards your chestand hold with your hands
Push your opposite leg down flat on to
the bedHold for 30 – 60 seconds, then relax
Repeat five times
Repeat the above with the other leg

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Bridging
Lie on your back with your arms at theside
Place a couple of firm pillows or rolledup blankets under your thighs
Pull in your stomach, tighten your buttocks
and lift your bottom up off the bed
Hold for five seconds
Repeat ten times
To make this exercise more difficult, ask yourpatient to place their arms across their chest,
as shown in the picture
Hip abduction in side lying
Lie on your side
Bend the bottom leg
Keep hips and top leg in line with yourbody
Slowly lift your top leg up, keeping yourknee straightSlowly lower
Repeat ten times
NB Do not to let the patient’s hips roll forwards or backwards
Repeat the above with the other leg
Hip extension in prone
Lie flat on your stomach for ten minutes,
three time per day
Lie flat on your stomach, keeping your hips
flat on the bed left your leg off the bed
Hold for five seconds
Repeat ten times
Upper limb amputation pre-prosthetic exercises
Function, range and power of the upper limb are often neglected, but are key to good outcomesand quality of life. Scapular range is very important if using upper limb for greater function, e.g.
following bilateral lower limb amputation, or a patient sustaining a triple amputation needing toachieve getting on and off the floor independently. Also note that pectoral major/minor tightness
is very likely, due to greater sitting time, and needs to be counteracted.
All these exercises should be completed through your patient’s full available range, unlessindicated otherwise.
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Neck (to be completed gently and within thepatient’s range) – if these exercises cause any
dizziness/double vision/fainting, stop them
immediately and liaise with the medical teamRotation to the left and right x5

Trunk rotation

To the left and to the right x 5

Side flexion to the left and right x5
Extension x5

Shoulder elevation x10
Shoulder girdle

Shoulder protraction x10
Shoulder retraction x10
Flexion x10
Extension x10

ShoulderAbduction x10
Medial rotation x10
Lateral rotation x10
Flexion x10

If below elbow

Extension x10

For more information on upper limb functional rehabilitation, refer to the short video from HI
and BACPAR:

Improve mobility and independence
By teaching bed mobility, safe transfers and safe use of wheelchair or other mobility devices.
Bed mobility: Rolling: This is useful in both directions and is an excellent early core exercise thatis often underused.
Lie to sit: People with a transfemoral amputation experience a change of centre of gravity, especiallythose with a bilateral amputation, due to their lack of counterbalance. The lie to sit transfer will need
to be re-educated. Blocks or locally made equivalents can be useful in practising this.
Up and down the bed: Beware of sliding and shearing forces if the patient has any wounds orvulnerable skin. Slide sheets may or may not be available, therefore you will need to consider
how to reduced shearing forces and friction. During pre- or immediately post-wound closure,greater protection of the wound may be necessary.
Sitting balance: Start with sitting balance while sitting upright in bed.
Standing: Progress from sitting to sit to stand (with and without support). Work on standingbalance at the bedside with support present – educate the patient that they may be off-balance
due to their limb loss, or may still automatically try to use their amputated limb.
Patients with an amputation are at higher risk of falls, due to possible phantom sensations;readjustment of centre of mass after loss of body part and loss of strength; additionally when
standing, the lower limb stump is hanging down, which may increase oedema and pain.

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Transfers
When teaching transfers, this should be adapted for both the hospital and discharge environment:
Beds are less likely to be height-adjustable and this must be considered
Where patients may be sleeping at floor level (or are at risk of falling), transfers from thefloor should be taught
If a patient has stairs in their discharge environment, safe mobility on stairs must betaught
Where patients are required to squat to use the toilet, this must be included
Consider buttock wounds and avoidance of shearing forces in all transfers
Sideways transfers: whilst common, are not always appropriate depending on otherinjuries
In patients with bilateral or triple amputations, consider forwards/backwards transfer for
initial assessment. They are much safer to apply, easier to assist the patient and morestraightforward to stop and return to bed if any issues
Warn the patient about phantom limb sensation and mobility. When they may bedisorientated, especially at night time, they may forget about the residual limb and try to
stand and walk
For demonstrations of safe transfers for patients with an amputation in conflicts and disasters,
see the video from HI and BACPAR:

Temporary mobility device prescription
Wheelchairs are essential during early rehabilitation for people with a bilateral lower limb
amputation. However, their use in cases of unilateral lower limb amputations in disaster settings
attracts some controversy.
Controversy: In high-income settings, the use of crutches for unilateral amputees is discouraged,
with wheelchairs preferred, followed by the use of devices such as pneumatic post-amputation
mobility aids (PPAM aids) and then prosthetics. However, in conflict and disaster settings, PPAM
aids may not be available, length of stay in hospital may be short and the conflict/disasterenvironment may not be suitable for wheelchair use. Patients may also face severe waits forprosthetics. The use of crutches may still be judged to be appropriate – therapists need toconsider both options for their patients.
Pros of using a wheelchair
Safer due to:
Reduced risk of falls
Reduced chance of hitting/banging (and damaging) the stump on surrounding environment
Protects the sound leg (in the presence of other injuries or diabetes) – it will reduce therepetitive pressure of the sound leg, and therefore reduce chance of secondary injury tothat foot and leg, which could result in a second amputation

137 | EARLY REHABILITATION OF AMPUTEESCHAPTER 6 | AMPUTEESCons of using a wheelchair
Unable to negotiate steps and uneven or soft ground, potentially limiting access to essential
services, or increasing dependence on others
May be in short supply and prioritise for those who cannot otherwise mobilise
Wheelchair needs to be maintained in full working order to be beneficial
If the use of walking aids cannot be avoided (i.e. if awheelchair is not appropriate or the patient is selfselecting crutches)
Ensure that walking aids are properly adjusted
Teach the patient how to use the walking aids safely
Give education on preventing falls
Explain to the patient the dangers of the stumphanging down (i.e. may increase oedema, pain andhealing time)
People with a transtibial
amputation should use astump board when sitting in awheelchair or chair
Provide ongoing psychological support and education
Those who have had an amputation may experience significant fluctuations in their psychologicaland emotional state; delayed responses to a traumatic event are common. Therapists mustobserve each patient’s mental state during every treatment session and respond appropriately
if issues are identified. By remaining alert to signs of psychological or emotional distress andresponding appropriately, therapists can promote positive coping strategies and improveengagement in rehabilitation. Providing ongoing education will ensure the patient has an accurate
and realistic understanding of the phases and timeframes of post-amputation rehabilitation,
thereby minimising anxieties and potential disappointments. Involve family and friends inrehabilitation where possible.
Goal setting in early rehabilitation
Goal setting in early rehabilitation requires therapists to find a balance between the priorities
demanded by the setting in which they are working, and the person-centred goals expressedby the patient and their family/caregiver. Clearly, early rehabilitation will not be able to meet
all the rehabilitation requirements or goals of patients with an amputation. Constraints such as
time, limited resources and facilities and high demand for services limit the scope of the goals
that can be set with patients. This does not mean disregarding the perspective and prioritiesof the patient and their family/caregiver, however. In fact, understanding the patient’s homeenvironment, previous medical and functional history and goals for recovery is vital to working
collaboratively and can be pivotal to understanding their motivations and psychological responses
to their injury. The following tips can support effective goal setting in early rehabilitation:

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Provide clear, accurate and consistent education to the patient and their family/caregiverthroughout all interactions. For example, about length of admission, the recovery process,pain management and the priorities and limitations of available rehabilitation services
Be honest and truthful at all times, even when this may be difficult. For example,
about suitability for prosthesis use, availability of prosthesis services and likelihood ofachieving a return to specific activities. If you are unsure, it is better to state this, rather
than being vague or misleading. Effective and compassionate communication skills are
required. Sensitivity to the timing of these conversations is important and involvement of
psychosocial or psychological supports should be arranged wherever possible
When setting small functional therapy goals, it is important to explain how these activities
will build towards more significant achievements. For example, explaining how transfer
practice will facilitate the achievement of independent toileting/showering, or how
strengthening exercises contribute to successful use of crutches or a prosthesis
Goals should be relevant to the patient’s context. Ask the patient to describe their homeand community environment to ensure their rehabilitation contributes towards building skills
that are useful following discharge. For example, teaching wheelchair skills to a patient who
lives in an area that is inaccessible in a wheelchair is not appropriate, whereas teaching safeuse of crutches on sloped surfaces and uneven terrain, or on stairs, will be important
Regularly check the patient and their family/caregiver’s understanding of the rehabilitation
programme and goals of treatment. Be prepared to repeat explanations and instructions.
Use written and pictorial resources wherever possible and make time for questions.
Engage the use of an interpreter where possible if there is a language barrier
Pre-prosthetic stage
This should be continuous from the post-operative phase and start as soon as your patient cantake on board the appropriate and relevant information this setting part contains
The objectives of the pre-prosthetic phase are:1.

To assess for prosthetic provision or not

2.

To prepare for prosthetic use (until decision to proceed or not is taken)

Aims; continuing treatment started in pre- and post-operative phase, following revision oftreatment plans and goals
Oedema management/compression
Pain management
Prevention of contractures
Promotion of healing
Treating concurrent injuries as necessary
Increase range of movement and muscle strength
Improve posture/balance/mobility/function
Promote activities of daily living and independence, including on/off floor
Education of patient and family; psychological support
Issue of equipment and teaching safe use
Liaison with MDT and prosthetic centre re ongoing treatment plan and goals
Preparation for discharge to rehabilitation unit or community
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Pre-prosthetic training continues and progresses with strengthening exercises, ROM andstretching exercises for the whole body, as well as specific stump strengthening exercises
started post-operatively. It also introduces balance and coordination exercises and functional
activities. Please see the following links:
Transtibial exercises: https://bacpar.csp.org.uk/system/files/?file=pirpagexercisestranstibial_0.pdf
Transfemoral exercises: https://bacpar.csp.org.uk/system/files/documents/2018-09/
pirpagexercisestransfemoral_1.pdf
Assessment for suitability of prosthetic provision for lower limb amputation
During the pre-prosthetic phase, the MDT will determine, along with the patient (family/
caregiver), if the use of a prosthesis is the most suitable solution for the patient.
Factors impacting prosthetic provision
Living environment
Level of amputation or presence of a double amputation
Cognitive issues: difficulties learning, retaining and using new information
Patient’s own goals and motivation
Physical condition and ability
Concurrent injuries/co-morbidities
Availability of prosthetic services
The presence of significant hip or knee contractures
The presence of open wounds or other stump complications
For lower limb amputation
If the prosthetic solution is suitable:
Liaise with prosthetic service for planning prosthetic provision
Participate in the MDT discussion about for the selection of prosthetic type, socket design,
components and materials for the manufacturing of the prosthetic
Update the treatment plan and goals if necessary
If the prosthesis is not suitable:
Liaise with relevant provider to see if there is a service for the provision of a permanent wheelchair
Participate in the MDT discussion about the most appropriate mobility option is for yourpatient - Wheelchair versus crutches (see below)
Update the treatment plan and goals if necessary
For upper limb amputation
In conflicts and disasters, prosthetic devices for people with an upper limb amputation may be
more limited than for those who have sustained a lower limb amputation and may be restricted
to passive (cosmetic) prostheses or static terminal devices
Liaise with rehabilitation unit for planning prosthetic provision process

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Participate in the discussion among the team for the selection of the prosthetic type,socket design, components and materials for the manufacturing of the prosthetic
Update the treatment plan and goals if necessary
Prosthetic rehabilitation phase
Prosthetic rehabilitation starts at the time of prosthetic fitting and should provide your patientwith a good understanding of how they can achieve the most with their prosthetic. Close
teamwork with the prosthetist is vital, and they will be able to help you understand how theprosthetic works. The objective of the prosthetic rehabilitation phase is to achieve the highest
level of mobility and independence.
Aim

Achieved by:Understand thedifferent typesof prosthetics
and prosthetic
suspension
available for yourpatient

Understand the pressure tolerant areas of the stumpContinue
exerciseprogramme

Understand appropriate exercises to teach patients who are new totheir prosthesis

Teach patient
how to use andtake care of theirprosthesis

HygieneWork closely with the prosthetist

Pressure areas
Maintenance of the prosthesis
Be able to teach a patient how to correctly don and doff their prosthesis
Understand the specific sit to stand techniques needed for patientswith transtibial and transfemoral amputations
Recognise when adjustments to the prosthesis may be needed – as
the stump volume decreases, due to reduced swelling or muscle
atrophy – to ensure a good socket fit and alignment of the prosthesis

Gait training

Understand how different levels of amputation will affect what
prosthetic components are needed, and how the prosthetic
componentry used will affect their gait
Teach your patient to laterally weight transfer
Teach your patient anterior and posterior weight transfer
Understand principles of gait re-education for someone using a
prosthesis
Understand and recognise basic gait faults following amputation
Understand how a patient can go up and down stairs if they have atranstibial or transfemoral amputation

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PTs and OTs should ideally be present during fitting sessions, as it is useful to know how thepatient stood in their new prosthesis, what changes have been made, how the prosthesis issuspended (attached to the patient stump) and what prosthetic components have been used.
Training with the prosthesis starts at the first fitting, although necessary adjustments may bemade subsequently, due to fluctuation of stump volume or muscle atrophy.
All rehabilitation activities should be focussed on supporting the person with an amputation toparticipate in their meaningful functional activities. All exercises should therefore contribute to
the patient’s ability to complete their ADLs as independently as possible. Integrating functional
activities into rehabilitation is vital to the patient’s long-term outcomes. Examples of this could
include practising showering or dressing, recreating housework tasks, integrating long-distancewalking if the patient needs to reach distant places, or cycling, driving, gardening or farming.
Assistive devices can be used to support functional independence where retraining or prosthesis
use is not sufficient to allow task completion. This is of particular relevance for amputations inupper limbs, which will likely always leave the person with some degree of functional impairment.
In conflicts and disasters, priority should always be given to establishing safe and independentfunctional skills that contribute to safe discharge over the more discrete clinical goals that might
be addressed in rehabilitation settings in higher-resource environments.
Permanent Mobility Device Prescription:
Many patients will need to use walking aids, prosthetic devices or wheelchairs (also referred
to as ‘mobility devices’) for the rest of their lives. These devices should therefore meet theuser’s requirements and environment, provide a proper fit, alignment and support that meetssound biomechanical principles and be safe, durable, affordable and maintainable in the countryof use. They and should always be provided alongside appropriate physical rehabilitation andtraining. Mobility devices for long-term use are thus best provided by local services that canadapt them to the local context and remain available for follow-up, including maintenance and/or replacement.
Wheelchairs
Wheelchairs can be used to enhance mobility and independence until:
The person receives their prosthesis
As a complement to prosthetics for use in different situations and activities of daily life
If the person is unlikely to be a candidate for prosthetic rehabilitation
For users (temporary and permanent), the wheelchair should be safe, durable and provide proper
fit and postural support, including a stump board for patients with a transtibial amputation anda pressure relief cushion. In the early rehabilitation phase, use of a wheelchair for mobility
should be encouraged and walking aids discouraged, unless unavoidable. Wheelchair skills
should therefore be taught to all patients who have sustained an amputation as part of theirrehabilitation programme.

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Wheelchair fitting and user training
For permanent wheelchair users, it is important that the fitting of the wheelchair is completed
properly before completing the user training (which is more comprehensive at this stage thanwheelchair user training provided in the early rehabilitation phase). Please see the following
links: Wheelchairs considerations for amputees: https://www.motivation.org.au/limesquare/
wp-content/uploads/2018/01/FJ-Wheelchairs-for-Amputees-REVA.pdf and
WHO WSPT Basic Level Reference Manual for Participants: https://apps.who.int/iris/bitstream/
handle/10665/78236/9789241503471_reference_manual_eng.pdf
Check the following during wheelchair fitting:That the wheelchair is the correct size, and all necessary modifications and adjustments
have been made, i.e. provide a stump board for patients with a transtibial amputation.
Patients with high level or double amputations may also require the rear wheel axis to bepositioned behind the level of their shoulders to reduce the risk of the wheelchair tipping
That the wheelchair and cushion support the wheelchair user to sit upright; andThat the wheelchair effectively relieves pressure
Carry out fitting in this order:
Check size and adjustments
Check posture
Check pressure
Check fit while the wheelchair user is moving
During wheelchair user training the six most important things to remember to teach are:
How to handle the wheelchair, including how to use the brakes, move foot plates and arm rests
How to transfer floor to chair, chair to chair, chair to bed, bed to chair, in/out of thewheelchair and how to propel it safely
Wheelchair mobility – matched to the user’s needs
How to prevent pressure sores and what to do if one develops
How to care for the wheelchair and cushion at home
What to do if there is a problem
To ensure wheelchair user training is successful:
Find out what the wheelchair user already knows
Explain, demonstrate and then allow the wheelchair user to practise.
Use language that everyone can understandHave wheelchair users teach other wheelchair users for peer support
Use good communication skills
Be encouraging

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Prosthetics
Though the focus of this chapter is on early rehabilitation, as prosthetics are often an end goalof early rehabilitation, it is important to understand them. A prosthetic is an externally applied
device used to replace, wholly or partly, an absent or deficient limb segment. There are various
types of prostheses, with different components, materials and working methods, but all withthe same goal: to support function, body balance, ease of use and optimal cosmesis, in order torestore self-image, quality of life and independence.
Prosthetic components include the socket (interface between the person with an amputation’s
residual limb and the prosthesis), terminal devices (feet for lower limb and hands/hooks forupper limb), mechanical joints (knee, hip, wrist, elbow and shoulder), pylon (which allows
adjustment of the length of the prosthesis) and a suspension system (to keep the prosthetic
attached to the body).
The socket is the most important component of the prosthesis, as it determines the user’s
comfort and ability to control the prosthesis. Upper limb prostheses could be ‘body-powered’,
in which case the terminal device is controlled by movements of the shoulder captured by aharness system, or ’cosmetic’, which does not provide any active grasping capability.
Prosthetic components range from basic to advanced levels of complexity. In conflicts anddisasters, the more commonly used components provide essential functions and comfort for
the user and are usually made of a limited range of materials. These basic components are
relatively low-cost and may include simple knee joints, cushioned-heel feet (SACH foot) andpassive hands and hooks.
In conflicts and disasters, it is recognised that prosthetic provision is best met by national
providers or long-stay INGOs, such as ICRC or HI. This is vital as prosthetics require regular
refitting and adjustment to ensure that the technology used is appropriate and sustainable.

Transtibial
Supracondylar Suspension

Transfemoral
Belt Suspension System
socketmechanical joint(knee)

pylon

terminal device(feet)

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PTs and OTs work closely with the prosthetist and, if working regularly with people who havesustained an amputation, they should become proficient in the following areas:
Prosthetic fit and alignment; to be able to evaluate if any gait deviation and/or pain are
resulting from a poor fit and alignment
The functions of the different prosthetic components; to be able to teach the patient how
to use the prosthesis properly and to apply the correct gait training strategy
Correct donning and doffing of the prosthesis
How to adjust for volume fluctuation and what to do if the socket sits uncomfortably
Identifying pressure sensitive and tolerant areas of the stump
Any redness in sensitive areas lasting more than ten minutes should be addressed by theprosthetist
Pressure sensitive areas (red) and pressure tolerant areas (green)
Transtibial
Anterior view

Transfemoral

Lateral view

Anterior view

Lateral view

Discharge Planning
In conflicts and disasters, discharge from acute/inpatient care can happen at any time. Planningfor discharge must commence during the pre-operative phase, when the person’s likely discharge
destination should be known in as much detail as possible. As the patient’s functional abilities
become better established, it will become possible to assess the assistive devices required fordischarge. Careful consideration must be given to how the person’s independence in activities
of daily living can be facilitated, in order to support a better long-term outcome and reduce
caregiver burden. The objectives of the post-rehabilitation phase are:To facilitate a safe discharge from inpatient and/or rehabilitation care
To ensure patients with amputations and their caregivers are educated about long-term
management and where/when to seek help
To ensure patient and caregiver are referred for all necessary support services

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Aim

Achieved by:

Identify discharge destination

Discuss with patient where they will be going on discharge:

Inpatient/outpatient rehabilitation, own home/other private dwelling, camp/temporary shelter
Is the discharge destination damaged/safe/
accessible/adequately supportive?
Identify what assistive devices
are required for discharge

Ensure any devices provided can be maintained/
sourced locallyEnsure patient is educated appropriately about
safe use of the devices

Ensure patient has accessto disability organisations or
peer support networks, whereavailable

Refer patient to, or at least provide information
about, locally available networks

Ensure patient’s shelter,
protection and water sanitationand hygiene (WASH) needs
have been addressed

Refer to specific services if concerns exist andservices are available

Ensure patient’s psychosocial
needs have been addressed

Refer for ongoing psychosocial support services if
required and available

Ensure patient has accessto livelihood support and or
vocational retraining

Refer patient to, or at least provide information
about, locally available support

Multiple factors will influence the timing of a patient’s discharge from hospital. Therapists
should be aware discharge may occur as soon as the surgeon is satisfied with wound healing,
and the majority of rehabilitation may occur as an outpatient. In other situations, patients willremain in acute hospital settings until they are ready to transition to inpatient rehabilitation.
Clearly, the timing of discharge from inpatient care will have a direct influence on dischargeplanning and needs.
Post Rehabilitation Phase
When people who have sustained an amputation are discharged from rehabilitation, they should
be fully trained in care of the prosthesis and stump. This should be an integral part of theirrehabilitation programme from its commencement and should include caregivers when possible.
A leaflet detailing the advice given during rehabilitation and suggesting exercises to be carriedout at home can be given to amputees to help them to remember what to do. Patients should
also be able to obtain proper follow-up services and return to the centre if they have problems
with their prostheses.

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The patient leaflet should contain the following information:
Donning and doffing the prosthesis
Stump care
Prosthesis (or wheelchair) care
Bandaging
Where to go and what to do if they experience any problems with the prosthesis or
wheelchair
Instructions about any assistive devices provided

KEY pointSA MDT approach, including the patient and local services as available, is essential toensure an efficient and effective rehabilitation of the person sustaining amputation
A traumatic amputation drastically alters an individual’s life; not only does it create
unalterable physical changes, but can cause serious psychological impact as well
For the optimal use of a prosthesis, the affected limb should not develop any additional
deformity or contracture and should be pain-free
Early rehabilitation will lead to a greater potential for prosthetic success. The longer
the delay, the more likely the development of complications will be, such as joint
contractures, general debilitation and a depressed psychological state. However, aflexible approach is also important to adapt to concurrent injuries and/or psychologicalimpact
OT/PT’s should remember that prosthetic rehabilitation is logical and follows asequence of: donning the prosthesis, ensuring a proper prosthetic fit and alignment,
sit-to-stand, gait re-education (stance phase, swing phase and functional tasks)

147 | EARLY REHABILITATION OF AMPUTEESCHAPTER 6 | AMPUTEESKEY REFERENCES
Wheelchair Service Training Package: Basic Level Reference Manual. WHO
https://apps.who.int/iris/bitstream/handle/10665/78236/9789241503471_reference_manual_eng.pdf
Clinical guidelines for the pre and post operative physiotherapy management of adults with lower limb
amputations. BACPAR (2016) https://bacpar.csp.org.uk/system/files/bacpar_guidelines_nice_35_lr.pdf
Management of limb injuries during disasters and conflict. Geneva: ICRC, 2016.
https://icrc.aoeducation.org/

148 | EARLY REHABILITATION OF AMPUTEESCHAPTER 7 | ACQUIRED BRAIN INJURIESCHAPTER 7
CHAPTER 7: EARLY REHABILITAITON OF
ACQUIRED BRAIN INJURIES
AIMS:
By the end of this chapter, you should be able to:
Demonstrate a basic knowledge of acquired
brain injury (ABI)
Perform a basic assessment for a patient with an ABIDevelop a problem list for a patient with an ABIDevelop and deliver a basic rehabilitation plan
for a patient with an ABI

7

149 | EARLY REHABILITATION OF ACQUIRED BRAIN INJURIESCHAPTER 7 | ACQUIRED BRAIN INJURIESCHAPTER 7:
EARLY REHABILITATION OF ACQUIRED BRAIN INJURIESINTRODUCTION
An acquired brain injury (ABI) is a leading cause of death and disability in situations of conflictor disaster settings. Brain injuries can range from a temporary, mild injury to a severe, lifelong
impairment. In this chapter, we refer to an ABI as any injury to the brain that is not present atbirth or inherited. ABIs can be sub-divided into either traumatic or non-traumatic brain injury. A
non-traumatic brain injury, for example, can be caused by lack of blood supply to the brain, as
in ischaemic stroke, or by an infectious disease, such as meningitis. A traumatic brain injury iscaused by external forces, such as a gunshot or blunt force wound.
In conflicts and disasters, rehabilitation professionals are likely to see different types of ABIs,
both traumatic and non-traumatic. Conflicts and disasters increase the incidence of ABI, boththrough persons who are directly injured, and over the longer term where disrupted healthcare
systems prevent people from accessing their regular medication. For example, prolonged
conflict or road damage due to earthquakes may prevent the distribution of antihypertensive
drugs, leading to an increase in the occurrence of stroke.
In conflicts and disasters, you may see traumatic brain injuries caused by gunshot, a blow to
the head or a penetrating injury, such as debris piercing the skull or trauma caused by rapid
deceleration in a car crash. The shockwaves from blasts, e.g. bombs or exploding debris, cancause damage to the brain and open or closed head injuries. Due to their size and relative
frailty, e.g. thinner skin and softer skull bones, children are particularly vulnerable to brain
injury as a result of blasts. Non-traumatic causes of brain injury seen in conflict and disastersettings include cerebral malaria, meningitis, stroke related to cardiovascular or sickle celldisease, tumour causing pressure on the brain or near drowning. There are many potential
sources of brain injury and you should not consider these examples an exhaustive list of all
possible causes.
In settings where healthcare services are severely disrupted or poorly developed pre-crisis,
people with the most severe brain injuries are unlikely to survive, while those with less severe
injury may be missed when emergencies or mass casualties overwhelm available healthservices. Therefore, rehabilitation professionals are most likely to treat mild-moderate severity
brain injury.
All rehabilitation professionals working in conflicts and disasters should be able to provide
aftercare information to patients with mild brain injury or suspected brain injury, including
how to recognise signs of deterioration. Rehabilitation of an ABI is frequently complicated by
the presence of poly-trauma, such as associated skull (and other) fractures, open wounds andinternal injuries. The principles of assessment and treatment shown in this chapter can beapplied to all ABI presentations.

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Cerebral palsy (CP) is typically caused by damage to the brain before or at birth and is characterisedby disordered movement. Rehabilitation has a significant role to play. CP is not classified as
an ABI and is therefore not addressed in this chapter. There are online resources available
to guide you, e.g. https://www.physio-pedia.com/Managing_Children_with_Cerebral_Palsy
ABI in the developing brain of a baby or toddler presents with similar rehabilitation needs to
CP. In these cases, you are best to use paediatric-specific resources to guide you.

Presentation of an ABI in conflicts and disasters
In conflicts and disasters, certain factors will impact a rehabilitation professional’s approachto assessing and treating a patient with an ABI. Please refer to Chapter 3 of this handbook forgeneral factors that could impact your rehabilitation care, however, please keep the following
points in mind that are specific to an ABI:
Behavioural aspects: While brain injury can directly result in changes in behaviour and decreased
inhibitions (e.g. frontal lobe injury), in conflicts or disasters reactions to traumatic experiences
can also present as changes in behaviour or expressiveness. Social interactions and expressionof emotions can also vary across cultures and alterations may be missed if you are treatinga patient from a different cultural background. Ask a family member whether the person’sinteractions have changed since the injury, and how.
Profile of ABI: Patients with catastrophic brain injury are more likely to die due to the limited
availability of neurosurgery and ventilatory care. Unconscious patients are also unable to call forhelp and so in earthquakes, for example, they may be the last to be pulled from the rubble. You
are most likely to see patients with mild and moderate head injuries. These individuals are usuallydischarged quickly because inpatient beds are in high demand. Make sure you are familiar withthe signs of deterioration in a head injury (these signs of deterioration are explained later in thischapter) and can explain them to the patient and caregiver before their discharge.
Neurosurgery: If you work in an area where neurosurgery with aftercare support is available,
note that there are often special considerations and contraindications related to positioning thepatient, ventilatory support and other factors. Only work within your scope of practice andalways be guided by the medical team in these situations.
AnatomyClinical reasoning in ABI requires an understanding of basic brain anatomy; in the absence ofimagery, symptoms can still give an indication of the location and the extent of injury, while any
information about the injury can tell you some symptoms to expect and watch for.
The brain is made up of right and left sides (cerebral hemispheres), which communicate by nerve
tracts known as the corpus callosum. Each side has four lobes: frontal, temporal, occipital andparietal; at the base of the brain lies the brain stem consisting of the medulla oblongata, pons
and midbrain. The cerebellum sits behind this.
Chambers, called ventricles, within the brain make cerebrospinal fluid (CSF), which circulates
between protective outer linings to cushion the brain. The brain has three protective layers(meninges): the external dura mater between the brain and skull; the arachnoid mater in the
middle; and the pia mater layer closest to the brain.

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Blood supply to the brain from internal carotid and vertebral arteries forms a ring at the base of the brain(the circle of Willis) protecting the brain when a supply artery becomes blocked. Terminal branchesfrom this circle supply regions of the brain and blockage in these branches, e.g. stroke, results intissue damage. Pressure in the skull (intracranial pressure (ICP)) is controlled to ensure adequate blood
supply to brain tissue. Trauma to brain tissue raises ICP, which can cause further tissue damage.
Diagram 1: Circle of Willis
Anterior communicating
Middle cerebral

Anterior cerebral

Ophthalmic

Posterior communicating
Posterior cerebral

Internal carotid
Basilar
Vertebral

Diagram 2: Brain areas and functions
Frontal Lobe

Parietal Lobe

· movement· thinking initiation· reasoning (judgement)· behaviour (emotions)· memory· speaking· knowing left from right· sensation· reading· understanding spacial
relationships
Occipital Lobe
· vision· colour blindness

Temporalal Lobe
· understanding language· behaviour· memory· hearing
Brain Stem
· breathing· blood pressure· heartbeat· swallowing· alertness/sleep· body temperature· digestion

Cerebellum· balance· coordination· fine muscle control

152 | EARLY REHABILITATION OF ACQUIRED BRAIN INJURIESCHAPTER 7 | ACQUIRED BRAIN INJURIESClassification of ABIMultiple systems for classifying brain injury exist. In conflicts and disasters, it is unlikely that youor your patient will have access to many of the types of investigations, such as MRI or CT scans,that usually inform classification systems; however, it is still useful to have the knowledge aboutclassification. Brain injuries can be described by their cause, the area of the brain involved or the
progression of the injury. In conflicts and disasters, it is most important to focus on obtaining
the answer to three basic questions:
Is the ABI traumatic or non-traumatic? You can find this out through the mechanismof injury, either from the patient themselves, their medical notes, at handover or froma family member or caregiver. This may have implications for possible associatedinjuries and the emotional state of the patient and their readiness to engage with earlyrehabilitation
Is the ABI open or closed? The patient, their caregiver or their medical notes should containthis information. Be careful not to make assumptions – a patient may have dressings andbandages around their head because of a scalp laceration, but the head injury itself may
be closed. This may have implications for the stability of the patient and the education you
should provide about positioning and pressure careIs the ABI primary or secondary? Primary refers to the initial injury, which could betraumatic or non-traumatic, while secondary means an ongoing response to the primary
injury, such as swelling, raised ICP, seizure or infection. You may be able to gain thisinformation from your subjective assessment, but it is likely you will need to check the
medical notes or speak with the medical team. If the patient’s history of the injury isunclear, this may have implications on providing education on the prognosis of recovery
and making an accurate treatment plan
Severity of an ABI:
Many systems exist to classify the severity of a brain injury. The ‘Alert, Verbal, Pain Unresponsive’(AVPU) tool is a simplification of the Glasgow Coma Scale (GCS), which can quickly and accurately
be used in conflict or disaster setting. Please refer to Chapter 3 for more information on how to
use this tool.
Where haematoma (bleeding) is present in a traumatic brain injury, the injury can also be
described by where the bleed is located, either above (extradural) or below (subdural) the duramater, or lining of the brain. You are only likely to have this information if brain imaging isavailable. Haematomas cause injury to the brain through the pressure exerted on the surrounding
areas, which cuts off oxygen supply. They are common in the frontal and temporal areas where
the brain gets pushed against prominent areas of the skull.
Be aware that there are multiple labels for brain injury, including intracerebral haemorrhage,
diffuse axonal injury, subarachnoid haemorrhage or ischaemic stroke. Your approach forrehabilitation should always be guided by information from the medical team, a thoroughassessment and working within your scope of practice.

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Associated injuries to be aware of:Skull fractures
As with other bones of the body, skull fractures can range from simple, with no obvious lumps
or bumps, to more complicated, where the shape of the skull may be noticeably deformed.
Fractures to the skull may also be open or closed (refer to the fractures chapter). Open fractures
carry a high risk of secondary infection. You should be aware that fractures at the base of theskull may be associated with leakage of pale yellow, sticky fluid (CSF) from the ears or nose andcan lead to infection, such as meningitis, in the future.

Signs and symptoms of a skull fracture: Bleeding, pain, swelling, deformity and bruising of theface. Bruising can include behind the ears or the presence of black eyes; it is best to be review
bruising more frequently.
Deterioration
Any injury to the head, whether mild, moderate or severe, can worsen as the injured brain swells
and creates more pressure and further damage. Remember that, in patients with other injuries,
such as spinal cord injury or multiple fractures, a mild brain injury may initially be overlooked
and symptoms may only be noticed later in treatment or after discharge. It is important to teachfamily members what signs of deterioration to look out for, and that they should return to adoctor if they suspect the person is getting worse. If the patient is alone, or has been separated
from friends or family, alternative plans for monitoring should be made, such as informing aneighbour or health focal point in emergency accommodation.
The following symptoms indicate potential signs of deterioration:
Unconscious patient or altered consciousness (the patient can’t keep their eyes open)
Unusual tiredness
Headaches that worsen or do not resolve
Increased tiredness (feeling sleepy when normally would be awake)
Double incontinence
Dizziness or loss of balance
Nausea or vomiting
Irritability or altered mood
Slurring of words or problems understanding speech
Difficulties with concentration or memory
Weakness in one or more limbs
Visual problems, such as difficulty focusing or sensitivity to light
SeizuresAny bleeding or discharge of clear fluids from the nose or ears

154 | EARLY REHABILITATION OF ACQUIRED BRAIN INJURIESCHAPTER 7 | ACQUIRED BRAIN INJURIESASSESSMENT
The assessment of a patient with a brain injury in conflicts and disasters should follow the sameformat as a standard neurological assessment, as identified below. Due to the nature of the injury,
it may be difficult to complete a subjective assessment and the patient may be unaccompanied. If
this is the case, it is acceptable to only complete the parts of the assessment that it is possible to do.
Only assess the components you feel competent to complete and work within your scope of practice.
At the end of the assessment you want to be able to produce a list of priorities and goals, a
corresponding treatment plan and to be able to set some goals with your patient or their family/
caregiver where possible.
General assessment guidance is provided in Chapter 3 of this handbook, however, giveconsideration to the specific elements for an ABI stated below.
Subjective assessment
History of Presenting Condition (HPC):
How long ago was the injury?
Was there a loss of consciousness?
Have the symptoms progressed or deteriorated?
Past Medical History (PMH):
Find out if the patient has had any surgery/medical conditions which may influence therehabilitation outcome
Social History (SH):Who is the main caregiver/family member to involve in rehabilitation?
Objective assessment
Things to looks out for:Signs of trauma, including wounds and signs of surgery
Signs of infection (refer to Chapter 3 for these)
Any attachments (e.g. a catheter)
Heart and respiratory rate (if they are abnormally high or low, alert the medical team)Position and symmetry of their eyes, face, head, trunk and limbs
Function (i.e. what are they able to do?)Behaviour (see presentation of an ABI)
Remember to always be aware of signs of deterioration for your patient. Please refer to Table 1
for more information.
AVPU
This can be used to quickly assess the severity and check for deterioration of an ABI in conflicts
and disasters. A stable patient is likely to be A, but if the AVPU decreases it means the patientis deteriorating; in which case you must inform the medical team. When using the AVPU (or any
measure) to assess the patient, the score should be noted as a baseline and then repeated atregular intervals (e.g. daily) to assess any change. Refer to Chapter 3 for information on how to
use the AVPU Scale.

155 | EARLY REHABILITATION OF ACQUIRED BRAIN INJURIESCHAPTER 7 | ACQUIRED BRAIN INJURIESRed flags and complications
These are specific to an ABI only; however, you should always be aware of non-condition
specific red flags/complications. Refer to Chapter 3 for more information.
Table 1: Red flags for ABI
Red flag

Meaning

Action to be taken

Deterioration of AVPU
or list of signs ofdeterioration

Sign of worsening or
previously missed brain
injuryAlert the medical team
immediately

Sudden change(increase or decrease inblood pressure)

May indicate serious
medical condition, includingexcess pressure in thebrain, or insufficient blood
supplyAlert the medical team
immediately

Pressure ulcer which isopen or not healing

The patient is prone todevelop an infection. A
pressure ulcer that is
not healing can lead toosteomyelitis

You may be able to continue
treatment if it does not disturb
the wound, but you should
alert the nursing team

Patient may havedeveloped a lung infection
and/or may have problems
with swallowing. If thecough is more prevalent inassociation with oral intake(food/drink), they may haveproblems with swallowing

Alert the medical team. Educate
family about safe feeding
guidelines: upright posture,slow rate, small mouthfuls.
Some patients may benefit fromfood being mashed/pureed or
drinks being made thicker. Keepmouth clean of residue food andbacteria

Patient has persistentor productive coughReview the patient’s positionand cleaning, and avoid laying
the patient on the pressure sore

Range of motion (ROM): First check the active ROM and then the passive ROM at each joint.
This will tell you the ability of the patient to follow commands and if they have any weakness
or contractures.
Tone: When moving the joints through their passive ROM, you may feel a catch or resistance,
which indicates high tone. Alternatively, the limb may be floppy, which indicates low tone.
Power: Test all major muscle groups using the Oxford MRC Scale. Refer to Chapter 3 for more
information on its use. Trunk strength can be broadly assessed by the patient’s ability to do a
sit up.
Sensation: Check for ability to feel light touch and pain on all four limbs – ensure the patient has
their eyes closed during the assessment.
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Proprioception: The easiest way to check proprioception is to use joint position sense using the
thumb and big toe. Ensure the patient has their eyes closed. Passively move the distal phalanx
and ask the patient to identify if the movement is up or down. Proprioception can also be tested
by placing the patient’s affected limb passively in a position and asking them to copy it with theirunaffected limb if they have a hemiparesis; eyes need to be closed.
Coordination: For the upper limb, test finger to nose and look for any signs of tremor or over orunder shooting. For the lower limb, test heel slide along the shin from the ankle to the knee. There
are additional assessments for coordination that can be done, but these should only be carried out
if it is within your scope of practice. More information about other assessments can be found in the
Rehabilitation in Sudden Onset Disasters manual, referenced at the end of this chapter.
Vision: A detailed vision assessment is beyond the scope of this chapter; however, rehabilitation
professionals are often the first to notice visual problems after an ABI. Visual problems may
include blurred vision, double vision and/or reduced peripheral vision. You may also noticechanges in size/reactivity of pupils, or failure of an upward gaze.

Behaviour and mood: An ABI, especially with the involvement of the frontal lobe, can result inchanges in behaviour and mood. Patients may lose the ability to control their emotions. Emotional
outbursts, involving shouting, crying or laughing, may occur and pass quickly. Patients may become
very rigid in their thinking, have low motivation or be uninhibited in their behaviour or speech, using
rude or suggestive language that would have been out of character before their ABI. If the patient ishaving difficulty controlling their emotions, they may experience bouts of crying or laughing unrelated
to the emotion they are feeling in the moment. The patient’s personality may also appear quieter
than before the ABI, and they may have difficulty demonstrating emotion, known as the ‘flat affect’.
Cognition, memory and perception: Changes in cognition, memory and perception may present
as a decrease in attention, difficulty understanding complex tasks and sentences or difficulty
reading emotion in others. Try to conduct your assessment in a quiet, distraction-free space,using clear and simple instructions. Take breaks as needed.
Communication: Communication challenges are very common after brain injury. You can screen
for communication difficulties by:
Observing communication during conversation with the patient (e.g. during your otherassessments)
Asking the patient/person accompanying them about changes in communication (usethe prompts below or the Cognitive Communication Checklist for ABI) https://www.
assbi.com.au/resources/Documents/Assessment%20Resources/Free/CCCABI%20
checklist%20FINAL.pdf
Swallow: Coughing when eating or drinking is a sign that the patient may have a problem withswallowing. This could increase the risk of food/drink entering the lungs, which could cause achest infection.
Functional assessment: As part of any physical assessment, it is vital to assess the functional
ability of the patient. When assessing functional tasks, you should consider the following:
Can the patient complete the task?
Can the patient order tasks correctly?
Can the patient manage distractions?
Is the patient impulsive and do they have insight?
Does the patient present with any neglect to one side of their body?
If the patient has neglect to one side of their body, can they compensate for this?
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Note

Note: Due to the nature of an ABI, the patient may have poor balance and be at risk of falling;
therefore, you need to stay close to the patient during task assessments and may require asecond person to help you. Begin your functional assessment with easier, lower-level tasks:
Bed mobility – can the patient roll to one side and can they sit up on the edge of thebed? What level of assistance is required?
Transfers – bed to chair, bed or wheelchair to toilet etc. How much assistance orequipment does the patient need?
Sitting (with feet on the floor) – can the patient maintain sitting position independently
or with assistance, and then can they maintain balance while reaching?
Sit to stand and standing (only test if the patient has good sitting balance) – how muchassistance (person or equipment) is needed and how long can the patient stay up? If thepatient can stand, can they take a step?
Walking – (only test if the patient can safely stand and step) – can the patient walk andhow much assistance and/or equipment is required? Balance problems and difficulty
coordinating movement (apraxia) are more common in cerebellum injuries
Activities of daily living – can the patient perform routine tasks, such as eating, drinking,washing, dressing, toileting, cooking?
See treatment section below for additional information
See this video for a rehabilitation assessment of a patient who has experienced a stroke:https://www.youtube.com/watch?v=XbI9-uSwtBg&t=1130s
Outcome measures
Detailed information about outcome measures (OM) can be found in Chapter 3 of this handbook.
OMs should be used at the start of an assessment/treatment and may be repeated regularly toidentify any progress the patient is making. Therefore, in conflicts and disasters, it is importantto choose an OM that is simple and quick to use. Outcome measures can be quite detailed,assessing multiple tasks, such as the Rivermead Motor Assessment, or they can be simple andrequire little to no equipment, such as the ten-metre walk test. You can find a wide selectionof patient outcome measures online at https://www.sralab.org/rehabilitation-measures andhttps://www.strokengine.ca/en/. Timing how long it takes the patient to transfer from the edgeof the bed into the wheelchair can be used as an OM to measure progress.
Problem list, treatment plan and goal setting:After completing the assessment of an ABI patient, it is helpful to create a list of the patient’s
problems. This will then allow you to make a treatment plan based on the areas with which you
want to assist the patient. It is important to ask your patient what they want to achieve withrehabilitation. This will allow you to build up a set of goals that you can work towards together.
Remember, you may only have limited time with each patient. So, prioritise the aspects of theassessment that you need to complete, in order to give you the information that you need tostart rehabilitation. Education is an important component of your treatment plan, and you should
identify the main family member or carer who will be involved in treatment.
158 | EARLY REHABILITATION OF ACQUIRED BRAIN INJURIESCHAPTER 7 | ACQUIRED BRAIN INJURIESREHABILITATION TREATMENT
Rehabilitation treatment has two main aims for an ABI:1.

To restore as much independence in the patient as possible

2.

To educate the patient and their caregiver about realistic expectations and management
strategies

The process of rehabilitation should start from basic activities, such as changing postures (whennecessary), and then focus on other activities, increasing level of difficulty step by step (sitting,standing, balancing, walking). Important principles of effective neurological rehabilitation include
practising specific functional tasks, such as sit to stand, regularly and repeatedly.
Positioning in bed
The patient’s position should be frequently changed (every 3-4 hours) to avoid complications,such as developing pressure sores, contractures and respiratory problems.
The aim of positioning is to avoid shortening (i.e. developing contractures) of muscles or puttingpressure on particular joints or areas of skin. The patient can be moved from supine to right orleft side lying in bed. If the patient presents with a hemiplegia (weakness on one side of thebody), their position can be changed according to the pictures below. The use of pillows is usefulfor positioning; however, if you do not have pillows, rolled-up blankets/towels can also be used.
Sitting out of bed
Positioning in sitting should start as soon as the patient is medically stable, as it can improve theirlevel of alertness and it allows the patient to take deeper breaths. (For information on normal levels
for heart rate, respiratory rate, blood pressure etc., please refer to Chapter 3 of this handbook).
Diagram 3: Patient with left hemiplegia
Sitting

Lying on unaffected side

Back supported
by chairShoulder andAffected arm pelvic girdle
supported forward

Headand trunk
straight

Lying on affected side

Lying down

Ease affected shoulder
blade forward

Affectedarm
supportedby pillow

Feet flat on the floor

Arm and leg
relaxed on
pillows

Pillowbehind backArm resting
on bed, palm
upwardAffected leg
flexed forward

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Diagram 4: Patient with right hemiplegia
Sitting

Lying on unaffected side

Back supported by chair
Affected arm
supported

Feet flat on the floor

Headand trunk
straight

Pillowbehind backLying on affected side

Lying down

Shoulder and Ease affected shoulder
pelvic girdle blade forward
forward

Arm and leg
relaxed on
pillows

Arm resting
on bed, palm
upwardAffected leg
flexed forward

Affectedarm
supportedby pillow

Sitting out of bed also promotes activity in the muscles needed to keep an upright posture. As
early as possible, teach the caregiver and other staff, e.g. nurses, to safely position the patient.
The patient may need support to achieve a good posture and alignment. Sitting training canstart with sitting over the edge of the bed. They may need support for their body or head anda second person nearby. If the height of the bed prevents the patient’s feet from touching thefloor, put a block or support on the ground to ensure the feet are supported, rather than hanging.
Once the patient has sat out over the edge of the bed, they can progress to sitting seated in achair or wheelchair.
Training of bed mobility
Treatment should also include teaching the patient how to change position alone or with as little
assistance as possible. The caregiver should be included in this training to learn how best to
help the patient.
Diagram 5: Postural management in sitting

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Mobilisation
Passive movements can help to avoid the development of contractures and help with sensory
problems if present. Assisted selective movement, if the person has some muscle activity, canstimulate and guide active movement recovery. If there is high muscle tone and loss of rangeof movement, prolonged stretches with casts, splints and positioning can be useful (they canbe used while patient is resting). If you have access to plaster of Paris (POP) or thermoplastic
splinting material, you can make basic splints to prevent contractures. If the patient requires
long-term splinting you may need to work with local material and ask help from craftsmen.
Splinting and plaster casting for a patient with central nervous system injury is a difficult andcomplex skill. It requires a high degree of clinical reasoning to understand the risks and potential
adverse effects, which are more complicated than in the case of a patient with a peripheral
nerve injury. See https://www.kcl.ac.uk/cicelysaunders/attachments/splinting-guidlines/
neurosplinting-quick-reference-guide.pdf for further guidance.
Trunk control
Trunk control is an important early predictor of functional outcome after an ABI. If control insitting is poor, it’s important to focus treatment on trunk training exercises by gradually reducing
the support given from behind and at the sides and then progress to dynamic sitting balance
activities.
Standing in the early stages
Standing can be beneficial for:preventing shortening of ankle plantar flexor
hip flexor muscles
preventing loss of bone density in the lower limbs
encouraging deep breathing
increasing alertness
addressing postural hypotension (low blood pressure causing dizziness) after prolonged
bed rest
Heart rate, respiratory rate and other signs, including sweating, colour, facial expression and levelof alertness, should be monitored; this will indicate how the patient is tolerating the treatment.
When standing the patient for the first time, it is better to have two people help them to standup from sitting on the bed, so that in case of dizziness or feeling faint, you can immediately lay
the patient down and raise their legs.
Mobility skills (bed to chair transfer, sit to stand, standing, balance, walking, floor transfer)
If the patient can independently maintain sitting position, they can be trained in transferringfrom bed to chair and back. If it’s not possible for the patient to perform this by themselves, thecaregiver can be trained to assist.
Where available resources allow, you can give the patient a walking aid (a walking frame if they
can use both arms or a single-point or quad cane if they cannot). It is important to teach thepatient how to safely use the walking aid. As the patient improves, they may need less support,
e.g. moving from using a walking frame to a single cane. In case of ankle plantar flexion due to161 | EARLY REHABILITATION OF ACQUIRED BRAIN INJURIESCHAPTER 7 | ACQUIRED BRAIN INJURIES

high tone or dorsi flexor weakness, an ankle foot orthosis (AFO) may be provided to improve
walking by helping the foot to clear the ground.
If the patient has poor balance, work in different positions i.e. sitting, kneeling with one or bothknees and standing to improve their stability. If the patient usually spends a lot of time sitting
on the floor at home, you should train them to sit on the ground and get back up into standing.
Upper limb function
Patients can experience arm weakness,swelling and tight muscles in the upper limbs.
This can be due to high tone or low tone in themuscles, contractures, shoulder instability,changes in sensation and pain.
In cases of mild to moderate weakness,encourage use of the affected hand as muchas possible. A sling on the unaffected handor arm can be used (constraint-induced
movement therapy) to prevent it frommoving. This this can promote improvement
in a weaker side, with active wrist and finger
Picture 6: Resting Splint Positioning
extension. If the arm/hand is swollen, support
it in a raised position when sitting using a pillow or rolled-up towels. To help prevent contracturesand shoulder pain, regularly position the arm as shown in the diagram below, as long as thepatient is comfortable. In case of high tone causing a tight hand, a resting splint can be used
to avoid contractures. Refer to the peripheral nerve injury chapter for further information on
splinting and use of local materials.
Shoulder instability or pain: The patient may need an arm support (via pillows/rolled-up
blankets) or a sling for shoulder instability. You should teach the patient and the caregiver how
to protect the arm by avoiding pulling on it or avoiding letting it hang in a dependent position.
More information about pain can be found in Chapter 3 of this handbook.
Sensory problems: Sensation can be affected in different ways; touch may be reduced, lost or
exaggerated, with certain sensations feeling uncomfortable or intolerable to the patient. If so,
you can help retrain the patient’s sensation by using different materials, objects and textures tostimulate sensory fibres in areas of absent/ altered sensation. Proprioception may be reduced
and the patient may have difficulty understanding where their limbs are in space withoutobserving them. If so, teach the patient basic compensatory strategies, such as observing thelimb when moving it, i.e. reaching for something.
Fatigue: Fatigue is a significant problem in an ABI, even among patients with only mild brain
injury, including concussion. If the patient reports or demonstrates fatigue, include advice
regarding sleep hygiene (a dark, quiet bedroom with limited noise and a routine sleep and waketime) and pace activities. During rehabilitation sessions, limit noise and interruptions to preventthe patient from becoming over stimulated.
Self-care skills, including activities of daily living (ADLs): Encourage use of the affected limb
where possible, or incorporate activities involving limbs. If necessary assist the affected limb
during the movement. If the affected limb does not have any active movement, teach bathing

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and dressing techniques with one limb (remember that the weak limb/side should be put in thesleeve first and out last). You can also teach the caregiver to do it without injuring the patient by
dragging or creating friction over delicate skin, or pulling on the shoulder/limb on the affectedside. Find aids that can be provided or built to help the patient increase their independence (suchas toileting aids). This video shows a patient dressing themselves after a stroke: https://www.
youtube.com/watch?v=zZkwr_mfU5Y
Constipation can be a significant problem that causes pain and worsens spasticity. Establishinga bowel and bladder routine as early as possible is important to limit complications and pain.
Bladder and bowel retraining is usually led by the nursing team, with the input and cooperationof rehabilitation professionals. If a bladder and bowel routine has not been established, consult
the medical team.
Breathing: Respiratory problems are a common complication of an ABI. Refer to the respiratory
section in Chapter 3 for more information.
Education: An important component of treatment for both the patient and their caregiver isteaching them about the condition. Family should be made aware of different aspects of thepatient’s condition, difficulties they encounter and their residual capabilities.
Swallowing: Only give food to the patient when they are alert and able to engage in oral intake.
The patient should always be advised to sit in an upright position when eating or drinking andto eat at a slow pace, taking small amounts at a time. Alternating mouthfuls of food and drink
can help (though avoid having two different consistencies in the mouth at the same time).
Encouraging the patient to cough every few mouthfuls can help protect the airway. Somepatients may benefit from food being softened to minimise the need for chewing. Thin fluids canpose a dangerous risk to patients with swallowing difficulties. Providing drinks that are naturally
thicker and flow slower can be beneficial in giving the patient more time and more control whenswallowing. For example, you can add mashed potato to soup or banana to juice or use flour tothicken some drinks. Maintaining good oral hygiene, so the mouth is free of excess saliva or fooddebris, which can be aspirated, is critical in minimising the risk of aspiration.
Mood and behaviour: It is important for the patient and their family to understand that thesechanges are a result of brain injury and not the injured person’s fault. It’s advisable to stay
calm when the patient is upset to avoid increasing their agitation. If the patient demonstrates
behaviours that are spontaneous or aggressive, plan your treatment accordingly; attend with acolleague, use a private space that is cleared of material that could injure the patient or othersand do not overload the patient with tasks or instructions. Reassure the family that it is unlikelythat their behaviour or actions triggered an emotional outburst. Gently redirect the patient toanother topic, once they have calmed down, and reassure the patient themselves.
Cognitive skills: Cognitive changes are often associated with an ABI and it is important toreassure patients and carers that memory or attention problems are due to the brain injury.
Advise the family that strategies, such as keeping a diary, regular routines and repetition, may
be helpful.
Communication: Ideally, if communication difficulties are noted, a speech and language therapist(SALT) should be involved. In conflicts and disasters, it is unlikely that a SALT will be available;
therefore, one of the most effective ways to support successful communication is to ensure that
other people in the environment (staff and family) are using good communication strategies. Try toestablish a clear means of communicating ‘yes’ or ‘no’, as this provides a way to obtain consent foryour interventions and enables the use of closed questions, e.g. about pain, hunger, toileting etc.
163 | EARLY REHABILITATION OF ACQUIRED BRAIN INJURIESCHAPTER 7 | ACQUIRED BRAIN INJURIES

To support connection:
Approach the conversation with the assumption that the patient is competent and able
to interact
Avoid test questions and aim for a genuine, two-way interaction
To support understanding:
Use a natural, conversational tone of voice
Use one idea per sentence
Introduce topics and be clear when changing the subject
Try visual supports or writing key words – talk and point/write at the same time
To support expression:
Allow the patient time to respondUse visual supports or write key words
Use choice questions (e.g. ‘is this about your mother, your brother or someone else?’)Confirm that you understand the patient by repeating what you understood (e.g. ‘you’reasking about your brother, is that right?’)
Communication aids:
These may be useful for some patients. Communication boards are not an automatic ‘solution’but require a degree of design, support and practice for the patient and those around them.
Generic communication boards can be designed for specific conflict and disaster settings. Here isan example used in Mozambique during an emergency response: https://www.up.ac.za/media/
shared/212/ZP_Files/humanitarian-aid-emergency-medical-services-portugese.zp172927.pdf.

164 | EARLY REHABILITATION OF ACQUIRED BRAIN INJURIESCHAPTER 7 | ACQUIRED BRAIN INJURIESREHABILITATION TREATMENT OUTCOMES
Immediate: Anyone who has experienced a head injury is at risk of deterioration. Before
discharging the patient, or sending them home, ensure that they and their caregivers are awareof the signs of deterioration and how they can contact medical services if they experience ornotice these signs occurring.
Short-term: Around one in every eight patients with a mild brain injury will experience persistent
symptoms, such as headaches, problems with their balance, tiredness and changes in the moodor cognition. These should resolve over time, but it is important to advise the patient to takethings slowly and not return to all of their previous activities too quickly.
Medium-term: By the time you discharge your patient, or finish the early phase of theirrehabilitation, you should have achieved certain goals listed below:
Patients (possibly with the assistance of the caregiver) should be able to manage theirhighest level of independent movement. This may be bed mobility and positioning,transfers or standing/walking with an aid
The patient and their caregiver should know their exercise regime to continue at home,with a focus on functional exercises repeated often. They should know that improvement
can continue with these exercises
If the patient uses any splints or aids, such as a wheelchair, they should be able to safely
use it and check for signs of damage to the equipment or to their own skin
The patient and their caregiver should know which activities and positions should be
avoided as they may cause harm, e.g. pulling the patient by the weak arm or lying in
bed without a position change for more than four hours when they are unable to moveindependently
You should have reviewed the appropriate patient information leaflet with them and given
the patient and their caregiver a chance to ask any additional questions they may haveLong-term: It is unlikely that in a conflict and disaster setting you will be able to continue to
see your patient beyond the acute phase, but linking them to any available longer-term services
is important. Long-term improvement and outcome depend on many factors; these include
the severity of the initial injury, the presence of additional injuries (which can complicate or
slow down recovery) and the ability of the patient and their caregivers to understand/adhere
to a home exercise programme. Unfortunately, not all patients will make a complete recovery
following brain injury; some will be left with lifelong difficulties as a result of their injury. If it
seems relevant, you may inform the patient’s family that, as the conflict or disaster situation
resolves or stabilises, more rehabilitation services may become available and they can seek
these out for additional care and rehabilitation.

165 | EARLY REHABILITATION OF ACQUIRED BRAIN INJURIESCHAPTER 7 | ACQUIRED BRAIN INJURIESCASE STUDY
Background
The patient is a 32-year-old female who was pulled from the rubble of a collapsed building threehours post-earthquake, ten days ago. She sustained an injury to the head and multiple fractures(left humerus, left tibia/fibula, ribs 7, 8, 9 on the right-hand side) and some facial injuries. Her
sister, who was present when the patient was rescued, reports temporary loss of consciousness
on the way to the hospital and the patient was confused. She reports no vomiting or seizures.
The nurse accompanying the patient to the rehabilitation department reports the medical notes
are not available and she does not know the patient well.
Assessment
Observation: Patient is lying in bed, she appears tired, emotional and cries easily, but consents
to treatment. She is wearing a left, below-knee cast and her left arm is in a sling.
Active range of motion: unable to assess on left side due to fractures, but able to wriggle fingers
and toes. Asked the patient to do simple movements, bending her right knee and taking her
hand to her mouth. The patient is able to move her right leg, but not through its full range of
motion; no movement seen in right arm.
Passive ROM: tested in all joints (free from casting) on both sides with no problems noted.
Tone: Tested on the right side only, since left side is immobilised by cast and sling. The upper limb
felt very floppy during testing, but some resistance to dorsiflexion was noted at the right ankle.
Power: Tested using the Oxford MRC Scale, graded as 0/5 for all major muscle groups throughright upper limb and 2/5 in the right lower limb
Sensation: On testing, reduced sensation to light touch was noted in the right arm and leg,
proprioception was normal in all limbs.
Coordination: Not tested due to fractures on the left side and extensive weakness on the right.
Speech and comprehension: Patient seems to be communicating normally and following basic
commands in her own language.
Functional assessment
The patient is reluctant to roll due to pain, especially around her ribcage. Lying to sitting without
a full roll required the assistance of two people – one to support the lower limbs and one tomanage the trunk and arm. Once up, the patient does not report any dizziness and can sit
unsupported. The patient’s legs do not reach the floor, and so were supported on a block.
Sitting balance during movement was not tested due to lack of arm function and pain on trunk
movement. At this time, the patient requires full assistance with all basic tasks, such as eating
and drinking and personal care, and is being supported by family members. Transfers, standing
and walking were not assessed due to power of 2/5 in right leg. A non-weight-bearing status on
the left leg and arm is initially assumed, due to the lack of medical notes.
Clinical impression
Right-sided weakness and loss of sensation due to left-sided ABI, indicating likely parietal andfrontal lobe involvement. Rib pain is a limiting factor to assessment and a likely limitation for
166 | EARLY REHABILITATION OF ACQUIRED BRAIN INJURIESCHAPTER 7 | ACQUIRED BRAIN INJURIES

treatment unless better controlled. Right upper limb is low-toned, lacking activity and at riskof shoulder subluxation and development of shoulder pain. Increased tone in plantar flexors
on right-hand side and at risk of muscle shortening. Patient is currently fully dependent for
all transfers and daily activities. Noted that the patient was tearful and may need further
assessment due to recent psychological trauma and frontal lobe involvement.
Treatment goals (short-term): Get patient out of bed for sitting and clarify weight-bearing statuson the left leg and precautions for left upper limb.
Treatment approach: Build time in upright sitting for now and allow weight bearing in sitting
through the right foot while maintaining good ankle positioning. Patient to sit out in a chair regularly
but requires a lift transfer to the chair at present. Avoiding complications related to immobility by
regular position changes, advice to the patient to wriggle fingers and toes and maintain movementin the left side as pain and fracture sites allow. Confirm weight-bearing status on left leg withmedical team. If the patient is non weight bearing, consider splint for right ankle to maintainmuscle length during rest. Start regular, repeated right leg exercises to improve activity andpower. Once right gluteal and quadriceps are 4/5 on the Oxford MRC Scale, the patient can single
leg stand on this leg with assistance. Begin sensory re-education of right side.
Education: Advise and teach the patient’s sister about the importance of and how to change
position regularly. Teach her sister to do safe, daily, passive range of motion exercises for rightarm, noting that abduction and forward flexion should remain below horizontal level. Inform her
about the risk of developing shoulder pain and how to care for the arm by supporting its weight
when upright and avoiding pulling on the arm. Inform her about the possibility of ongoing alteredor low mood. Use her sister to identify motivating/interesting stimuli for meaningful activities andto monitor mood. Inform her about the possible development of shoulder pain and how to carefor the arm. Ensure her sister is aware of the patient’s need for assistance with daily activities.
Outcome: As the rib pain decreases, the patient can become more actively involved in bed
mobility. Once patient has enough power in her right lower limb to stand and/or fractures havehealed or weight-bearing status has changed to full weight bearing (whichever is first), sheshould then be in a position to work on standing and stepping. At this time, it is not possible
to predict the outcome of her right arm function, but once the left arm fracture is healed, sheshould be more independent in daily activities.

KEY pointS
1.

In conflicts and disasters, rehabilitation professionals are most likely to encounter
mild or moderate brain injuries, rather than severe injuries as severe brain injuries do
not survive

2.

Rehabilitation professionals must know signs of deterioration of a mild head injury
and be able to educate the family/patient on how to spot these and to refer or returnback to the medical team

3.

Treatment should be based around functional activities/exercises with high repetitionand prevention of secondary complications

4.

Due to the limited duration of treatment in conflict and disaster settings, educationand inclusion of the caregiver should form key parts of your treatment

167 | EARLY REHABILITATION OF ACQUIRED BRAIN INJURIESCHAPTER 7 | ACQUIRED BRAIN INJURIES

Core recommended text

Rehabilitation in Sudden Onset Disasters manual
Physical Management for Neurological Conditions Lennon S, Ramdharry G, Verheyden G (Eds.)
2018. 4th Edition, Oxford, Elsevier
Starting again, Davies, Patricia M., Springer ed. 1994

REFERENCES
Web-based resources have been linked throughout the chapter.

Cognitive Communication Checklist for Acquired Brain Injury (CCCABI) MacDonald, Sheila (2015) CCD
Publishing; Guelph, Ontario, Canada, N1H 6J2, www.ccdpublishing.com available from https://www.
assbi.com.au/resources/Documents/Assessment%20Resources/Free/CCCABI%20checklist%20
FINAL.pdf
Video demonstrating the use of some strategies with a person having difficulty expressing themselves
https://www.youtube.com/watch?v=KWVoqM9jmEM

168 | EARLY REHABILITATION OF ACQUIRED BRAIN INJURIESCHAPTER 8 | SPINAL CORD INJURIESCHAPTER 8
CHAPTER 8: EARLY REHABILITAITON OF
SPINAL CORD INJURIES
AIMS:
By the end of this chapter, you should be able to:
Demonstrate a basic knowledge of a spinal cord injury (SCI)
Perform a basic assessment for patients presenting with SCI,
or possible SCI, including complication monitoring
Develop a problem list for a patient with an SCI
Develop and deliver a basic rehabilitation plan
for a patient with an SCI

8

169 | EARLY REHABILITATION OF ACQUIRED BRAIN INJURIESCHAPTER 8 | SPINAL CORD INJURIESCHAPTER 8:EARLY REHABILITATION OF SPINAL CORD INJURIESINTRODUCTION
Spinal cord injuries (SCIs) are commonly seen following earthquakes, and much of the publishedliterature relates to this presentation. It is important to recognise, however, that these injuries
will present in any conflict or disaster setting where people may experience a direct crush injury,
crush with traction/rotation (particularly in the pre-hospital recovery phase when extracted froma building or vehicle with limited understanding of spinal precautions), falling from a height or
blast injuries which involve a fall or direct trauma to the spine from shrapnel or bullet wounds.
Following conflicts and disasters, hospitals can expect an acute surge in admissions of patientswith SCI, and these generally increase for several weeks as people are extracted, identified,or new injuries arise in the aftermath of the event. Complications, such as pressure ulcers
and urinary tract infections, are common in conflicts and disasters, due to delayed transfers tospecialist centres, high health worker-to-patient ratios, inadequate equipment and consumables
and premature discharge related to bed pressures.
During the Nepal earthquake in April 2015, the Spinal Injury Rehabilitation Centre had a totalof 38 patients at the time of the first earthquake. Within the first three weeks, an additional
62 patients were admitted, with subsequent daily admissions. Earthquake-related admissions
continued for months, with the final known earthquake-related patient being admitted in March2016. 33% of patients had documented pressure ulcers and urinary tract infection was seenin 29%. Other challenges faced during the surge of patients included inadequate numbersof beds, patients being nursed on the floor and inadequate numbers of staff, equipment andconsumables.
In many low-income countries, the level of pre-existing services for SCI is minimal. There canalso be a limited cultural understanding of SCI, poor practices in handling people with suspected
SCI after immediate onset of injury and inadequate management of skin, bladder and bowel.
The preventable secondary conditions are just as threatening to these patients as their initial
injury, leading to compromised health and functioning outcomes or death. Early assessment andrehabilitation may prevent or reduce many of these issues.
Rehabilitation needs for people with SCI will persist far beyond the initial acute stage, therefore,close, supportive collaboration must be established with local services from the outset. Basic
information about expected outcome is important to be able to communicate with the patient
so they can initiate long-term goals. In conflicts and disasters it should be noted however thatthe realisation of long-term goals for the person with SCI may be affected if they cannot returnto their own home or find appropriate sources of income.

170 | EARLY REHABILITATION OF SPINAL CORD INJURIESCHAPTER 8 | SPINAL CORD INJURIESANATOMY, PHYSIOLOGY AND PATHOLOGY
It is important for any rehabilitation professional working with a person with an SCI to havea thorough understanding of the anatomy and physiology of the nervous system, in order tounderstand the presentation and the impact of the pathology on functioning. The spinal cord
Diagram 1: Normal spine
1st cervical
2
3
4
5
6
7
1st thoracic
2
3
4
5
6
7
8
9
10
11
12
1st lumbar

cervicalthoracicthoracolumbar

2
3

invertebral
4
disk

lumbar5
sacrumcoccyxside view of spineback view of spineconsists of 31 segments, associated with
31 pairs of spinal nerves (eight cervical, 12thoracic, five lumbar, five sacral and one
coccygeal). The ascending sensory nerves
within the spinal cord receive and transmit
sensory information to and from the brain.
The descending motor nerves transmit
information from the higher brain structures
to various parts of the body to initiate motor
functions, such as movement, and to regulate
autonomic functions, such as respiration andblood pressure. The spinal cord is also critical
for transmitting and integrating information
within the spinal cord. SCI which results in
disruption of the nervous transmission canhave considerable physical and emotional
consequences to an individual’s life. Paralysis/
weakness or altered sensations in parts of the
body innervated by areas below the injured
region almost always occur. In addition,individuals also experience other changes
affecting bowel, bladder, pain, sexual function,
gastrointestinal function, swallowing ability,
blood pressure, temperature regulation andrespiration.

For more information, pelase refer to: https://www.mascip.co.uk/wp-content/uploads/2015/02/
MASCIP-SIA-Guidelines-for-MH-Trainers.pdf

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Diagram 2: Dermatomes and myotomes map

ASSESSMENT AND MONITORING
Assessment is the first step in the management of the person with an SCI. All patients witha diagnosed or suspected traumatic SCI must be considered to be critically ill, due to both thesevere changes related to the interruption of neural transmission conveyed by the spinal cord andthe high risk of related complications. During the early rehabilitation phase, it is recommended
that a multidisciplinary team (MDT) assessment is carried out. This assessment must include an
overview of the risk of developing complications.
Three factors may affect the overall clinical condition of patients with an acute SCI:
1.

The extent of neurological damage, including the completeness of the injury and zone ofpartial/lack of innervation

2.

Presence of associated trauma

3.

Age and/or pre-existing medical history

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Complications
These complications are specifically highlighted for SCI; however, you should always be awareof non-condition-specific red flags/complications. Refer to Chapter 3 for more information.
Table 1: SCI-specific complications
Complication

Meaning

Action to be taken

Autonomic
dysreflexia (AD)Those with lesions at T6 and above after
resolution of the spinal shock phase are at riskof AD, which refers to an uncontrolled andexcessive increase in sympathetic activity, usuallycaused by:

ALERT MEDICALTEAM IMMEDIATELYThis condition, if notrecognised and treated,
may result in death

Nociceptive stimuli under level of thelesionDistended bladder due to blockedcatheter, or full bag
Distended bowel
Signs and symptoms include:
Sudden rise in blood pressure(>20mmMg)
Decreased heart rate/bradycardia
Flushing above level of injury
Sweating above level of injury
Tight band around chest depending on
sensory deficit
Feeling unwell
Sudden headache
Blurred vision
Stuffy nose
Feeling of impending doom
Change inneurology

Particularly relevant in the acute SCI phase andmaybe a sign of an unstable spine. It is important
to be aware of signs indicating damage at ahigher level of the spinal cord. New signs ofdeterioration in respiratory function can be anindicator can be an indicator that this may haveoccurred (respiratory functions are affected byinjuries at C5 and above)

ALERT MEDICALTEAM IMMEDIATELY
Risk of further damage
to spinal cord andsupporting structures
Ensure safe handlingtechniques and maintaina stable spine (seetreatment section)

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Complication

Meaning

Action to be taken

Neurogenic shock

Sudden disruption of signals that maintainautonomic nervous system control overvasoconstriction leading to hypotension. Occurs
in acute SCI at cervical or high thoracic level thatblocks sympathetic activity

ALERT MEDICALTEAMSecondary effects of general autonomic
disturbance following SCI can include:
Bradycardia (HR less than 60bpm), hypotension(systolic <90mm/hg), sudomotor changes,
thermoregulation poikilothermia
Spinal shock

All reflexes lost below level of injury for threedays to three months. Loss of gastrointestinal
function, resulting in paralytic ileus andneurogenic bladder/bowel

ALERT MEDICAL
TEAM

Difficulty digesting food with subsequent
abdominal distention and vomiting
Patient has
persistent or
productive coughPatient may have developed a lung infection
and/or may have problems with swallowing(dysphagia). If the cough is more prevalent inassociation with oral intake (food/drink) they
may have problems with swallowing, resulting
in fluid and food entering the airway. This could
increase the risk of developing pneumonia

ALERT MEDICAL
TEAM

Pressure injury

A pressure injury is localised damage to the skinand underlying soft tissue usually over a bonyprominence.

Identify issue withnursing teamMay present as intact skin that is red and fails toblanch (may be difficult to detect in dark pigmentedskin) or an open ulcer and may be painful if theperson has sensation in the affected area

Educate family about
safe feeding guidelines:
upright posture, slow
rate, small mouthfuls.
Some patients may
benefit from food being
mashed/pureed or drinks
being made thicker. Keepmouth clean of residue
food and bacteria

See treatment section
for pressure injury
prevention and careOccurs as a result of intense and/or prolonged
pressure or pressure in combination with shear
Typical areas where people develop pressure
ulcers include the heels, buttocks, shoulder
blades, thoracic spine, posterior ears andocciput, depending on positioning and how
much time is spent in prone
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Complication

Meaning

Action to be taken

Deep veinthrombosis (DVT)
and/or pulmonary
embolus (PE)

Signs and symptoms include:

ALERT MEDICALTEAM IMMEDIATELY

Swelling of the lower limb (usually
unilateral)
Reduced peripheral pulses
Erythema/redness of the skin (not seen
in dark pigmented skin)
Heat of skin increased

Stop passive
movements,
mobilisation and manual
respiratory techniques
until after medical
review

Pyrexia
Autonomic dysreflexia symptoms inpatients with a T6 and above lesion
Pain depending on sensory deficit
Increased leg spasms
Heterotopic
ossification (HO)Abnormal calcification that develops in soft
tissues outside of the joints.
Signs and symptoms include :Erythema/redness of the skin (not seen
in dark pigmented skin)

ALERT MEDICALTEAM FORASSESSMENT
Care required withmanual therapy

Heat and swelling of affected area
Hard, palpable mass
Reduced joint mobility and subsequentloss of function
Pain depending on sensory deficit
Increased spasticity
Pressure area
Autonomic dysreflexia
Spasticity/
contracture

The cause of contractures can be:

Neurally mediated – due to spasticity
or involuntary contraction of muscles
which are velocity dependentNon-neural mediated – primarily due toprolonged positions and immobility

Maintain joint mobility
and prevent oedema
through exercise,positioning or splinting
Link with medical teamfor medication options
related to pain andspasticity management

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Complication

Meaning

Action to be taken

Unmanaged
bladder andbowel issues

Incontinence, retention and constipation may
cause significant complications such as:

Co-ordinate with the
MDT for assessmentand ongoing
management

Infection (see Chapter 3)
Autonomic dysreflexia
Pain

See treatment section
for details

Functional, social and psychologicalimpact
It is important to follow a systematic approach to assessment and treatment. General
assessment guidance is provided in Chapter 3 of this handbook; however, give consideration to
the specific elements for a SCI stated below. Assessment should be part of the MDT approach.
At the end of the assessment you should be able to produce a list of priorities and goals and acorresponding treatment plan, and be able to set some goals with your patient or their family/
caregiver where possible. It is important to begin planning for discharge with a patient withan SCI and their caregiver as early as possible; therefore, this should be thought about while
creating a plan after your initial assessment.

The key specific areas of assessment for patients with an SCI, both initially and ongoing, are:Identification of complications (see Table 1 above)
Autonomic function
Bladder and bowel function
Motor function
Sensory function
Activities of daily living (ADLs)
Psychological and emotional wellbeing
It is imperative that assessments, as a minimum, include the ISNCSCI 2019 Revision (International
Standards for the Neurological Classification of Spinal Cord Injury) – formally known as the ASIA
assessment, the ASIA Impairment Scale (AIS) and the SCIM III (Spinal Cord Independence Measure).

ASIA ASSESSMENT

176 | EARLY REHABILITATION OF SPINAL CORD INJURIESCHAPTER 8 | SPINAL CORD INJURIESThe International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI)This gold standard assessment for documentation of the level and severity of an SCI provides
an internationally standardised classification system for SCI, giving a ‘neurological level of injury’and also an ‘incomplete’ versus ‘complete’ injury classification:. https://asia-spinalinjury.org/
wp-content/uploads/2016/02/International_Stds_Diagram_Worksheet.pdf.
To learn more, please access the free online e-learning resource from the American Spinal Injury
Association (ASIA): ’The International Standards Training e-learning Programme (InSTeP)’. This
modular course is designed to enable clinicians to perform accurate and consistent neurologicalexaminations: https://asia-spinalinjury.org/learning/.
The Spinal Cord Injury Independence Measurement Scale (SCIM III)A clinician-administered disability scale, developed to specifically address the ability of people
with an SCI to perform basic activities of daily living independently. The SCIM assesses threeareas: self-care, respiration and sphincter management and mobility (including toileting). A
self-report version of SCIM (SCIM-SR) is also available: https://scireproject.com/wp-content/
uploads/SCIM_Toolkit_Printable-1.pdf.

REHABILITATION TREATMENT
Regardless of context, the fundamentals and management principles of SCI rehabilitation
are similar. www.elearnsci.org physiotherapy and occupational therapy modules provide acomprehensive educational resource relating to the management and treatment of the personwith an SCI, and are a recommended resource.
Initial medical and surgical management
Vertebral injuries are managed either conservatively or surgically. If managed conservatively, patientsare typically immobilised in bed for six to eight weeks. If managed surgically, patients are typicallymobilised sooner after injury. The way vertebral injuries are managed has implications on the typeand intensity of rehabilitation provided. For immobilised patients, it is important that the patient isfacilitated to be as physically and psychologically active as possible. It is critical to prevent stiffness
and oedema and maintain muscle strength, so the focus should be on active rehabilitation.
Precautions and safe handling of the unstable spine
Rehabilitation professionals involved in the care of these patients need to follow specificprecautions for an unstable SCI when carrying out their assessments and treatments to protect
the spine from instability. This will be dependent on the level of injury.
The Multidisciplinary Association of Spinal Cord Injury Professionals (MASCIP) Guideline ‘Moving andhandling patients with actual or suspected spinal cord injuries’ provides therapists with a practical
pictorial guide to ensure the safe handling of a patient with SCI, or a suspected SCI: https://www.
mascip.co.uk/wp-content/uploads/2015/02/MASCIP-SIA-Guidelines-for-MH-Trainers.pdf
The integrated care pathway for patients with an acute SCI involves numerous transfers
between surfaces, wards and departments, or even between different hospitals before eventual
admission to a specialist care facility. Wherever there is a reasonable suspicion of acute SCI,
the aim is to maintain full spinal alignment during any moving and handling activity. Carefulhandling, positioning and turning, on every single occasion, can prevent or significantly reduce

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the patient’s pain and discomfort. It will also reduce the potential for skin damage and secondaryspinal cord trauma. The pictorial guidelines by MASCIP are provided as a resource for moving
and handling trainers to support the promotion of best practice: https://www.mascip.co.uk/wpcontent/uploads/2015/02/MASCIP-SIA-Guidelines-for-MH-Trainers.pdf
Number of persons required for turning a patient with an unstable SCI, according to ATLS
(Advanced Trauma Life Support) and MASCIP guidelines, are:For an injury of T9 and above: a five-person turn
For injuries T10 and below: a four-person turn
BreathingRespiratory problems are a common complication of SCI. Refer to the respiratory section in Chapter
3 for more general information. Paralysis or partial paralysis has a marked impact on respiratory
function, due to respiratory muscle weakness, plus decreased pulmonary and rib compliance.
Tetraplegia has a marked effect on all lung function apart from residual volume, which meansthat people with a tetraplegia are at risk of respiratory complications throughout their lives, due torespiratory muscle and decreased pulmonary and rib compliance with a restricted pattern of breathing.
For more information, please refer to the MASCIP Guideline (link above).
Diagram 3: The effect of an SCI on respiration and assisted coughThe effect of SCI on respiratory
Intercostals elevatechest wall

Normal abdominal
muscle tone

Diaphragm
descends

Raise in resp rate:
due to fatigue?
infection?
pulmonary embolism?
pain?
pneumothorax?
ascending neurology?

Respiratory management: Assisted CoughMonitor respiratory effort:
SaO2
Oxygen requirements
Respiration rate
Vital capacity
Breathing pattern - paradoxical?
Flaccid intercostals allow
chest wall depression

Monitor vital signs for respiratory compromise:
Resp rate, resp effort, SaO2, O2 requirements,
secretions (amount, colour, consistency)
and evaluate respiratory care given

Flaccid abdominal
muscles

Diaphragm
descends

Swallowing
Patients should not eat before a swallow assessment is made. The patient should always beadvised to sit in an upright position when eating or drinking if possible and to eat at a slow pace,taking small amounts at a time. See the acquired brain injuries chapter for more information
regarding treatment of patients with dysphagia.
Bladder and bowel management
Although assessment, care and education in this area is all generally provided by the MDT it
is important for the rehabilitation practitioner to be aware of bladder and bowel management
within SCI treatment.
People with SCI commonly use a technique called intermittent self-catheterisation, in which
they insert a catheter every few hours for a few minutes to drain their bladders. Alternatively,

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they use indwelling (in acute care phase) or suprapubic catheters to manage their bladders.
Rehabilitation Professionals require a general understanding of bladder management whentreating people with an SCI. Assistance may be required with balance, spasticity and/or handfunction to enable bladder management. The rehabilitation professional should be aware of theimportance of pelvic floor muscle strengthening in individuals with an incomplete SCI.
People with SCI have a bowel management programme, so that they are continent and evacuate theirbowels at a planned time. This programme commonly involves the use of enemas or suppositories(i.e. medication inserted into the rectum). People with SCI also need to be mindful of their diet.
Rehabilitation Professionals require a general understanding of bowel management when treating
people with SCI. Support may be required with activities of daily living to enhance bowel management.
Positioning
Positioning will be important for managing an unstable spine (see above), but this is an ongoing
aspect of treatment and education for the patient and caregiver, both in bed and while sitting
to manage respiratory health, avoid contractures and maintain skin health. Please refer todisasterready.org for a full resource of SCI patient information leaflets.

Picture 1: Supine positioning of a patient withan SCI in a low resource setting© Davide Preti/HI

Picture 2: Side lying positioning of a patientwith a SCI in a lower resource setting© Davide Preti/HI

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Motor Tasks
After an SCI, further learning of motor tasks is required to maximise functional independence,and so is one of the primary goals of rehabilitation. For example, a person with an incomplete
tetraplegia may have suﬃcient strength but insuﬃcient dexterity and a person with paraplegia
will need to learn transfer skills. Sub-tasks are critical steps required for successful performanceof a task and it is imperative that the rehabilitation professional has a good understanding of the
optimal levels of motor function expected (see rehabilitation treatment outcome section), alongwith common ways of performing tasks following SCI. Any motor training is often most effective
when done repetitively, broken down and graded in small steps and practised in a relevant
environment with a common functional activity, where possible.
Motor training is commonly used to improve:
Balance
Rolling
Bed mobility
Transfers
Wheelchair mobility
Upper limb and hand function
Standing
Walking
People with a SCI are prone to low blood pressure. This is a problem particularly when a patientis first mobilised in a wheelchair after injury, or when a patient first stands on a tilt table. Thisshould be done progressively. Rehabilitation professionals need to take appropriate action whenmobilising patients to avoid dizziness and fainting, such as using an abdominal binder and/or
compression stockings when available.
Hand function will need to be optimised, as virtually all activities of daily living rely on somedegree of hand movement. If no active grip function is preserved, the tenodesis function is
crucial to obtain, in order to facilitate active use of the hands despite loss of active functions (seepicture below). Tenodesis is possible for those with active wrist extension but no active finger
flexion (lesion at C6).

Picture 4: Tenodesis grip; passive grip

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Tendonesis grip
The functional hand or tenodesis grip; with the wrist extended, the fingers flex into the palm
and the thumb touches the index finger (Picture 3). Opening the hand; when the wrist flexes, allfingers move to open position and the thumb is abducted/extended, allowing release of objects(Picture 4).
Daily activities and technical aids
Following an SCI, a person’s ability to perform a task may be entirely or partly impaired. However, it
is important that, even though a person requires a large amount of assistance, being able to performa few key aspects of the task themselves provides the satisfaction of independence and privacy
and avoids total dependence on another person. If it becomes apparent that the person will not beable to gain independence in a particular task, compensatory techniques and equipment should be
investigated as soon as possible to provide support and assistance to meet the person’s needs.
Compensatory strategies and skills might also be needed to initiate even basic activities early on.
Despite being in an acute crisis, it is important to promote regaining of activities and roles andencouraging the patient to be engaged in the care of their body. The engagement includes being
both physically active and able to verbally instruct their own care. It is imperative to involve nursing
staff, caregivers and relatives in this process. The webpages elearnsci.org and spinalistips.se/en
are useful links for hands-on information, strategies and adaptations in daily activities.
The main therapy activities used are purposeful activity, and occupational-based activity. It is
important within the first weeks to progress towards a real, occupational-based activity in acurrently relevant environment, where able, having established whether corrective and/or
compensatory strategies should be included in the treatment plan:
Corrective strategies include exercises and activities to increase strength and range of movement(ROM) to meet specific activity-based goals.
Compensatory strategies enable independence in particular activities, and may be required if theperson does not have potential for neurological recovery to enable pre-injury performance. This
may involve the use of:
Static splints/orthotics to position or stabilise body parts to enable activities. For
example, wrist splints to facilitate specific grip function
Functional splits to enable task-specific grasp, such as a splint designed to hold a pen or cutlery
Mobility/functional aids. For example, wheelchair or walking aids
Task modifications. For example, lower limb dressing in bed (when dressing in bed, first
get the patient in a seated position by raising the head of the bed up and use pillows to
help them get into a good position. Roll or bunch each trouser leg into a ring and slip thefoot into it. While working with each leg, put on a sock and shoe. Slide the trouser legs
up a little and repeat the process for the other leg. Safely roll the patient side to side andpull trousers over one buttock at a time)
Alternative movement patterns. For example, the tenodesis function of the hand to
facilitate adapted grasp and grip activities (see pictures below) or locking the elbow
during transfer if triceps are weak.
For more information, please refer to: http://www.spinalcordessentials.ca/PDF/SCE2-Sd1Dressing.pdf.
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Picture 5: Cylinder grip

Picture 6: Palmar grip

Picture 7: Key grip

Picture 8: Woven grip

Picture 9: Thumb hook grip

Picture 10: Squeeze grip

Managing pain
Pain can affect performance, participation in activities and quality of life, and is a common
complication following SCI in both acute and chronic forms. Specifically for SCI, it is important to
identify pain associated with autonomic dysreflexia, as this can be a life-threatening emergency.
See Chapter 3 for more details on assessment and general management of pain.

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Preventing contractures
It is crucial to avoid contractures. Attention is needed from day one, as they cause:
Restrictions in independence and performing daily activities
Difficulties in maintaining hygiene
Pain
Pressure injuries
Long-term deformities
Contractures are very time-consuming to reverse and detract time and focus from functional
rehabilitation. Contracture intervention should be linked to activities and participation restrictions
during any goal planning, especially motor tasks. Prevention and treatment of contractures
include the following:
Active movement via physical training and daily activities
Stretching
Passive movements
Positioning in a lengthened position
Maintain joint mobility and prevent oedema through exercise or positioning for optimal rangeof motion, actively or passively. All mobility/coordination and skills should focus primarily on
helping the patient achieve their goals and can play a significant role in reduction of pain andspasticity through active exercise and maintenance of joint mobility.
Remember to involve patient and family/caregiver early. For example:
Ensure the feet are supported in bed with a pillow to stretch or maintain length of theankle plantar flexors
Alternate arm and shoulder position in bed to maintain full shoulder motion.
Maintain full elbow extension to enable independence with bed-to-wheelchair transfer
Regularly sleep in prone position to stretch or maintain hip flexors
Stand on a regular basis to stretch or maintain length of the lower limb muscles
Regularly sit with one foot on the opposite knee to stretch or maintain length of hipinternal rotators and stretch of hamstrings to facilitate lower limb dressing
Stretches to the hand to stretch the MCP and IP joints to maintain tenodesis function
PROM EXERCISE,
SPLINTING

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Equipment use
In the immediate phase of a response where you anticipate working with patients with SCI,
from a rehabilitation perspective there is some basic equipment you may wish to prioritise
stockpiling or obtaining. Some equipment for the patient’s home (e.g. standing frames) can bemade by local carpenters.
Supports for leading your information-sharing/education role with the patient andcaregiver, covering complication management, options for using assistive products,
environmental adjustments for activities of daily living, hygiene and incontinence
management
Mobility aids provided to the patient should adhere to widely accepted guidelines,
more particularly wheelchair provision that fits with WHO guidelines, as outlined here:
https://www.who.int/disabilities/publications/technology/wheelchairguidelines/en/.
Aspeople with an SCI may require a wheelchair for lifelong use, it should ideally be customised
to their exact needs, and will require ongoing repair and replacement. It is therefore best torefer to a local provider who can provide ongoing services wherever possible.
Link to priority assistive products list (APL) that can help to direct the choice of overall
assistive products for disability and SCI alike: http://apps.who.int/medicinedocs/
documents/s22396en/s22396en.pdf
Psychological and emotional distress
People with an SCI and their families will experience varying degrees of psychological andemotional distress. Rehabilitation professionals need to be mindful of this when treating patientsand refer appropriately to other team members. Rehabilitation professionals spend large
portions of time with patients and develop a close rapport that means they have a significant
role in supporting them and helping them manage psychological and emotional distress. Whilethey are not specialists in this area, therapists should be mindful of the potential for patients tohave days when they feel more affected than others. They should listen actively, validate theirpatient’s feelings and adapt the intensity of their sessions according to what a patient can copewith on any given day. Referring to peers, as well as a psychologist, can also be useful. It is
important that the rehabilitation professionals instil hope without making false promises abouta patient’s potential for recovery.
Goal setting
The rehabilitation professional should have clear knowledge on expected outcomes according
to level of injury (see Table 3 below). The rehabilitation professional should be able to makeshort- and long-term (patient-centred) goals with the family/caregiver if available, as well as the
MDT. Goal setting must be holistic, meaningful and patient-centred. Therapy treatment plan
influences will include:
Level and completeness of injury
Expected functional outcome for the level of injury
Cultural factors – in some countries, a patient with an SCI is considered ‘sick’ and will befully dependent/reliant on their caregiver
Pre-injury function/ability

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Motivation
Functional expectations of the patient
Discharge planning – use realistic environment for practice, realistic timings for bladder/bowel management and home modifications required, if able to go home
Resettlement issues/plans – particularly in a conflict and disaster setting
Goal planning programmes are a useful rehabilitation framework for improving the physical,
social and psychological functioning of inpatients with an SCI.
Using a checklist (see below) ensures a systematic approach for the patient, caregiver and the
MDTPhysical: activities of daily living (dependence, independence), skin management, bladder andbowel management, mobility, wheelchair management and other equipment required
Psychological: depression, anxiety, family considerations
Social: community preparation, discharge coordination, employment/education
Prognosis discussed: Short-term goals agreed and planned, long-term goals agreed and aimed
for: Expected functional outcomes discussed
REHABILITATION TREATMENT OUTCOMES
Table 3: Functional outcomes following rehabilitation (table representing expected outcomes as
per level of lesion). For more information, please refer to disasterready.org for a resource on
Functional Outcomes.
Level

Abilities

Functional goals

C1-C3

Limited movementof head and neckBreathing: Depends on a ventilator for breathing
Communication: Talking is sometimes difficult, very limited
or impossible
Daily tasks: Fully dependent
Mobility: Fully dependent

C3-C4

Usually has headand neck control.
Individuals at C4
level may shrug
their shoulders

Breathing: May initially require a ventilator for breathing; may
adjust to breathing full-time without ventilator assistanceCommunication: Normal
Daily tasks: With specialised equipment some may have limited
independence in feeding and independently be able to operate
an adjustable bed

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Level

Abilities

Functional goals

C5

Typically has headand neck control,
can shrug shoulder
and has shoulder
control. Can bend
elbows and turnpalms face up

Daily tasks: Independence with eating, drinking, face washing,brushing of teeth, face shaving and hair care after assistance insetting up specialised equipment

Has movement
in head, neck,shoulders, arms
and wrists. Can
shrug shoulders,bend elbows, turnpalms up and down
and extend wrists

Daily tasks: With help of some specialised equipment, canperform daily tasks with greater ease and independence, suchas feeding, bathing, grooming, personal hygiene and dressing.
May independently perform light housekeeping duties

Has similar
movement as anindividual with
C6, with added
ability to straighten
elbowsDaily tasks: Able to perform household duties. Need fewer
adaptive aids in independent living

Has added strengthand precision of
fingers that resultin limited or natural
hand function

Daily tasks: Can live independently without assistive devices in
feeding, bathing, grooming, oral and facial hygiene, dressing,bladder management and bowel management

Has normal motor
function in head,neck, shoulders,arms, hands
and fingers. Has
increased use of rib
and chest muscles,or trunk control

Daily tasks: Should be totally independent with all activities

C6

C7

C8-T1

T2-T6

Healthcare: Can manage their own healthcare by doing selfassist coughs and pressure reliefs by leaning forward or side-toside
Mobility: May have strength to push a manual wheelchair for
short distances over smooth surfaces. If available, a power
wheelchair with hand controls may be used for daily activities.
There is potential to drive, but will require further assessment
and adaptations

Healthcare: Independent in pressure relief, skin checks andturning in bed
Mobility: Some individuals can independently perform transfers
but frequently require a sliding board. Can use a manual
wheelchair for daily activities, but may use power wheelchair for
greater ease of independence

Healthcare: Able to do wheelchair push-ups for pressure relief
Mobility: Daily use of manual wheelchair. Can transfer withgreater ease

Mobility: Uses manual wheelchair. Can transfer independently

Mobility: A few individuals are capable of limited walking withextensive bracing. This requires extremely high energy and puts
stress on the upper body, offering no functional advantage. Can
lead to damage of upper joints

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Level

Abilities

Functional goals

T7-T12

Has added
motor function
from increased
abdominal control

Daily tasks: Able to perform unsupported seated activities

L1-L5

Has additional
return of motor
movement in thehips and knees

Mobility: Walking can be a viable function, with the help ofspecialised leg and ankle braces. Lower levels walk with greater
ease with the help of assistive devices

S1-S5

Depending on levelof injury, there arevarious degrees ofreturn of voluntary
bladder, bowel andsexual functions

Mobility: Increased ability to walk with fewer or no supportive
devices

Healthcare: Has improved cough effectiveness
Mobility: Same as above

Prognosis
The chance of marked recovery in people with a complete SCI (AIS grade A and no Zone ofPartial Preservation) is very low. In contrast, those with incomplete SCI have a reasonably goodchance for some recovery. Rehabilitation professionals need to be aware that most recovery
occurs within the first eight months after injury, and that it is difficult for doctors to provide an
accurate prognosis in the first few weeks after injury.

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A 27-year-old male sustained a spinal cord injury caused during the 2015 Nepal earthquake. He
was admitted to the Spinal Injury Rehabilitation Centre three weeks later, after being referredfrom another hospital with a diagnosis of T12 – L1 fracture that had been surgically managed.
He was discharged five months post-injury.
On admission: Bedridden, Foleys catheter, irregular bowel habit and totally dependent withactivities of daily living. All vital signs were stable.
Medical management: Pain management, wound management (multiple soft-tissue injury).
Nursing management: bladder, bowel management, education, intermittent catheterisation,
personal care, bowel routine, prevention of complications, pressure injury and urinary tract
infection.
Physiotherapy management: included passive ROM exercises of bilateral lower limbs, active
ROM exercises of bilateral upper limbs, strengthening of upper back and upper limbs, mobility(room and toilet), independent in bed mobility and pressure relief techniques, transfers from bed
to wheelchair independently. Wheelchair skills: basic and advanced, balance training ongoing instatic and dynamic settings, education on DVT and its prevention, education to caregiver andpatient on ROM exercises and bedside positioning.
Occupational therapy management: Independent in most activities of daily living, including
feeding, upper and lower body dressing (in chair), upper and lower body bathing and grooming,
toilet transfer and use of toilet, all level transfer, basic and advanced wheelchair skills. Educatedabout and accomplished home modification, initiated a return to work and leisure activities(artist) and has regained his previously role in his family and community.
Psychological: Realisation counselling on expected functional outcomes, deep relaxation therapy,
individual/group session on safe reintegration to community, group education on sexuality
and fertility after an SCI, education on disability rights, encouraged to participate actively all
rehabilitation activities, including music therapy and yoga.
Wheelchair service department provided a Motivation three-wheeler wheelchair.
Functional outcome measure: AIS on admission: T12 AIS- A; AIS discharge: T12 AIS –A SCIM
at admission: 10 SCIM at discharge: 69
Community reintegration: Has been working as a peer counsellor at SIRC since 2016. Active rolemodel to newly injured people with an SCI. An excellent artist!

188 | EARLY REHABILITATION OF SPINAL CORD INJURIESCHAPTER 8 | SPINAL CORD INJURIESKEY pointS
Be aware of SCI complication risks and act upon early signs with proper techniques,communication with the MDT, monitoring and assistive products use and maintenanceadviceInvolve any caregivers from onset of treatment. Providing information on prognosis,
adaptations and ongoing care needs to help support both patient and family for the
long-term
Ensure understanding of diagnosis
Assessment and goal setting with the patient and caregiver crucial tofacilitate ongoing progress after the early rehabilitation phase and toassist transfer of longer-term ongoing care needs

189 | EARLY REHABILITATION OF SPINAL CORD INJURIESCHAPTER 8 | SPINAL CORD INJURIESREFERENCES
International Perspectives on SCI WHO/ISCoS, WHO, 2013
Descriptive study of earthquake-related spinal cord injury in Nepal Groves C.C. et al. 2017 Spinal
Cord
Emergency Medical Teams: Minimum Technical Standards and Recommendations for Rehabilitation
WHO 2016
Overview for the whole team, Physiotherapy, Occupational Therapy modules. Available at: www.
elearnsci.org
www.physiotherapyexercises.com
www.spinalistips.se/en

Moving and Handling Patients with Actual ore Suspected Spinal Cord Injuries (SCI) MASCIP
Guidelines 2009
Psychological guidelines in spinal cord injury ASCoN, 2015. Avilable at: https://ascon.info/wpcontent/uploads/2018/05/psychosocial-guidelines15.pdf
ISCoS Textbook on Comprehensive Management of Spinal Cord Injuries ISCoS, 2015

APPENDICESFound on disasterready.org
1.
2.
3.
4.
5.
6.

MDT SCI Assessment
Assessment cheat sheet
Positioning, including 30-degree tilt
Functional outcomes
SCI passport
SCI abbreviations

190 | EARLY REHABILITATION OF SPINAL CORD INJURIESCHAPTER 9 | BURNSCHAPTER 9
CHAPTER 9: EARLY REHABILITAITON OF
BURNS
AIMS:
By the end of this chapter, you should be able to:
Demonstrate knowledge of a burn
Perform a basic acute assessment of a burnUnderstand the surgical management of a burnDevelop and deliver an acute rehabilitation treatment
plan of a burn9

191 | EARLY REHABILITATION OF BURNSCHAPTER 9 | BURNSCHAPTER 9:EARLY REHABILITATION OF BURNSINTRODUCTION

Esselman et al assert that burns injuries can result in significant and complex rehabilitation
challenges, given the long-term complications and psychological issues that are associated. Thisis especially relevant in low-to-middle income countries, where access to timely and adequate
medical and therapeutic management may be very limited.
Regardless of the context, burns presentations in conflicts and disasters will reflect those commonly
seen in industrial or domestic burns. The management approach for these will be similar.
With conflict/blast injuries, one can expect more combined trauma, e.g. a burn overlying afracture, as well as a high risk of wound contamination. Wounds should be initially debrided
and then left open with a protective dressing covering for delayed primary closure to prevent
infection. Shrapnel that is easily accessible should be removed; however, if there is a risk ofextensive tissue damage in searching for the piece of shrapnel, it will be left in-situ. Blast injuries
can cause significant soft-tissue and bony injury with extensive defects, as well as accompanying
burn wounds and injury to hollow organs, such as the bowels and lungs. These require careful
and ongoing assessment. Chemical burns, such as napalm and phosphorous, will likely cause
more severe burns and are thus rehabilitated in the same way as a deep burn.
The treatment principles remain the same for treatment of burns in poly-trauma injury scenarioswith considerations for relevant safeguards.
In the very acute care of major burns injuries, medical management will include: fluid resuscitation,
airway management, wound debridement and, where relevant, may involve surgical procedures,such as escharotomy and/or fasciotomy.
Rehabilitation for burn injuries starts from day one of the injury, right through the period ofscar maturation, and often for years after the injury, especially relevant to the prevention ofcontractures and in children where growth is not complete.
Diagram 1: Anatomy of the skinhairsebaceous glandsensory ending
epidermis

dermissubcutaneous tissue
capillaries

sweat glandmusclearteriolefat, collagen, fibroblasts
192 | EARLY REHABILITATION OF BURNSCHAPTER 9 | BURNS

Diagram 2: Depth of burn injury
Superficial
dermalSuperficial

DeepdermalFull
thickness

Sensitivity to
pain

Health time andprognosis

Epidermis

DermisSubcutaneous

Table 1: Depth of burn characteristics
Burn depth chart
Depth of burnTissues destroyed

Superficial

Outer layer of
epidermis (stratum
corneum)(1st degreeburn)Appearance of burns
Red

PainfulBlistering notcommonLess than 14days
No scarring
expected
long-term

Slight oedema
Wound blanches withpressure and refills

Superficial

All of epidermis

Red

Very painful and7-20 days

PartialThickness
Burn (SPT)

Upper layers ofdermisBlisters

hypersensitive

May scar in rarecases

Some hairfollicles andsweat andsebaceousglandsdestroyed

Oedema(2nd degreeburn:superficial/intermediate)

Moist subcutaneous
Blanched (capillary
refill)193 | EARLY REHABILITATION OF BURNS

Pigment change

CHAPTER 9 | BURNS

Burn depth chart
Depth of burnTissues destroyed

Deep Partial
Thickness
Burn (DPT)(2nd degree
burn: deep)

Full Thickness
Burn (FTB)(3rd degreeburn)Appearance of burns

Epidermal andsevere dermis
damageVariable in colour(white with red, e.g.
mottled)

Most nerve
endings, hairfollicles andsweat glands
destroyed

Wet or waxy dry

All skin layers
damaged or (invery severe cases)
destroyed; may be
down to fat or bone(epidermis/dermis
and subcutaneousis damaged or
destroyed in very
severe cases)

Generally blisters

Sensitivity topainLess sensitive
to paindue todestroyed
nerve endings

No or slow capillary
refillNo blisters
If circumferential– can havetourniquet effect andescharotomy needed

Difficult todeterminehealing time, atleast 21+ days
Scarring
Risk ofcontractures
May needgrafting,
especially if
has not healed
within 15-21
days

Eschar forms

White, charred, dry,inelastic (tight)

Health time andprognosis

No pain fromlost cutaneous
pain receptors
but situation isoften painful
for the patientand be awarethat pain
will develop
following
first surgicaldebridement

Very severe
scarring
Risk ofcontractures
No skinregeneration
Will needexcision andgrafting
Prolonged
hospitalisation

Note

Note: Burns injuries can have a mixed pattern presentation in terms of depth, especiallythermal and electrical burn (internal injury – entry/ exit wounds may not immediately bevisible/obvious).

ASSESSMENT
Assessing the area of a burn
The area of a body that has been affected by a burn is measured by Total Body Surface Area
burned (TBSA), expressed as a percentage, e.g. a 15% TBSA burn would mean that 15% of thetotal surface area of the body is burnt/affected.
The two most common methods of recording this is by ‘Rule of Nines’ and ‘Lund and Browder’(note adults and children have differing percentage mapping) described in Chapter 7 of themanual Rehabilitation in Sudden Onset Disasters, page 196.

194 | EARLY REHABILITATION OF BURNSCHAPTER 9 | BURNSTBSA percentage is used to calculate fluid requirements and, together with depth of burn, is thebiggest predictor of survival and final outcome.
Major burn: over 30% TBSA for adults; over 20% TBSA for children.
Location and type of burn will also influence the severity and functional impact to the patient,e.g. deep burn of both hands can be very functionally severe for the patient, although a relatively
small TBSA%. An electric burn can cover only a small percentage of the TBSA, but can bedisastrous for the patient due to the potential internal damage; patient is also at risk of requiring
limb amputation to manage the injuries.
Diagram 3: Lund and Browder Chart
A

A

1

2

2

13

1½

2

1½
1

1½

B

2

13

1½
1½

1½

B

1½
2½

2½

B

B

C

C

1¾

1¾

1½

%
REGION

PTL

FTL

Head

C

Neck

C

Ant, trunk
Post, trunk
Right arm

1¾

Left arm

1¾

Buttocks
Genitalia
Right leg
Left leg
Total burn
AREA

Age 0

Age 1

Age 5

Age 10A = ½ of headB = ½ of one thighC = ½ of one lower leg

195 | EARLY REHABILITATION OF BURNS

Age 15

Adult

CHAPTER 9 | BURNS

Diagram 4: Rule of Nines
9% (Entire head and neck)
18% (Back)
18% (Front)
9%

9%
18%
18%

18% (Back)

9%

1%
18%

18%

9%

1%
13.5%

Adult percentages

13.5%

Percentages in a child

Emergency care of burns
Assess:A = Airways
B = Breathing (any signs of inhalation injury may require prophylactic intubation, followed by chest
physiotherapy) and circumferential deep or full thickness burns to chest (and abdomen in children)
may require escharotomy)
C = Circulation (emergency escharotomy may be necessary with circumferential full thickness
burns to limbs)
D = Disability (no associated trauma, e.g. head injury)
E = Exposure (assess area and depth of burn injury)
F = Fluids (calculate and administer fluid requirements – medical team responsibility). Fluid
resuscitation to prevent hypovolemic shock is required for all burns over 10% in a child and 15%
in an adult.
Complications: (red flags)
Hypovolemic shock/inadequate fluid resuscitation (too few or too much)
Infection
Compartment syndrome (5P’s: pallor, pulselessness, pain, paraesthesia, paralysis)
Inadequate pain management
Severity of burns injury may be increased with any of the following:
Extremes of age
Co-morbidities
Associated injuries, e.g. fractures
Inhalation injury
Location of burns: face/eyes/ears/hands/perineum/feetElectrical injuries
Blast injuries
Poor nutritional status (including anaemia)
196 | EARLY REHABILITATION OF BURNSCHAPTER 9 | BURNS

Physiotherapy burns assessment pro-forma*With assessment and treatment, always follow a systematic approach
Please follow the ‘ABCDEF’ approach to encompass full medical management (see case studies forexamples)Cause of burn: ______________________________________________________________________________
Type of burn/injury: scald/flame/electrical/chemical (alkaline/acid/other)/blast/other:_______________________________________________________________________________________________
Inhalation injury: Yes/No (See ‘treatment’ section for signs and symptoms to watch out for)Any other injuries/conditions:_______________________________________________________________________________________________
Relevant PMH: _________________________________________________________________________________
SH: smoker: Yes/No ________________________________________________________________________
Medications/drug hx: _______________________________________________________________________
Occupation: _______________________________________________________________________________
Hand dominance: R/L/Both __________________________________________________________________KEY:
Superficial

Circumferential: Yes/No ___________________________________

Partial thickness		Joints involved: ___________________________________________

Full thickness		

Face structures involved: __________________________________

		

Inhalation injury: Yes/No ___________________________________

Surgical management (pre-rehabilitation assessment):
Split skin graft: Yes/No
Detail: _____________________________________________________________________________________________________________________________
Donor site: _________________________________________________________________________________
Flap: Yes/No

Detail: _____________________________________________________________________

Other surgical intervention: __________________________________________________________________
Pain (location, description and VAS) ___________________________________________________________
Mobility: __________________________________________________________________________________
Wound/infection* __________________________________________________________________________
Scar tissue* ________________________________________________________________________________
Oedema* ___________________________________________________________________________________
Range of Movement (ROM) - active/passive at affected joint/s

Function: __________________________________________________________________________________

197 | EARLY REHABILITATION OF BURNSCHAPTER 9 | BURNS*BE AWARE*
Wounds can deepen due to, e.g. infection, lack of nutrition, poor handling and the scenario
of granulating tissue and delayed grafting and wound healing can be a recipe for disaster interms of preventing significant scarring and being able to prevent contractures. Also be awareof any signs of psychological distress.
Ongoing assessment of the burns and ROM are important, as is assessing to check for infection.
4.5%

4.5%

7%

7%

18%

18%

18%
4.5%

4.5%

4.5%

4.5%
4.5%

1%

9%

9%

9%

4.5%

4.5%

4.5%

9%
9%

9%

9%

9%

TREATMENT
Rehabilitation treatment starts immediately (as soon as haemodynamically possible).
Focus of rehab in this very acute stage is:
Respiratory care
Oedema management
Positioning, splinting and pressure relief
Mobilising/early and progressive exercise
Maintaining function
Education
Respiratory care
Inhalation injury: be aware of signs or symptoms that may indicate an inhalation burns injury, including:Burns to face, neck or upper torso
Singed nasal hair
Carbonaceous sputum or soot particles or oropharynx
Change in voice with hoarseness or harsh coughDyspnoea, stridor
198 | EARLY REHABILITATION OF BURNSCHAPTER 9 | BURNSErythema or swelling of oropharynx on direct visualisation
History of reduced consciousness
Physiotherapy aims:

Tools to achieve these aims:

Maintenance of the airway (discuss withmedical team)Removal of excess bronchial secretions
Improvement of gaseous exchange
Prevention and/or treatment ofatelectasis
Maintenance of thoracic expansion andgeneral mobility
Positioning

Positioning for facial oedema
management – sit patient up
Positioning to maximise secretion
clearance and ventilation
Positioning
Manual hyperinflation
SuctionSaline/humidification
Active cycle of breathing
Forced expiratory technique
Vibs/percussion (if none of the above/other manual or active treatment
modalities are an option (more specificto young children)
Oxygen therapy
Mobilisation
Manage pain

Oedema management
Oedema is a normal response to the injury and to the fluid resuscitation (N.B. important to avoid
over-resuscitation).
Oedema can compromise wound healing.
In the acute stage, manage and limit oedema by:Appropriate positioning: e.g. elevation hand/s above the heart level with elbows
extended (elbow flexion can cause oedema to collect around the elbow and wrist flexion
can cause significant hand oedema to develop)
Encouraging the muscle pump action through active movement
Patients with facial oedema must be sat up at least 45 degrees even at night (as safely
appropriate)
Dressings should be firm but allow maximum active movement of all joints
Positioning and splinting
Correct positioning is essential to prevent contracture
Positioning is used prophylactically when there is no sign of loss of range and can beused to increase ROM if there is a loss of range
Burn patients will typically adopt positions of comfort, especially in low-resource
environments where pain limitation is minimal; generally, this is in a pattern of flexion.
Joints will literally get stuck in the position of comfort over time as the developing scar
adapts to the shortened position
199 | EARLY REHABILITATION OF BURNSCHAPTER 9 | BURNS

Anti-deformity positioning:

✔
✔
✔
✔
✔
✔
✔

Shoulders abducted to 90 degrees,
horizontally adducted 20 degrees,
encourage ext. rotation
Scapula – retraction, depression
Arms in neutral rotation, forearms
supinated
Elbows in extension
Wrist 30-40 extension, with MP
45-70 flexion, IP extension, thumb
abducted and opposed
Neck slightly extended (no pillow)
Hips in slight abduction with full
extension, block external rotation

Extension/
hyperextension

Abduction, external rotation

Supination

Straight alignment90°

No externalrotationno flexion
20°

Straight
Dorsiflexion

Consider pressure areas with positioning. The burn area is very prone to progressing in depth if
under continual pressure and the non-burned areas are also prone to breakdown, as many burns
patient in low resource settings are malnourished.
SplintingIs generally indicated to
Position limbs/joints at rest if/as required to reduce contracture risk.
Protect grafts or flaps during initial phase healing/take post-op as required.

Note

Note: splints may need remoulding after a change of dressings and to accommodate, e.g.
fluctuations in swelling, particularly relevant for the hand.
NB: for splint safeguards please refer todisasterready.org

SPLINTING

Mobilisation and maintaining function
This is essential to ensure that the patient returns to activity and participation in their life activities. Thisis achieved through gentle ROM, which should be slow and smooth to avoid pain and inflammation,
as well as engagement in functional tasks, especially encouraging some level of independence inself-care and graded mobilisation (walking/moving as able) in the early stage of rehabilitation.
ROM AND ITU

200 | EARLY REHABILITATION OF BURNSCHAPTER 9 | BURNS

Education

Thinking ahead – Educating/giving patient and relevant carer/s information is vital and should
include:Basic ROM and stretching exercises. The patient can be fearful of movement, especiallywith the therapist indicating very early active mobilisation of joints and whilst wound
is still healing. It is important to explain to the patient (and relevant carers/family) the
reason for us doing this, especially for the prevention of contractures
Anticipated time-frames for wound healing and scar maturation to ensure patientengages in the often longer-term rehabilitation regime – this will have direct correlationon continuing management in positioning, active movement, and later more stretchingand exercise through function
Expectations with/for e.g. delayed wound healing, pruritus (severe itching), alteredsensation (especially hypersensitivity), contracture formation and management thereof
Scar management: on complete wound healing, advice about scar massage andmoisturisation technique and daily regime with plain emollient cream (find out about
locally sourced appropriate options), as well as compression. If pressure garments are
not are not available, advise re safe and appropriate alternate options, e.g. compression
bandages, tubular dressings, e.g. tubigrip
Functional activities (especially self-care tasks, such as feeding) as possible toprevent complications linked to continuous bedrest, enhance ROM and help restore
independence
Splinting regime e.g. timing – removal and fitting of splints in relation to eating, drinking
and personal care, and safety in wear regime, including pressure care
Factors that may exacerbate risks to e.g. infection in surroundings (sanitisation)

CONSIDER✔
✔
✔
✔

Age and co-morbidities impact on healing and complications✔

Location of burn, e.g. small superficial on forearm, get them going quickly andanticipate nil further complications versus same type burn on foot – would want
to be more careful for healing with oedema management and anticipate slightly
lengthier healing time-frames

Ethnicity and culture will also play a role in the expected outcome
Coexisting injuries (fractures, amputations, inhalation injury) will impact recovery
Secondary complications of burns, such as heterotopic ossification, severe
inhalational injury and graft/flap failure (e.g. shear forces, infection)

201 | EARLY REHABILITATION OF BURNSCHAPTER 9 | BURNS

Table 2: Surgical management options in burns care
Surgery

Details of procedure

Therapy aftercare

Split skin
graft
(SSG)

SSG is used to save life
and improve/promotewound healing

Grafts over/near joints:

All skin grafts rely on
the UNDERLYING blood
supply so the burn tissue
needs to be excised rightdown to the healthy
bleeding bed
Taken from a donorsite of intact skin on
the patient’s body,commonly the thighor, in paediatric cases,
scalp
Taken from a slice ofsome of the dermis.
Often fenestrated ormeshed to expand
the skin and allow
exudate to escape

Immobilise for five days unlessthe surgeon says is happy
with mobilisation. If the part is
not immobilised with bulky or
tie-over dressings in theatre
then make a splint/back slab –discuss with the surgeon
Ensure the splint will notcause damage to the area
The first change of dressing(COD) of the grafted area is
at 48 hours to five days
Mobilisation should be
progressive 5-7 days
post-graft then normally norestrictions to movement
post seven days

Comments/caution
Donor site takes up to two
weeks to heal and canbe very painful. But once
healed, the areas can be
re-used to take more skinIn poor resource
environments, SSG isoften delayed and limited,resulting in sub-optimal
outcomes, to include morerisk of infection and scarring
Hydration of the area canstart as soon as healed, scarmassage when the area isstableIn extensive burns, any areaof non-burned skin may be adonor site

Grafts over non-joint area:
Usually mobilise from 48
hours unless specific reason
not to. For lower limb grafts
early mobilisation may be
indicated by some surgeons.
May otherwise be instructed
to wait 3-5 days (average) for
first dressing change before
giving mobilisation green
light to walk the patient
Ensure the lower limb has
a supportive dressing, e.g.
coban/elastic bandage before
mobilisation

Full
thicknessskin graft(FTG)

FTG takes the
epidermis and entiredermis, therefore thedonor site needs tobe directly closed.
Common donor sites
are behind the ear andthe groin

As per SSG therapy aftercare,
unless the FTG is OVER a joint
such as the hand when there is
LESS focus on immobilisation
through splinting – Discuss withsurgeon202 | EARLY REHABILITATION OF BURNSFTG are NOT commonlyused in acute burns care
(apart from eyelids) but forreconstructive purposes

CHAPTER 9 | BURNSSurgery
Flaps

Details of procedure
Flaps are used to fill
defects when the bed
is not graftable such as
exposed tendon, boneetc.
Unlike SSG, flaps comewith their own blood
supply (can include skin,fascia, muscle, bone etc.)

Therapy aftercare
Flaps will vary, therefore
discussion with surgeon is
VITAL for safe and appropriate
post-operative rehabilitativecare. The pedicle is the LIFELINE
for the new flap and needs tobe protected till blood supply is
re-established – usually takes
three weeks
Key principles to safe flap care:
DO NOT kink, stretch orcompress any part of the blood
supplyAVOID shearing movement
through positioning or handling

Comments/caution
Causes of flap failure
are: tension, kinking,compression, infections andvascular thrombosis
Uncommonly used inacute burns care (except
sometimes in electricalburns or very deep burns
with exposed tendons,
joints or bones without
their periosteum), but arecommon in reconstruction ofburns and used in acute soft
tissue injury
Continually monitor: colour,
temperature, texture andblanching of the flap toensure viability

Areas that have been grafted or flapped need to be elevated post-op. Mminimising shearing and not disturbing
blood supply is vital, so dressing not too tight.
! INFECTION !
Is the most common cause of death of patients with burns injuries who survive the initial injury.

Infection can significantly delay donor site wound healing and cause failure of grafts
and flaps.
Wound dressings = KEY part of burn management: clean and correctly applied dressings
improve outcomes with several areas of the body requiring special care.

REHAB THERAPISTIN THEATRE

Overleaf is a summary table intended to help guide you in your treatment approach in thepositioning, splinting and mobilisation of specific joint areas that may be affected. Splinting andpositioning programmes depend on the severity of the injury and may need to be continued forat least six months to be effective.

203 | EARLY REHABILITATION OF BURNSCHAPTER 9 | BURNS

Table 3: Splinting and positioning recommendations in the rehabilitation of burns
Burn
site

Risk of contracturethat can develop

Anti-contracture position

SplintingFace

The face can beaffected in various
different ways,
including the inability
to open or close mouth
fully inability to closeeyes fully and theclosing of nostrils

Regular change of facial expression
and manual stretching regimen oflips and eyes is required

Oral appliances that need toeducate the patient. (NB, bemindful of safeguards with useof splinting with dental care(especially in children with facial
growth and teeth position)

Mouth: achieving a horizontal/
vertical/circumoral stretch of thetissue around the mouth* Certain devices facilitate
mainly vertical opening stretch. A
horizontal lip opening device canbe added, and ensure exercises
encompass ALL movements

Examples: locally-sourced options
for splint materials: use of awell-padded cylindrical tube or
wooden tongue-depressors
stacked and safely boundtogether with plastic wrap
MAKE SURE NOT TOOBSTRUCT AIRWAY

Face exercises:
Opening mouth, smiling, top lip over bottom lip, bottom lip over top lip, puckering lips, pull back corners ofmouth, mouth side stretches, blowing up your cheeks, eyes open wide, eyed tightly closed, chin poke, neckstretch back with mouth closed.
Other activities to assist with face exercises:
Say the vowels of the alphabet slowly and over exaggerate each movement, use a straw, eat an apple withlarge bites, use your tongue to stretch your lips and cheeks out.
Hold your mouth open as wide as you can when you clean your teeth, use your hands to push upwards on yourcheeks to assist with closing your eyes.
Burn
site

Risk of contracturethat can develop

Anti-contracture position

Splinting

Front ofneck

Neck flexion. The chinis pulled towards thechest reducing neckmovement

Neck in extension (also whensleeping)

Contours of the neckare lost

Head tilted back in sitting. Avoid
hyper-extension during the night

If soft cervical collar is not available,
a neck collar can be fashioned fromflexible suction tubing cut into
lengths and stuck together withsticky-tape. The collar is paddedwith soft gauze and wool and held
together with a bandage

No pillow behind head, roll behindneck e.g. rolled towel/big scarf

204 | EARLY REHABILITATION OF BURNSCHAPTER 9 | BURNS
Burn
site

Risk of contracturethat can develop

Anti-contracture position

Splinting

Posteriorneck

Neck extension andother neck movements

Sitting with head in flexion. Lying
with pillows behind the head

Fabricate similar splint, as above

Neck exercises:
Work through passive and active range of movement activities for head and neck, to include ear to shoulder(side flexion), chin to chest (flexion), chin to sky (extension) and rotations.
Burn
site

Risk of contracturethat can develop

Anti-contracture position

Splinting

Axilla oranterior
andposterioraxillary
fold

Limited abduction,
extension and flexion

Lying and sitting – arms abducted
to 90 degrees supported bypillows between chest andarms. Figure-of-eight bandaging
or strapping to provide stretch
across chest

Examples:Use of a plastic-moulded pipe or
POP (plaster of Paris)(Be mindful of where your splint ends
on the arm to ensure nil adverse
pressure with pull of arm down)
If elbow/forearm
included, rotate
betweensupination andpronation position)
Paeds:
Scarf ina figure-of-eight

Axilla/shoulder exercises:
Work through all the active and passive range of movement planes of the shoulder.
Burn
site

Risk of contracturethat can develop

Anti-contracture position

Splinting

Elbow
(and
forearm)

Limited extension(and limited supination)

Extension and mostly supination,
as relevant. In the case of
circumferential burns, also workon flexion and pronation

Fabricate splint with elbow inextension Can use e.g. POP,
reinforced carboard (padded!),padded plastic pipe, all of whichmust be safely bandaged in place

Elbow (and forearm) exercises:
Active and passive: extension and flexion of the elbow and supination and pronation of the forearm.

205 | EARLY REHABILITATION OF BURNSCHAPTER 9 | BURNS

Burn
site

Risk of contracture thatcan develop

Hand
and
wrist

Characteristic posture of
the burnt hand is:

Anti-contracture position

Splint in POSI (Position of Safe
Immobilisation)

Flexion of wrist
Extension or
hyperextensionof MCPJ’s(metacarpophalangeal
joints)
Flexion of IPJ’s(interphalangeal joints)
Adduction of the thumbLittle finger rotation/
deviation

Splinting

Examples: use PADDED POP,
reinforced cardboard, moulded
plastic tube, scotch cast

Wrist 30-40 degrees extended,
MCP’s 60-70o flexion, IP joints
in extension, thumb mid-palmar
radial abduction.

Burns isolated
to palm: Fingers
adducted and flexed;
palm pulled inwards

Wrist hyper- extended, minimal
MCP flexion, fingers extended
and abducted
Hand and wrist:
These joints will become tight/contract and the hand badly deformed if the patient does not continuously
encourage to move the hand and fingers.
Initially, pain and oedema limit movement of the hand
Early vigorous exercise (where no autograft/FLAP)
Advocate dressing application that DOES NOT HINDER movement too much!
Recommended to also carry out exercises (where appropriate) during change of dressings
NOTE: suspicion of extensor tendon or extensor hood is involved, limit to gentle active movements only!

206 | EARLY REHABILITATION OF BURNSCHAPTER 9 | BURNSExercises:
Active tendon glides wrist (flexion and extension); passive-assist where necessary
Active tendon glides fingers: composite AND isolated, especially concentrating on MCPJ isolated flexion(patient may need gentle assistance with movement/s – careful assistance when active ROM is incomplete)
Thumb flexion and extension composite and isolated IPJ
Opposition: thumb to individual fingers ‘O’ tip-to-tip active movements
Fingers abduction/adduction
Radial and ulna deviation

Straight

Hook

Hanging Limp Wrist

Duck

Straight Fist

Full Fist

Wrist Extension

Encourage functional activities (self-care/feeding self/brushing hair/etc.) – consider building up grips with utensils, forexample fibreglass volar slab covered with wadding/bandaging and then LIGHTLY bandaged onto patient’s hand/arm
Wear: when patient asleep, for example, otherwise
encourage patient to use their hand!
NB ensure splint sides not too high and splint notconstrictive! Consider fluctuating swelling andassociated risks, as well as changes in shape with,e.g. change of dressings.

REHAB THERAPISTIN THEATRE

Burn
site

Risk of contracturethat can develop

Anti-contracture position

Splinting

Groin
(hip)

Hip flexion; hip
adduction.

(for anterior groin burn) Liein prone position with legs
extended; no pillow behind knees

Abduction foam wedge

Limit sitting and side lying.
Supine lying with legs extended;no pillow behind knees
Ideally, also allow for some hip
abduction

Abduction using rolled-up
towels/pillows etc. Moulded
thermoplastic
Personal care for toileting meansincreased risk of infection, soemphasise wound care andhygiene. Prevent prolonged timein hip flexion, e.g. sitting

Groin (hip) exercises:
Active and passive ROM activities for flexion extension abduction, adduction and internal and external rotation.
If patient is stable enough, then work on sit-to-stand, balance activities, early mobilisation, getting patient tonormalise posture (in all positions) and gait pattern (no hip hitching or limited extension).
Anterior surface; avoid hip flexion and adduction. Positioning in prone is useful if no other contraindicat
207 | EARLY REHABILITATION OF BURNSCHAPTER 9 | BURNS

Burn
site

Risk of contracturethat can develop

Anti-contracture position

Splinting

Back ofknee

Knee flexion

Legs extended
in lying andsitting positions

Splint withknee inextension.
Materials to
use asbefore(POP/PVC,etc.) andsafelybandage inplace

Knee exercises:
Active and passive full knee range of movement – focusing on extension if burn is posteriorly. Burns at the frontof the knee may need a larger focus on active flexion. Exercises to include one leg stand, heel walking (so withknee extended), etc. and controlled squats.

Burn
site

Risk of contracturethat can develop

Anti-contracture position

SplintingAnklesand feet

Feet are complex
structures and canbe pulled in different
directions by healing
tissues preventing
normal mobility.

Ankles at 90 degrees, use pillows
to maintain position. Encourage
sitting with feet flat on floor as
long as no oedema present.

Splint ankle
in 90 degrees(plantigrade)using padded
POP/cardboard.
Safely securein position ****In cases of deep burn on
anterior side of the ankle, periodof splinting in plantar flexion isrequiredAnkle/feet exercises:
It is vital the patient maintains adequate dorsiflexion for walking with a heel-toe gait, so include exercises towork on active and passive ROM in dorsiflexion, plantarflexion, eversion and inversion.
Ask the patient to ’tap/move their toes up/down and in/out like windscreen wipers.’ Make sure the movement
is coming from the ankle and not the hip. This can be done in bed or sitting. When safe to do so, get patient towork on weight bearing.
Get patient to also flex/extend and ‘wriggle’ toes. NB, dressings should take care of toe spaces.
Friction of shoes may require linings or special footwear. Toe contractures may impact on fit of shoe.

208 | EARLY REHABILITATION OF BURNSCHAPTER 9 | BURNSPain management
A team approach to pain management is needed. Ensure close collaboration withnurses/doctors to optimise exercises after pain meds have been administered. It is vitalthat patients are prescribed background pain medication, as well as for interventions(e.g. physio/dressings) and breakthrough pain. The timing of such medication is also
crucial to ensure optimal efficacy: try and ensure patient has had their analgesics 3060 minutes prior to dressing changes and/or exercises (or play in the case of children).
Children

REHAB THERAPISTIN THEATRE

Encourage play activities to incorporate as part of treatment. Ensure the play areas are safe/
protected and, if possible, completely dissociated from where child is having wound debridement/
dressings, as this location will be associated with fear/anxiety/pain etc. Consider bringing itemswith you, such as blow-up light plastic beach balls in different sizes or smaller balls (that can be
wiped clean after use), blowing bubbles, crayons/coloured chalk for active play therapy.

CASE STUDIESCASE STUDY 1
Mrs T is a 35-year-old lady who was cooking
over a fire in a temporary camp following anearthquake that destroyed her house. The fire
was put out with a bucket of cold water andshe presented to your facility four hours later.
There is no history or additional trauma andyou do not suspect C-spine injury, so she does
not require neck collar/sandbags and tape.
A: Airway and C-spine control
Is patient maintaining airway? Yes, Mrs T is maintaining her airway. However, there
are burns to face and neck, so we are concerned that the airway may be at risk due toswelling and/or inhalation injury. Sit patient up
Medical management – there is a need for oxygen: link with medical team
B: Breathing
Spontaneously breathing with normal breath sounds throughout
RR of 16BPM, breathing is a little shallow. Evidence of burns to her chest and upper back– burns appear deep, so patient may require escharotomy – link with medical teamSigns of superficial burn round nose and mouth (may be indicative of toxic smoke
inhalation)
C: Circulation
Patient is not haemorrhaging from anywhere
Pulse is 110, BP 100/70: likely to be dehydrated, but not in shock209 | EARLY REHABILITATION OF BURNSCHAPTER 9 | BURNS

Hands are cold with poor capillary return in fingers – the burns on the upper arm aredeep and circumferential
Medical team to insert cannulas and start fluid therapy and carry out escharotomy toboth arms and chest
D: Disability
Mrs T is conscious and talking when spoken to (V on the AVPU Scale)Examination of her pupils are equal and responsive to light, and there appears to be noneurological concerns
Patient able to sit up independently, so you do not need to log roll her
E: Exposure
Patient needs to be kept warm to prevent hypothermia
F: Fluid resuscitation
Crucial in acute burns management: medical team to lead on this (important to monitor
urine output, pulse, BP and capillary refill and continue to assess her airway and swelling
due to oedema)
Burns assessment – TBSA and assessment of depth of burns
Plot the burned area on the body chart: shading for TYPE of burns using the symbols or/and rule of nines (*either
shade or use symbols to depict depth of burn).
approx.
13%

4.5

18%

1%
9%

9%

9%

9%
2 x 0.5%

Pain management
Ensure pain management is covered, to include pre-change of dressings (COD’s)/therapy
analgesia
210 | EARLY REHABILITATION OF BURNSCHAPTER 9 | BURNSWound care
Discuss the plan for Mrs T’s wound care – therapy ties in well to COD’s and is a chance
to check on wound healing/assess for complications
From assessment, rehabilitation concerns
OedemaRespiratory
Joints affected (REMEMBER– maintain correct position, splint to prevent contracture andmobilise to encourage normal function)
Rehabilitation treatment
Nurse Mrs T sitting up due to inhalation injury risk – add breathing exercises and, if
required, chest physiotherapy (as with any other condition). Keeping the patient wellhydrated is important, so that secretions don’t dry up
NB, post-SSG to the chest area vibrations and percussion should be left for five days
if possible, and if necessary, done over Gamgee (absorbent cotton between gauze)
dressings/pads
Elevate her arms gently and keep them abducted and extended at rest, as safely
appropriate. (see treatment Table). Keep monitoring fingers to check on her circulation
Splint neck and axilla and, if needed, mouth (see Table)
Teach ROM and stretching (avoiding overstretch) exercises (see Table for area specificinformation)
Assess and advise on mobilisation
Ensure patient is feeding with her own participation as safely able, and monitor pain
levelsDocument everything clearly and COMMUNICATE everything clearly to patient and herfamilyShort-term
Encourage activity from day one.
Aim is to prevent contracture and maximise return to function – initial movements canbe limited if patient has had to undergo any skin grafts, but once surgeon allows it,
movement must be encouraged.
Outcome assessment to include measurement of active and passive ROM and also chinto-sternal notch measurement and commenting on mouth opening (limited/full), as wellas contours of the face, neck and trunk.
Long-term expected management and outcome
Assess stage of scar maturation and patient’s acceptance of altered body image and function.

211 | EARLY REHABILITATION OF BURNSCHAPTER 9 | BURNSCASE STUDY 2
Mr K is a 23-year-old man who sustained a high-voltage electrical injury trying to get someelectricity and has presented two days later with burns to his right hand and both feet.
* Already you will need to think about acute and ongoing care, as he has suffered a high-voltage injury andthe electric current has passed through his body, so he is at risk of cardiac and respiratory abnormalities,
as well as myoglobinuria (myoglobin in the urine, usually associated with rhabdomyolysis or muscle
destruction) and renal failure. Deep-tissue damage to muscles and the actual area of injury may be more
extensive than first observed to include nerve and tendon damage.

A: Airway and C-spine control
No history of added trauma and no C-spine injury suspected. He may have stopped
breathing at the scene, no-one is sure: he is now awake but confused
No C-spine management required. Give patient oxygen and monitor closely
B: Breathing
Spontaneously breathing with normal breath sounds throughout. RR of 22 BPM
There are no burns to chest or abdomen and no obvious other life-threatening chest injuries
C: Circulation
Patient is not bleeding from any wounds. Pulse is 130 but seems irregular. BP is 100/70
He has deep burns to the volar aspect of his right forearm and wrist with some swelling
but good capillary refill. He needs to be closely monitored, as he may require fasciotomy
because he has had a high-voltage injury, which leads to significant muscle damage:
Liaise with medical team
Medical team to insert cannulas and start fluid therapy and set up ECG monitor for heart rate
D: Disability
Mr K is conscious and talking when spoken to (V on the AVPU scale) and there appears
to be no central neurological concerns. Due to area of injury there will, however, likely be
peripheral nerve damage (median nerve in upper limb, peroneal nerve in lower limbs)
E: Exposure
Patient is able to sit up independently: burns evident on right arm and both feet – burnon left leg does not extend very far but it is circumferential and the foot is swollen,
as is the right wrist (escharotomy may be necessary in both regions plus or minus
fasciotomy). No other obvious injuries. Ensure patient is kept warm
212 | EARLY REHABILITATION OF BURNSCHAPTER 9 | BURNS

4.5%

Burns assessment – TBSA and assessmentof depth of burns

4.5%

Plot the burned area on the body chart:
shading for TYPE of burns using the symbols
and/or rule of nines (*either shade or use
symbols to depict depth of burn).

18%
4.5%

4.5%

4.5%

4.5%

1%
9%

9%

Superficial

Partial Thickness

9%

9%

Full Thickness*Approximately 7% of TBSA, but all burns are full thickness

F: Fluid resuscitation (and oedema management if required)
From a TBSA point of view, 7% is not a ‘resuscitation burn’, but we are concerned for deeper
tissue damage, therefore medical team needs to lead on this. Liaising with medical team is vital,
as after 48 hours of initial injury, if Mr K was in need of escharotomy/fasciotomy, it might be toolate: The patient would then have a high risk of requiring amputation.
It is important to then monitor urine output, pulse, BP and capillary refill and continue
to assess HR with ECG and carry on monitoring for further swelling or signs ofcompartment syndrome in right arm and both legs
Pain management
Linking with medical team, ensure pain
management is covered to include prechange of dressings (CODs)/therapy
analgesia
Wound care
Discuss with medical team what the plan isfor Mr K’s wound care – likely he will needescharotomy and all wounds will need to becleaned and dressed. Therapy ties in well to
COD’s and is a chance to check on woundhealing/assess for complications

Fasciotomy incision showing progressive muscle
damage at wrist due to an electrical burn213 | EARLY REHABILITATION OF BURNSCHAPTER 9 | BURNS

Rehabilitation treatment
Currently there is no indication for the need for chest physiotherapy. However, continue
to monitor respiration/cough etc.
Elevate arms gently, notably hand and wrist, and keep abducted and extended (seeTable 3). Keep monitoring fingers to check on his circulation
Elevate feet and keep in position of function (plantigrade splint). NB, it is highly likely hewill require bilateral amputation; however, it is vital to maintain correct position, even if
there is a later decision to amputate
Splint right forearm/wrist (see relevant section of Table 3). Get patient to keep moving
fingers and use local foam to encourage palmar contours and to create web-spaces(especially between fingers two and three). Aim to keep the interphalangeal joints
extended and the metacarpal joints in neutral
Continue to monitor cardiac signs for dysrhythmias and signs of swelling
Teach appropriate active and passive ROM and stretching exercises (see Table 3 for area
specific information)
Assess and advise on mobilisation
Ensure patient is feeding and has sufficient analgesia
Document everything clearly and COMMUNICATE everything clearly to patient and his family
Short-term result
The burns are very deep and will require debridement and graft and/or amputation.
Nerve and tendon exploration by plastic surgeon: Will need to be considered to check fordamage to these tissues
Patient is deemed a complicated patient and needs to be managed in an advanced
facility
Long-term expected management and outcome
Assess stage of scar maturation and patient’s acceptance of altered body image and function
NB, patients that present early from NON-war wound injuries should NOT need prophylactic
antibiotics.
Expected outcomes and need for continuing management
The ideal outcome is that wound and soft tissue healing is complete with maximal ROM achieved.
Additionally, ensuring previous function, cardiovascular endurance, independent ambulation andindependent activities of daily living is key to optimal recovery. Longer-term, the focus should
also encompass scar management and psychological motivation.
1.

Continuing prevention and treatment of contractures and joint deformities

2.

Continuous management scarring (hypertrophic)

3.

Possible need for surgery/further surgery for delayed healing wounds and/or contractures

4.

Pain management

5.

Management of scar hypersensitivity and pruritis (itching)214 | EARLY REHABILITATION OF BURNSCHAPTER 9 | BURNS

6.

Neuropathy

7.

Therapeutic pharmacologic and non-pharmacologic

8.

Reconditioning to activities and participation of functional activity

9.

Psychological considerations – burns are known to have psychosocial impact on patients,
whether in the acute or longer rehabilitation phase:
Depression and/or PTSD (post-traumatic stress disorder)
Impact on relationships
Support for community Integration

10.

Body image dissatisfaction (culture may increasingly influence this)11.

Children – growth considerations

12.

Maintaining good nutritional and fluid intake, seeking sun protection (for scarring),
padding to reduce shearing on scarring and wearing of protective gloves for hands

Especially consider the greater cosmetic and psychological impact for the face

KEY pointS
Key points of the chapter
In this initial phase of emergency management, it is likely that the therapist will not
be involved; however, early chest physiotherapy may be needed if inhalation injury
exists. In facilities with a high volume of patients, the therapist can be useful inalerting the team to potential life-threatening issues, such as restricted circulationor ventilation due to a deep circumferential burn, and also in assisting with secretion
clearance and correct positioning
Correct positioning is important at this early stage – keep in mind the anti-deformity
positioning for contracture prevention; this is the priority, especially for oedema
control. It is also important that the nursing/medical team should be well briefed in
knowing good positioning
Pain management
Infection prevention – be aware of and look for signs of infection or sepsis
Protection of flaps and grafts – failure of these will negatively impact the patient andtheir management
Splinting – be aware of splint safeguards and appropriate patient/carer education
Education – ensure the patient/carer understands importance of early active
mobilisation and assisted mobilisation from the therapist(s) and has information
about the long-term rehabilitation of burns injuries

215 | EARLY REHABILITATION OF BURNSCHAPTER 9 | BURNSREFERENCES AND CORE RECOMMENDED READING
Burn survivor rehabilitation; principles and guidelines for the allied health professional Australian and
New Zealand Burn Association (2007) ANZBAStandards of physiotherapy and occupational therapy practice in the management of burn injured
adults and children Burn therapy standards working group (2005) British Burn Association
Burn Rehabilitation – State of the Science. American Journal of Physical Medicine and Rehabilitation
Esselman P.C., Tombs B.D., Magyar-Russel G., Fauerbach J.A.: (review and analysis) April 2006; 383413
European Burns Association. 2017. Netherlands. Available at https://www.euroburn.org/wp-content/
uploads/EBA-Guidelines-Version-4-2017.pdf

Practice guidelines for the management of pain. Journal of Burn Care and Research Faucher, L. and
Furukawa, K. (2006) 27(5); 659-68
Essential Burns Care Manual International Network for Training, Education and Research in Burns(Interburns). 2016 www.interburns.org
War Surgery, Volume 2 International Committee of the Red Cross (ICRC) Geneva, Switzerland 2013.
Available at https://www.icrc.org/en/doc/assets/files/publications/icrc-002-4105.pdf
Standards and Strategy for Burn Care: A Review of Burn Care in the British Isles National Burn Care
Review Committee 2001 British Burn Association
Rehabilitation in Sudden Onset Disasters Humanity and Inclusion (previously Handicap International),
London, UK. Available at https://www.bond.org.uk/sites/default/files/resource-documents/
rehabilitation_in_sudden_onset_disasters_complete_manual.pdf
Splinting strategies and controversies. Journal of Burns Care and Rehabilitation Richard, R. and Ward,
S. 2005; 26:392- 396
The role of massage in scar management: a literature review Shin, T. and Bordeaux, J. Dermatologic
Surgery 2012; 38(3):414-23
Standards of Physiotherapy and Occupational Therapy Practice in the Management of Burn Injured
Adults and Children. 2017. Revised by the Burn Therapy Standards Working Group 2017. Endorsed by
the BBA Burn Therapists’ Interest Group, the British. Burn Association and the Four Burn Operational
Delivery Networks

216 | EARLY REHABILITATION OF BURNSEvery effort has been made to confirm the accuracy of the presented information. The authors andpublisher are not responsible for errors of omission or for any consequences from the applicationof the information in this book, and make no warranty, expressed or implied, with respect to thecurrency, completeness, or accuracy of the contents of this publication. Application of this information
in a particular situation remains the professional responsibility of the practitioner.
The development of this Field Handbook has been made possible by a grant of the AO Foundation,
Davos, Switzerland.
EARLY REHABILITATION IN CONFLICTS AND DISASTERS

This Field Handbook builds on the foundations laid by the ICRC and AO Foundation Limb
Injuries Guide and the Handicap International Rehabilitation in Sudden Onset Disasters manual.
The contents are directly linked to modules taught on disasterready.org where there are
additional accompanying resources designed to be used in conflict and disasters settings.
Each chapter has been developed by a team of highly specialised rehabilitation professionals,
using current evidence or based on best practice consensus, whilst highlighting clinical issues
which rehabilitation professionals may encounter in conflicts and disasters.

Humanity & Inclusion UK

T: +44 (0)330 555 0156

rehab.uk@hi.org