What part does clinical rehabilitation play in repairing people?

The nature of clinical rehabilitation

When people think about rehabilitation, it is only natural for them to do so in terms of their own experiences, or those of the people closest to them. For most, this will consist of some physiotherapy sessions or an exercise programme to be followed either at their local community hospital, the local gym or at home.

For some though, such as those who have suffered major trauma – people who have suffered very serious injury or wounding – rehabilitation means a great deal more than this and in these cases, access to specialists and equipment not available at local level – referred to as clinical rehabilitation – is required.

NHS England, the Department of Health (DH) and the British Society for Rehabilitation Medicine (BSRM) use the following definition:

'Rehabilitation is a process of assessment, treatment and management by which the individual (and their family and carers) are supported to achieve their maximum potential for physical, cognitive, social and psychological function, participation in society and quality of living.'

Representatives from the NHS in Nottinghamshire elaborate on this definition in the video below:

Miriam Duffy, Clinical pathway Lead NHS East Midlands Major Trauma Centre, Julie Hankin, Medical Director, Nottinghamshire Healthcare NHS Foundation Trust and Adam Brooks, Consultant, Clinical Lead NHS East Midlands Major Trauma Centre.

In terms of its scope, what NHS England has specified is that rehabilitation should reflect an assessment of the physical, functional, vocational, educational, cognitive, psychological and social rehabilitation needs of a patient. Treatment can include neurological care, mental health provision, occupational therapy, vocational rehabilitation, specific treatment for those with complex injury such as prosthetics and a whole range of exercise activity in gyms and pools – all under clinical supervision.

Specialist clinical rehabilitation is delivered by a multi-professional team who have undergone recognized specialist training in rehabilitation, including a consultant trained and accredited in rehabilitation medicine (RM) or neuropsychiatry in the case of cognitive/behavioural rehabilitation (BSRM).

When people are able to access clinical rehabilitation, provided this is early enough for it to be effective, it can make a huge difference. For example, a recent report by the Royal College of Physicians and BSRM recognized that those who acquire a disability and their families often have huge adjustments to make to their lives, but noted that proactive and integrated specialist rehabilitation can significantly reduce the impact of disability and prevent avoidable complications:

Adam Brooks, Consultant, Clinical Lead NHS East Midlands Major Trauma Centre responds to a question on whether specialist care saves lives.

The trauma care pathway

Clinical rehabilitation needs to be seen in the context of a wider patient journey – the trauma care pathway.

Care pathways are the end-to-end journeys made by patients from first injury/illness to the restoration of health and can encompass both clinical and non-clinical components.

Following injury (or potentially, in the case of the armed forces, combat wounding), rapid access is required to trauma medicine, which includes first responders, emergency and intensive care in hospital and clinical rehabilitation. All of this is clinical, in that patients are under the care and governance of trained and specialist clinicians and the care is provided through regional (or national) specialist centres.

Once they are well enough, patients can complete their care pathways in non-clinical recovery programmes delivered close to where they live.

Both are part of a pathway which ensures that those injured, by whatever means, have the best possible opportunity to recover – a journey that can take years in some cases.

The outcomes from several key studies in the past few years support early intervention and ensuring that patients are in the right beds for the appropriate stage in their recovery particularly in the realm of return to work. Integrated service models have proved the most efficient, especially if associated with some degree of flexibility.

Most notably these studies include:

  • “Improving Adult Rehabilitation Services in England” NHS Improving Quality
  • “The benefits to the Department of Work and Pensions (DWP), and Job Centre Plus (JCP), of providing an Early Rehabilitation Service.” John Pilkington Chair of Vocational Rehabilitation Association and Dr Emery McGilloway British Society of Rehabilitation Medicine.

Strong evidence has been found that early interventions, focused on work outcomes for people with ill health can:

  • Reduce sick leave and lost work productivity by more than 50%
  • Reduce healthcare costs by two thirds
  • Reduce disability benefits by 80%
  • Reduce permanent work disability and job loss by 50%
  • Deliver societal benefits by supporting people optimize functional capacity.
Miriam Duffy, Clinical Pathway Lead NHS East Midlands Major Trauma Centre. On the care pathways in Defence and the NHS

Who gets repaired and what are the outcomes

The Defence and National patient cohorts share many similarities but also some important differences. The objectives and expected outcomes for patients are broadly the same however, in terms of returning them not just to the best levels of health and fitness that can be achieved, but also enabling them to stay in, or return to work.

Defence patient cohort

By virtue of their background, what they have experienced and the competitiveness that exists in the military, Service patients undergoing rehabilitation do so with a real will, often against serious odds. They show a determination to get back to normal life that is unmatched, and they inspire the staff who care for them – as the Commanding Officer of Headley Court explains:

Complex trauma patients

The first group is those seriously wounded in combat operations and suffering from complex trauma injuries. As is well known, in recent years this group has included increasing numbers of single or multiple amputees, but also includes those having suffered Traumatic Brain Injury (TBI), or both. The nature of modern conflict includes the use by insurgents of Improvised Explosive Devices (IEDs) and, whilst there is no doubt that the level of protection afforded to service men and women today through advanced body armour has saved many lives, it does not protect the extremities and limb loss is all too frequent. But what is perhaps not so well known is that the percussive impact of IEDs often leads to TBI.

Defence rehabilitation has a long and proud record of managing members of the armed services with both brain injury and neurological disease (eg multiple sclerosis). The multi and inter-disciplinary model of care has produced some outstanding outcomes for this group of patients over the years and this will continue with the increased capability at Stanford Hall.

Many of these patients spend a considerable amount of time in the rehabilitation pathway, often returning several times for vocationally focused treatment. As some of these Service men and women will not be fit to remain in the military family, the process for transition into a civilian life is very important and the purpose-built ‘Back to Life’, domestic scale accommodation, at DNRC will benefit them and their families greatly.

Force generation

However, even at the peak of combat injuries, only 30% of patients at Headley Court are complex trauma patients (although due to the complex nature of their rehabilitation needs their care takes up to 75% of the resources). The majority of patients requiring clinical rehabilitation are patients injured in training (or occasionally suffering sports injuries) and for whom there is a great need to return them to active service at the earliest opportunity. Such treatment is termed by the Armed Forces ‘Force Generation’.

The levels of fitness demanded by the military and necessary to enable service men and women to undertake the jobs they are given in combat operations means that they undergo training regimes that are extremely challenging physically. The stresses and strains that this places on the body make it not surprising that musculoskeletal injuries to the back, limbs or musculature sometimes occur.

Outcomes for this group are remarkable, with up to 90% returning to active service in the military. Maximizing return to active service is key at a time when readiness to deploy to all parts of the world at short notice is a significant component of capability.

Civilian patients

From the outset the DNRC concept has been about enabling the nation to benefit from the rehabilitation expertise built up by the armed forces. But who are the civilian patients that might benefit, where will they come from and how will it work?

In the context of the aims and objectives of the DNRC around return to work, the starting point is people who are of working age. Major categories of people needing clinical rehabilitation include those who have suffered injury, for example road accidents and limb loss, head injuries, strokes, severe burns, musculoskeletal injury, spinal cord injury or progressive neurological disease.

It is estimated that there are 20,000 cases of major trauma in England each year with a further 28,000 not classified as major trauma but still with significant rehabilitation needs. (Transforming Trauma Rehabilitation, Recommendations for the North East Region, prepared on behalf of the North East Strategic Health Authority (SHA), 2013).

Miriam Duffy, Clinical Pathway Lead NHS East Midlands Major Trauma Centre talks about how the NHS trauma rehabilitation pathway could be improved. Julie Hankin, Medical Director, Nottinghamshire Healthcare NHS Foundation Trust on a key patient group that is not currently well served.