Rehabilitation after traumatic injury
Exam Tips
- In UK OSCEs, frame answers around a biopsychosocial MDT rehabilitation plan, not pain treatment alone.
- State that every patient should leave secondary care with a personalised rehabilitation plan and a named contact point for early post-discharge support.
- If progress is poor, always screen for psychological barriers (including suicide risk), cognitive issues, and reversible medical complications.
- Use SMART goals and mention serial PROMs/CROMs to demonstrate objective follow-up.
- Show prescribing safety: NSAID contraindications, opioid harm minimisation, renal dose adjustment, and anticoagulation bleeding risk.
- Common pitfall: assuming persistent symptoms are purely orthopaedic; include PTSD, depression, CRPS and missed injuries in differentials.
Definition
Rehabilitation after traumatic injury is a structured, multidisciplinary process that starts early and continues after hospital discharge to restore maximum physical, cognitive, psychological, and social function. In UK practice it is goal-directed and personalised, with ongoing reassessment of function, participation, and quality of life for the patient and, where relevant, their family or carers.
Pathophysiology
Traumatic injury causes tissue damage (bone, soft tissue, nerve, visceral or spinal structures) followed by inflammatory and neuroendocrine stress responses that can drive pain, weakness, deconditioning, and impaired mobility. Secondary effects such as immobilisation, sleep disturbance, malnutrition, fear-avoidance, and opioid exposure can perpetuate disability; psychologically, acute stress reactions may evolve into anxiety, depression, or PTSD, which then reduce engagement with therapy. Rehabilitation addresses this biopsychosocial cycle using repeated assessment, task-specific training, symptom control, cognitive/psychological support, and environmental adaptation (consistent with WHO ICF domains; see standard ICF framework figure used in rehabilitation texts).
Risk Factors
- Major trauma or polytrauma requiring hospital admission
- Older age, frailty, falls (especially low-height falls in older adults)
- Pre-existing disability, multimorbidity, or cognitive impairment
- Spinal injury, limb loss, complex fractures, nerve injury, or limb reconstruction
- High pain burden, prolonged immobility, or repeated surgery/readmission
- Limited social support, safeguarding concerns, domestic abuse, or socioeconomic vulnerability
- Previous mental health disorder or early post-traumatic psychological distress
Clinical Features
Symptoms
- Persistent pain, reduced exercise tolerance, fatigue, poor sleep
- Difficulty with mobility, transfers, self-care, toileting, or return to work/education
- Breathing, swallowing, eating/drinking, speech/language, or sensory complaints depending on injury pattern
- Cognitive symptoms: poor concentration, slowed processing, forgetfulness
- Psychological symptoms: intrusive memories, nightmares, flashbacks, anxiety, low mood, irritability
- Carer strain and loss of confidence with activities of daily living
Signs
- Reduced range of movement, weakness, gait disturbance, balance impairment
- Functional dependence on ADLs/IADLs and need for equipment/adaptations
- Objective communication/swallowing deficits on therapy assessment
- Weight loss, deconditioning, pressure-related skin risk in less mobile patients
- Features of depression/anxiety/PTSD on structured screening
- Fluctuating capacity or engagement with rehabilitation goals
Investigations
Management
Lifestyle Modifications
- Implement a personalised MDT rehabilitation plan with clear, time-bound goals and regular review in primary care and specialist services
- Early graded mobilisation and exercise therapy with pacing and energy-conservation strategies
- Sleep optimisation, structured daily routine, and self-management education (pain, activity planning, relapse prevention)
- Use a recovery diary/app to track symptoms, therapy, and goals to support shared decision-making
- Address social determinants: falls prevention, safeguarding, domestic abuse support, vocational/education planning, carer support
- Provide a clear single point of contact after discharge for advice and rapid re-escalation
Pharmacological Treatment
Non-opioid analgesia
- Paracetamol 1 g orally every 6 hours (max 4 g/day)
- Ibuprofen 400 mg orally three times daily with food
- Naproxen 250-500 mg orally twice daily
- Omeprazole 20 mg once daily when GI protection is indicated with NSAID use
Stepwise pain control to enable therapy participation; avoid NSAIDs in active peptic ulcer disease, severe renal impairment, or decompensated heart failure; use lowest effective dose for shortest duration.
Opioids for severe acute pain limiting rehabilitation
- Morphine sulfate immediate-release 5-10 mg orally every 4 hours as needed (use lower starting doses in older/frail adults)
Use short courses with frequent review; counsel on sedation, constipation, falls and dependence risk; avoid co-prescribing with other sedatives where possible and prescribe a laxative if needed.
Neuropathic pain agents (when neuropathic features present)
- Amitriptyline 10 mg at night, titrating gradually (commonly up to 75 mg nocte)
- Gabapentin 300 mg at night initially, titrating to 300 mg three times daily then according to response/tolerability
Monitor for anticholinergic effects (amitriptyline), dizziness/somnolence and misuse potential (gabapentin); adjust gabapentin dose in renal impairment.
Anticoagulation where VTE prophylaxis is indicated by trauma/immobility pathway
- Enoxaparin 40 mg subcutaneously once daily (dose-adjust if renal impairment or low body weight)
Contraindicated in active major bleeding; assess bleeding risk and platelet count as per local protocol.
Medication for comorbid depression/PTSD when clinically indicated
- Sertraline 50 mg once daily, increasing in steps to a usual maximum of 200 mg/day
Use alongside psychological therapy, not as a substitute for trauma-focused rehabilitation input; monitor early worsening anxiety, suicidal ideation (especially younger adults), hyponatraemia and bleeding risk with NSAIDs/anticoagulants.
Surgical / Interventional
- Further planned trauma surgery where needed (e. g, fixation revision, non-union surgery, tendon/nerve repair, flap/soft-tissue reconstruction)
- Limb reconstruction pathways or amputation/stump revision with prosthetic rehabilitation
- Spasticity or contracture procedures in selected patients after specialist assessment
- Urgent re-admission for surgical complications (infection, hardware failure, compartment sequelae) when identified during follow-up
Complications
- Persistent disability and reduced quality of life
- Chronic pain (including neuropathic pain and complex regional pain syndrome)
- Mood and trauma-related disorders: anxiety, depression, PTSD, self-harm risk
- Cognitive dysfunction affecting capacity, adherence and return to usual roles
- Dysphagia, communication problems, malnutrition, or respiratory complications depending on injury pattern
- Social isolation, loss of employment/education, and carer burnout
- Recurrent falls, readmissions, and delayed recovery after further surgery
Prognosis
Outcome is heterogeneous and depends on injury severity, premorbid health, psychological response, and quality/intensity of coordinated rehabilitation. Many acute stress symptoms improve within 4-6 weeks, but some patients develop recurrent or delayed mental health and functional problems requiring long-term MDT input. Early goal setting, regular review, and rapid escalation when recovery stalls improve functional outcomes and participation.
Sources & References
✅NICE Guidelines(1)
- Rehabilitation after traumatic injury[overview]