Operationalizing the Disaster Rehabilitation Continuum

Operationalizing the disaster rehabilitation continuum depends to a great degree on the severity of the disaster and resource availability. A developed region with a strong rehabilitation system may require only local and domestic support, whereas a developing region may seek international assistance. Rehabilitation systems in developing countries often have few human and physical resources. Facilities, equipment, and supplies are limited as well as trained providers and access to rehabilitation training programs and professional schools. In fact, many developing countries do not have accredited professional training programs in allied rehabilitation fields such as physical and occupational therapy, speech language pathology, and prosthetics and orthotics.⁴⁰ These countries also may lack local rehabilitation therapists, nurses, or doctors. For example, Sub-Saharan Africa has no PM&R physicians while Europe has more than 10,000 specialists who are unified by a comprehensive system of postgraduate education.^41,42 Consequently, rehabilitation practice may be entirely empirical in developing countries. Therefore, local specialized care for certain disabling injuries such as SCI and amputation may not be available in a disaster.

Societal variables in developing countries can severely affect implementation of rehabilitation services. Examples include medical, political, legal, economic, and cultural practices that limit pre-disaster acceptance of persons with disability and rehabilitation needs. Domestic physical factors such as geographical divisions, transportation corridors, and communication networks can also significantly impact disaster rehabilitation efforts. Making a positive operational impact requires effective coordination and collaboration between responding organizations, foreign and local disaster managers, and local rehabilitation services.

In a domestic disaster, rehabilitation professionals often respond to support plans by local employing institutions or government emergency managers. A rehabilitation physician may report to a local hospital and provide casualty triage assistance, for example. Providers may also deploy to another national region or internationally. International responders generally deploy as part of a civilian FMT or military unit. Others respond as employees of participating international rehabilitation NGOs such as ICRC, Christian Blind Mission, or HI. Responders provide rehabilitation in support of the sponsor’s mission objectives and within their credentialed professional scope of practice. They also should receive additional pre-deployment education and training in humanitarian core competencies as well as on standards of care and how to adapt these skills to a resource-constrained environment. Sponsoring organizations and professional societies may provide this supplemental training for those functioning as a humanitarian healthcare providers.⁴³ Training is currently available for U.S. orthopedists, surgeons, and SCI specialists, and is being developed for rehabilitation professionals.^13,37,44,45

The proposed WHO operational model for deploying FMTs in response to sudden-onset disasters recognizes rehabilitation as a core function of trauma care systems and recommends that FMTs provide post-disaster rehabilitation services. This model supports the WHO Humanitarian Reform process, which subsumes the WHO Emergency Response Framework, the Global Health Cluster response mechanism, and the Inter-Agency Standing Committee Transformative Agenda. This structure seeks to improve the effectiveness of humanitarian response through greater predictability, accountability, responsibility, and partnership.^46–48 A recent review of surgical care provided by FMTs in humanitarian crises also recommends that multidisciplinary surgical teams provide rehabilitation services.⁴⁹ Services should only be provided by teams with appropriate resources, however.⁵⁰ Appropriate level services are defined as Type 1 through Type 3 and would be provided by rehabilitation care teams attached to FMTs or a national hospital. They are defined as follows. A Type 1 FMT is associated with outpatient emergency care facilities and would ideally have rehabilitation capability to help provide initial emergency care for injuries. A Type 2 FMT is associated with inpatient surgical emergency care facilities and should, at a minimum, have a rehabilitation physician or physical therapist to help manage acute general surgical trauma patients. A Type 3 FMT is part of an inpatient referral care facility and should have a rehabilitation team including a rehabilitation physician, physical and occupational therapists, and rehabilitation nurses to help manage patients with complex trauma diagnoses that include SCI, TBI, and amputation.⁴⁶

A previous WHO guideline for rehabilitation of the physically wounded in disaster situations also proposes three levels of rehabilitation care. Level A (simple rehabilitation) would be provided in acute care general hospitals. Level B (general rehabilitation) would be provided in hospital rehabilitation departments for persons with complicated injuries affecting mobility. This involves mostly physical and occupational therapy and rehabilitation nursing. Level C (specialized rehabilitation) would be provided in rehabilitation hospitals by multidisciplinary teams for patients with complex injuries requiring comprehensive care including SCI, TBI, and amputation. This seminal consultation also considers continuity of care as well as the psychosocial and vocational implications. These guidelines were written primarily for non-rehabilitation professionals. However, other audiences who may find them useful include rehabilitation specialists supervising and training non-rehabilitation providers, primary care professionals engaged in the long-term care of the disabled, and community leaders.⁵¹

Role of Rehabilitation Providers

The role of the rehabilitation physician and other allied rehabilitation professional team members is determined by the FMT mission objectives, treatment care levels provided, rehabilitation team composition, resource availability, and a population’s rehabilitation needs distributed over the disaster rehabilitation continuum. Roles and competencies implemented in a disaster may be adapted from those performed in standard practice settings but modified due to the austere nature of the disaster environment.⁵² Rehabilitation physicians are experts in disability and trained in the diagnosis and treatment of musculoskeletal and neurological trauma and diseases. They can integrate acute rehabilitation into treatment protocols provided by FMT surgical and intensive care unit members, coordinate comprehensive inpatient rehabilitation, and facilitate discharge and referral planning. They prevent and treat secondary complications including pain and deconditioning. In addition, they prescribe medical therapies and assistive devices including prostheses and orthoses, mobility aids, and adaptive technologies. Rehabilitation physicians lead the multidisciplinary inpatient rehabilitation team and coordinate with various FMT and non-FMT providers to manage rehabilitation of patients with disabling and potentially disabling injuries.⁵³

Physical and occupational therapists provide interventions to improve patient range of motion, strength, and mobility. They also diagnose and monitor musculoskeletal and neurological disease processes. Occupational therapists facilitate regaining performance of daily activities previously lost due to injury through hand function training, cognition, and environmental adaptation. Physical therapists administer lower extremity gait training and movement and balance exercise. All these activities facilitate early post-surgical mobilization and functional recovery, thus decreasing time to hospital discharge and increasing turnover of limited beds. Therapists coordinate patient discharge from the hospital, arrange for necessary durable medical equipment and supplies, provide CBR, and educate and train local therapy providers as well as the patient and family on the home care plan (Figure 24.2).^54,55

Figure 24.2.

Occupational therapy is provided in a makeshift health center as part of the Handicap International disaster response to the 2008 Sichuan Earthquake.

Photo courtesy of Eric Weerts, HI.

Prosthetists, orthotists, and P&O technicians evaluate persons with amputations, fractures, contractures, weakness, and nerve injury. They design and fabricate prosthetic limbs and bracing in consultation with the rehabilitation team, provide training on device use, and perform modifications with replacement as needed. Prosthetists and orthotists also manage production workshops, train local service providers, and participate in CBR and long-term local rehabilitation needs planning (Figure 24.3).⁵⁶

Figure 24.3.

American orthotist Frank Shirley and prosthetist Al Ingersoll, as part of Handicap International France, provide therapy, data collection, and training to local non-rehabilitation staff in the days following the Haiti 2010 earthquake. Both Shirley and Ingersoll had extensive prosthetic and orthotic experience in Haiti prior to the earthquake.

Photo courtesy of Colleen O’Connell.

Rehabilitation nurses are experts in wound care. This expertise includes prevention of pressure ulcers, provision of bowel and bladder care, pain and nutritional management, and fall prevention. Nurses provide patient case management including medical documentation. They also provide essential education and training to patients, families, and caregivers to facilitate long-term recovery.⁵⁷

Psychological distress frequently results from a severe injury and the subsequent adjustment to a new disability. This is common following amputations. Psychologists provide needed screening for, and treatment of, post-injury mental health issues. Social workers can also provide counseling and emotional support in addition to case management services. Such services typically include coordination of necessary community resources for patients and families. Specialized rehabilitation services are especially useful in treating persons with TBI. Specialists in neuropsychology for the diagnosis and treatment of cognitive and behavioral impairment and speech-language pathology for the diagnosis and treatment of communication and swallowing disorders are particularly important.²²

Besides the education and training of patients, families, and caregivers, rehabilitation professionals also train non-rehabilitation FMT members in rehabilitation clinical care and skills. This task-shifting provides FMTs with additional expertise to manage rehabilitation needs during the high-volume emergency response phase. Such training is critically important if FMT rehabilitation responders are understaffed.^58,59 Similarly, training can be provided by FMT rehabilitation professionals to local providers and other personnel working in regional facilities and in the community. Capacity building within the local rehabilitation system leverages service provision over the disaster rehabilitation continuum. Following the 2010 Haiti earthquake, WHO/PAHO encouraged rehabilitation experts to provide rapid training to their teams and local staff, thus maximizing integration of optimal, post-disaster rehabilitative care.⁶⁰ Current proposed FMT guidance endorses this recommendation in order to maximize the impact of consistent and continuous rehabilitation care.⁴⁶

Based on its experiences in the Sichuan (2008) and subsequent Yushu (2010) earthquakes, HI China recognized these various training needs. It developed a technical rehabilitation training package that includes patient assessment and management tools for hospital non-rehabilitation medical staff as well as tools for patient, family, and caregiver education and training (Figure 24.4). A rehabilitation needs questionnaire is included for use by non-specialized providers to screen and refer patients to hospital rehabilitation staff for further assessment of potential needs for early intervention. An example is shown in Figure 24.5. This comprehensive collection of materials was employed during the earthquake rehabilitation response and has been integrated into standing operating procedures and emergency management plans in several hospitals within the earthquake zone.⁶¹

Figure 24.4.

Early physical rehabilitation assessment tool for use by local rehabilitation providers and community rehabilitation health workers in areas with limited pre-disaster rehabilitation capacity.

Document courtesy of Handicap International.

Figure 24.5.

Early rehabilitation needs questionnaire for non-rehabilitation trained health workers to facilitate early identification and referral of persons with rehabilitation needs.

Document courtesy of Handicap International.

In addition to providing clinical care to individual patients and education and training to various providers, rehabilitation team members participate in non-clinical, operational rehabilitation activities. These include: 1) development and implementation of triage and referral systems for all levels of rehabilitative care; 2) comprehensive data collection and patient tracking; and 3) ongoing assessment of rehabilitation needs and resource requirements. As an example, an assessment of inpatient facilities including field hospitals in the greater Port-au-Prince area occurred immediately following the 2010 Haiti earthquake. It provided injury and resource requirement estimates as well as useful clinical management recommendations to help guide the emergency rehabilitation response.⁶² Similarly, ongoing interval assessments can inform managers regarding emerging critical requirements. These include numbers and type of rehabilitation workers, durable medical equipment, rehabilitation beds and facilities, and community rehabilitation capacity. Accurate, current assessment data and effective cooperation between the rehabilitation team and the other stakeholders facilitates rehabilitation service delivery over the disaster continuum including transition of services to local providers and systems.

Rehabilitation of Traumatic Disabling Injuries

Rehabilitation of persons with traumatic disabling injuries begins as early as possible in the disaster response and continues over the rehabilitation disaster continuum. Typical conditions are SCI, TBI, burns, and extremity injuries such as amputations, bone fractures, and peripheral nerve injury. Local and national rehabilitation professionals will emergently respond. These are in addition to foreign responders embedded on FMTs with surgical capacity, on rehabilitation FMTs, or attached to international rehabilitation NGOs. Early involvement optimizes positive rehabilitation outcomes and reduces preventable secondary complications for many disabling injuries.^63,64

Injuries are identified, classified, diagnosed, and documented during rehabilitation triage. As an example, the International Standards for Neurologic Classification of Spinal Cord Injury (ISNCSCI) is used to classify patients with this condition.⁶⁵ Management of SCI within the critical first 72 hours after occurrence may determine outcomes, and specialized rehabilitative multidisciplinary team care is recommended.⁶⁶ Optimal management of patients with amputations also requires early rehabilitation expertise.⁶⁴ Acute rehabilitation activities can include consultation with the surgical team to determine at what level to perform the amputation. This optimizes postoperative prosthetic fitting, initiation of early mobilization protocols, and prevention and treatment of secondary medical complications. Management of complications related to SCI and amputation minimizes long-term disability and includes care for wounds, pressure ulcers, contractures, spasticity, and deconditioning. Other areas that benefit from assessment include bowel and bladder function, respiratory function, autonomic and cardiovascular function, thromboembolic risk, pain, nutrition, sexuality, and emotional health.

The surgical approach to performing a lower extremity amputation has rehabilitation implications. Ideally, the level of amputation should be below the knee and as distally as possible. Patients with a functioning knee joint will have a much better recovery. In addition, the greater the length of tibia preserved, the better will be the resulting ambulatory function. Amputations performed above the knee will significantly compromise mobility. The method of amputation used is dictated by the circumstances. The guillotine approach is indicated when attempting to free victims trapped in the rubble or when a person’s life is threatened by exsanguination and an amputation must be performed quickly outside the hospital. This approach has the advantage of speed and preserving as much leg length as possible. In most other situations, however, the guillotine amputation is less desirable and should not be used.⁶⁴ Important soft tissue may be lost and this will force the surgeon to resect more bone to create soft tissue coverage of the stump during definitive closure, thus sacrificing length.

Following acute interventions, core rehabilitation therapies aim to maximize physical activity and conserve body function. Mobility restoration therapies include training in: 1) strength, balance, and range of motion; 2) ambulation and wheelchair skills; 3) sitting, standing, and transfers; and 4) bed mobility and pressure relief maneuvers. Patients receive hand function therapy and training in the performance of activities of daily living (ADL). These self-care tasks include bathing, toileting, dressing, and eating. Assessment of functional outcomes is performed using standard measures such as the Spinal Cord Independence Measure that is serially documented for interval comparison.⁶⁷ Mobility-impaired patients are evaluated and prescribed durable medical equipment such as wheelchairs and orthotic braces, which should be contextually appropriate. For example, after the Haitian earthquake, an environmentally compatible, durable wheelchair was preferred for individuals with SCI that could be easily maintained by the patient.²⁰

During core rehabilitation, some patients with SCI may be transferred to a dedicated SCI center for more specialized care. Criteria for transfer will depend on injury severity and the level of rehabilitation expertise at the FMT Type 3 hospital. Persons with amputations may be discharged from a FMT Type 2 or 3 hospital to the community, depending on severity of injury. As part of the discharge process, they will receive a referral for prostheses assessment, fabrication, fitting, and functional training. Nerve injury patients who did not receive orthotic assessment in the hospital may also be referred. Most fractures can be appropriately managed at FMT Type 2 hospitals with outpatient rehabilitation referral. Patients with complex orthopedic trauma, burn injury, TBI, or multi-system trauma generally require specialized care at a FMT Type 3 hospital or a specialized center.^46,68

Discharge planning should begin early during hospitalization, given the critical demand for hospital beds, unclear referral pathways, and disrupted patient lives. Patient families may be missing or deceased, their homes destroyed, and livelihoods lost. Therefore, location of relatives, custodianship, accessible housing, and access to medications, equipment, and referral centers must be confirmed prior to discharge. Patient tracking processes should also be established to facilitate long-term follow-up and community integration. Investigators have shown that rehabilitation follow-up is lacking in sudden-onset disasters in developing countries. The Bam (2003), Gujarat/India (2004), and Kashmir (2005) earthquakes illustrate this problem, presumably in part due to faulty discharge planning.^12,18,69 Inadequate follow-up can contribute to secondary complications in these settings.^13,20 An example of a practice to improve follow-up and prevent complications includes an SCI database employed in post-earthquake Haiti by a coalition of SCI providers.⁶ Another option is establishing Disaster Vulnerability Focal Points (DVFPs). These are outpatient community and camp aid stations that are managed by HI. They provide on-site and mobile rehabilitation therapy, mobility aids, training, and psychosocial support to beneficiaries, families, and caregivers.⁷⁰ Educational training materials ensure basic continuing care for community-based rehabilitation workers, persons with disabilities, and their families and caregivers. Several model examples are worth noting. WHO offers two publications, The Rehabilitation of People with Amputations and SCI India: Guidelines for Care of Persons with Spinal Cord Injury in the Community, which are administered by the government of India’s WHO Collaborative Programme.⁷¹ The HELP Guide For Community Based Rehabilitation Workers is a notable training manual for non-specialized providers.⁷² Disabled Village Children: A Guide for Community Health Workers, Rehabilitation Workers, and Families is a widely used practical tool for rehabilitating children and includes guidance on common disabling injuries, medical complications, and managing a community rehabilitation program.⁷³ Provision of physical rehabilitation follow-up and additional CBR activities are fundamental components of the community integration stage of recovery. Such activities should address health, education, vocation, social inclusion, and other rights of persons with disabilities. If successful, these endeavors will facilitate full participation in society over the disaster rehabilitation continuum.

Rehabilitation of persons with traumatic disabling injuries is provided based on clinical best practices and established scientific evidence in countries with developed rehabilitation and health systems. However, meeting this standard of care is often not possible in many developing countries. Here, capacity to manage complex diagnoses such as SCI and amputation is severely limited, especially in a large-scale, sudden-onset disaster. Given the lack of evidence for rehabilitation interventions in disaster, local and foreign professional rehabilitation responders are guided by a combination of clinical practice guidelines, disaster-specific protocols, sponsoring organization recommendations, personal experience, and local practice. Some standards and guidelines are not appropriate for low resource settings such as disasters. Here, best clinical judgment based on case-specific risks and benefits is required. Consequently, roles, competencies, and interventions performed by foreign and local rehabilitation professionals may be adapted from those practiced in routine care settings. They can also innovate new approaches, creating other options for implementing the standard of care in disasters. The unique disaster context thereby impacts how the standard of care is interpreted. Significant disaster rehabilitation guidelines and other reference resources are listed in Table 24.1.

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