Principles of Care for Complex Injuries and Multi-System Conditions

Original Editor - Wanda van Niekerk based on the course by Jason Giesbrecht


Top Contributors - Wanda van Niekerk and Jess Bell  

Introduction[edit | edit source]

Rehabilitation professionals should strive to provide comprehensive person-centred care to patients with challenging, complex injuries and multi-system conditions. Complex injuries and conditions refer to situations where patients have multiple, often interrelated, health issues that require a comprehensive and coordinated approach to rehabilitation.[1] This approach leads to positive patient outcomes, and it can be achieved through interdisciplinary teamwork, goal setting, communication and function-focused care. Complex rehabilitation has evolved in the past few years, and rehabilitation professionals should understand the need for timely, coordinated and complex rehabilitation interventions by interdisciplinary teams.[2]

Types of Complex Injuries and Conditions[edit | edit source]

  • Multiple trauma or polytrauma[3]
    • the presence of two or more injuries to physical regions or organ systems, one of which may be life-threatening, resulting in physical, psychological or psychosocial impairments or disability.[4]
    • Berlin definition: Polytrauma is defined as patients with an Abbreviated Injury Scale (AIS) ≥3 for two or more different body regions with one or more additional features from five physiologic parameters of age, consciousness, hypotension, coagulopathy, and acidosis.[3]
  • Limb loss
  • Complex pain conditions, such as fibromyalgia and complex regional pain syndrome[5]
  • Multi-system challenges
    • for example, patients with multiple medical issues such as diabetes, heart disease, hypertension
  • Chronic illness, cancer, communicable diseases[6]
  • Neurological injuries
    • for example, traumatic brain injuries, stroke[7]
  • Cognitive and psychological challenges
    • for example, depression, anxiety, post-traumatic stress disorder
  • Other relevant conditions, genetic disorders, autoimmune diseases, age-related decline

Causes of Complex Injuries and Conditions[edit | edit source]

  • Trauma
    • road traffic accidents, falls, sports, acts of violence
  • Chronic conditions
    • diabetes, heart diseases, autoimmune disorders
  • Ageing
  • Genetic factors
    • muscular dystrophy[8]
  • Environmental factors
    • air pollution or exposure to environmental hazards[9]
  • Lifestyle choices[10]  
    • poor diet, physical inactivity,[11] substance use[12]

Socioeconomic Impact of Complex Injuries and Conditions[edit | edit source]

  • Healthcare costs – for the individual and the healthcare system[13]
  • Loss of productivity and income[14]
  • Social stigma and isolation[15]
  • Educational and vocational challenges[16]
  • Family and caregiver burden[17] [18]
  • Quality of life[19]

Principles of Care[edit | edit source]

Person-Centred Approach[edit | edit source]

Person-centred care means that the patient is treated as an individual and an equal partner in their healing, rehabilitation and recovery. It is a personalised, coordinated and enabling approach.[20]

  • Build a therapeutic alliance with the patient[21]
    • establishing meaningful connections between the patient and rehabilitation professional results in all parties being seen, heard and appreciated. Ways that rehabilitation professionals can establish these connections include[22]:
      • acknowledging the individual
        • rehabilitation professionals meet the patient as an equal, validate their experience and individualise treatment
        • for example, sit at the patient’s level, affirm the patient's expression of emotion, and adapt the rehabilitation programme by considering the patient’s unique circumstances
      • using the body as a pivot point
        • the rehabilitation professional can explain the patient’s physical problems and explain the treatment plan or solution and is in a position to facilitate the patient’s connection to their body
        • for example, providing the patient with clear explanations of the assessment findings and carefully handling the affected body regions
      • giving of self
        • this is the extra mile that rehabilitation professionals go to help their patients when it is needed; this can be inside or outside of the clinical interaction
        • for example, the rehabilitation professional shares a part of their life or experiences if and when appropriate and consults with the patient’s other healthcare providers
  • Understand the patient’s goals and values[21]
  • Empower the patients to participate in their care[21]
    • rehabilitation professionals can support patients in self-management of their condition through goal setting, shared-decision making, action planning and forming partnerships
[23]

Challenges to Person-Centered Care in Low- and Middle-Income Countries[edit | edit source]

Challenges can include the following[22]:

  • inadequate human resources
  • inadequate budget and finances
  • poor leadership and management

No matter what the situation is, an educated patient is an empowered patient.[22] Rehabilitation professionals should aim to empower patients through patient education. This will enhance patient autonomy and encourage patients to be partners in their care.[24] However, in low-and middle-income countries, there is often low health literacy because of low levels of general literacy and inadequately functioning health systems with limited resources.[25]

Implementation of Person-Centred Care in Clinical Practice[edit | edit source]

Suggestions on how to implement person-centred care into clinical practice may include[22]:

  • incorporate the patient’s perspectives as part of the rehabilitation process
  • pay attention to what you communicate and how you communicate
  • encourage patient involvement during the examination and management
  • create a personalised plan that is considerate of the patient’s context
  • rehabilitation professionals are encouraged to reflect on their own beliefs and practice through peer review or self-reflective questions such as[22]:
    • "am I communicating effectively with patients?
    • "is my consultation long enough to implement a person-centred approach?"

Read more: Therapeutic Alliance 

Interdisciplinary Team Approach[edit | edit source]

  • Within an interdisciplinary team approach, rehabilitation professionals from different disciplines work together, and there is overlap in their practice (instead of each person working individually) with shared goals coordinated into a unified management plan. Team members in an interdisciplinary team build on each other’s expertise to achieve common, shared goals.[26]
  • Patient progress is communicated through written documentation and regular team meetings, which are focused on the overall patient goals.
  • Rehabilitation team members generally consider the following questions when developing interdisciplinary care plans[27]:
    • what are the issues?
    • who will be involved?
    • what will the interventions be?
    • what are the goals of the intervention?
    • when will re-evaluation occur?
  • Interdisciplinary teams are common in inpatient rehabilitation centres and involve:
    • professionals involved in joint problem solving
    • overlapping, patient-focused treatment goals
    • collaboration with other disciplines
    • regular communication between team members
    • active involvement of the patient
    • balancing urgent treatment with comprehensive care[21]

Read more: Rehabilitation Teams; Characteristics of Successful Teams; Barriers to Effective Teams

Collaborative Goal Setting[edit | edit source]

  • Setting realistic and achievable goals with the patient[21]
  • Developing a plan to achieve these goals[21]

Person-centred and collaborative goal setting leads to improved outcomes and patient satisfaction. Goal setting provides a way to incorporate the patient’s perspectives and desires.[28]

Some guidelines on setting rehabilitation goals[29]:

  • Implement short- and long-term goals with the patient, family members and caregivers
  • Review these goals regularly
  • Set goals in line with:
    • what is most important to the patient
    • what is it that the patient values most
    • meaningful activities for the patient (these should also relate to what is most important to the patient)
    • strengths-based approaches - focus on the patient's strengths and not on their deficits to promote well-being
    • the patient's home circumstances
    • the patient's return to work or education plans
    • developing skills, confidence and knowledge so that the patient can manage their well-being and health
    • flexibility with goal setting - there will be setbacks and gains along the way
  • Monitor long-term rehabilitation goals through small steps that are meaningful and motivate the patient
  • The members of the team should be skilled and experienced in helping patients identify appropriate goals and also understand how the psychological impact of the patient's trauma will influence goal setting and rehabilitation

Read more: Goal Setting in Rehabilitation

Continuity of Care and Communication[edit | edit source]

  • Coordinating care across different settings[21]
  • Providing clear and timely communication to the patient and their family[21]

Read more: Continuity and coordination of care[30]

Ljungolm et al.[31] suggests a care continuity model with six interconnected concepts to achieve continuity of care in patients with complex care needs and their families/ caregivers. These concepts are[31]:

  • time and space
  • tailored information
  • mutual understanding
  • clarity in responsibilities and roles
  • interprofessional collaboration
  • trusting relationships

Patients and families feel that time is crucial in the continuity of care. It takes time to create and strengthen relationships with different members of the interdisciplinary team, and access to tailored information is key for mutual understanding to develop. For this to happen, it is necessary to have clarity in responsibilities and roles, interprofessional collaboration and to cultivate a trusting relationship between all parties involved.[31]

Some principles to consider for sharing information and involving family and caregivers[29]:

  • have patients, family and caregivers (as appropriate) involved in assessments, planning the patient's coordination of care and decision-making in all rehabilitation stages
  • encourage patients to be actively involved in decisions regarding their rehabilitation
  • encouragement from family, caregivers, friends and rehabilitation professionals have a positive effect on a person's rehabilitation journey
  • use clear language when providing information - be specific to the patient's injuries, sensitive, supportive and respectful

Function-Focused Care[edit | edit source]

Function-focused care analyses the patient’s underlying capabilities for function and physical activity and helps the patient to optimise and maintain these functional abilities. It is often used to develop the highest possible level of self-care and independence in patients.[32] A function-focused approach involves[21]:

  • emphasising functional outcomes and quality of life
  • addressing physical, cognitive and psychosocial aspects of rehabilitation
  • considering the impact on participation (quality of life, community and social engagement, self-care, work/employment)
  • monitoring progress and adjusting the care plan as needed

An interdisciplinary approach is encouraged when delivering function-focused care as it improves physical, social and cognitive function in patients with complex health statuses. These care goals should be accurately assessed and supported through continuous and integrated care.[32]

Complex Rehabilitation and the ICF Framework[edit | edit source]

Figure 1. The reciprocal relationship in the ICF framework

The International Classification of Functioning, Disability and Health (ICF) framework was created to improve understanding of the concepts of health and health-related status. It emphasises human functioning in relation to an individual's activities and participation. These can be influenced by environmental factors, health conditions and personal factors.[33] The framework has moved away from negative descriptors such as "impairment", "disability" and "handicap" to positive descriptors such as "body structures", "activities" and "participation." In this way, the framework focuses on positive reviews and enablement rather than negativity and disabilities. Complex rehabilitation should be considered as a process to discover and enhance what is possible for an individual and not focus on what is not possible. Rehabilitation professionals are encouraged to learn how to describe "rehabilitation processes according to its positive features."[2] Figure 1 shows the reciprocal relationship between the key components of the ICF framework.

The ICF framework provides rehabilitation professionals with a common language that is independent of their own areas of expertise. It can help rehabilitation professionals look beyond their expert areas and communicate with other members of the interdisciplinary team. It also helps keep the focus on functioning rather than the patient’s diagnosis or conditions.[2]

Read more: Introduction to the International Classification of Functioning, Disability and Health (ICF)

Resources[edit | edit source]

References[edit | edit source]

  1. ↑ Giesbrecht J. Principles of Care for Complex Injuries and Multi-System Conditions Course. Plus, 2023.
  2. ↑ 2.0 2.1 2.2 Pelser C, Banks H, Bavikatte G, editors. A Practical Approach to Interdisciplinary Complex Rehabilitation E-Book. Elsevier Health Sciences; 2022 Feb 1.
  3. ↑ 3.0 3.1 Iyengar KP, Venkatesan AS, Jain VK, Shashidhara MK, Elbana H, Botchu R. Risks in the Management of Polytrauma Patients: Clinical Insights. Orthopedic research and reviews. 2023 Dec 31:27-38.
  4. ↑ Al Hanna R, Amatya B, Lizama LE, Galea MP, Khan F. Multidisciplinary rehabilitation in persons with multiple trauma: a systematic review. Journal of Rehabilitation Medicine. 2020 Oct 2;52(10):1-9.
  5. ↑ Taylor SS, Noor N, Urits I, Paladini A, Sadhu MS, Gibb C, Carlson T, Myrcik D, Varrassi G, Viswanath O. Complex regional pain syndrome: a comprehensive review. Pain and Therapy. 2021 Dec;10(2):875-92.
  6. ↑ Kudre D, Chen Z, Richard A, Cabaset S, Dehler A, Schmid M, Rohrmann S. Multidisciplinary outpatient Cancer rehabilitation can improve Cancer patients’ physical and psychosocial status—a systematic review. Current oncology reports. 2020 Dec;22:1-7.
  7. ↑ Wagner AK, Franzese K, Weppner JL, Kwasnica C, Galang GN, Edinger J, Linsenmeyer M. Traumatic brain injury. InBraddom's Physical Medicine and Rehabilitation 2021 Jan 1 (pp. 916-953). Elsevier.
  8. ↑ Iftikhar M, Frey J, Shohan MJ, Malek S, Mousa SA. Current and emerging therapies for Duchenne muscular dystrophy and spinal muscular atrophy. Pharmacology & Therapeutics. 2021 Apr 1;220:107719.
  9. ↑ Meghji J, Mortimer K, Agusti A, Allwood BW, Asher I, Bateman ED, Bissell K, Bolton CE, Bush A, Celli B, Chiang CY. Improving lung health in low-income and middle-income countries: from challenges to solutions. The Lancet. 2021 Mar 6;397(10277):928-40.
  10. ↑ Mintzer J, Donovan KA, Kindy AZ, Lock SL, Chura LR, Barracca N. Lifestyle choices and brain health. Frontiers in medicine. 2019 Oct 4;6:204.
  11. ↑ Katzmarzyk PT, Friedenreich C, Shiroma EJ, Lee IM. Physical inactivity and non-communicable disease burden in low-income, middle-income and high-income countries. British journal of sports medicine. 2022 Jan 1;56(2):101-6.
  12. ↑ Shearer RD, Howell BA, Bart G, Winkelman TN. Substance use patterns and health profiles among US adults who use opioids, methamphetamine, or both, 2015-2018. Drug and alcohol dependence. 2020 Sep 1;214:108162.
  13. ↑ Khan F, Amatya B, Hoffman K. Systematic review of multidisciplinary rehabilitation in patients with multiple trauma. Journal of British Surgery. 2012 Jan;99(Supplement_1):88-96.
  14. ↑ Haas B, Jeon SH, Rotermann M, Stepner M, Fransoo R, Sanmartin C, Wunsch H, Scales DC, Iwashyna TJ, Garland A. Association of severe trauma with work and earnings in a national cohort in Canada. JAMA surgery. 2021 Jan 1;156(1):51-9.
  15. ↑ Ross E, Crijns TJ, Ring D, Coopwood B. Social factors and injury characteristics associated with the development of perceived injury stigma among burn survivors. Burns. 2021 May 1;47(3):692-7.
  16. ↑ Soberg HL, Roise O, Bautz-Holter E, Finset A. Returning to work after severe multiple injuries: multidimensional functioning and the trajectory from injury to work at 5 years. Journal of Trauma and Acute Care Surgery. 2011 Aug 1;71(2):425-34.
  17. ↑ Kjeldgaard A, Soendergaard PL, Wolffbrandt MM, Norup A. Predictors of caregiver burden in caregivers of individuals with traumatic or non-traumatic brain injury: A scoping review. NeuroRehabilitation. 2023 Jan 6(Preprint):1-20.
  18. ↑ Perfetti AR, Jacoby SF, Buddai S, Kaplan LJ, Lane-Fall M. Improving post-injury care: key family caregiver perspectives of critical illness after injury. Critical care explorations. 2022 May;4(5).
  19. ↑ Angerpointner K, Ernstberger A, Bosch K, Zeman F, Koller M, Kerschbaum M. Quality of life after multiple trauma: results from a patient cohort treated in a certified trauma network. European journal of trauma and emergency surgery. 2021 Feb;47:121-7.
  20. ↑ Coulter A, Oldham J. Person-centred care: what is it and how do we get there?. Future hospital journal. 2016 Jun;3(2):114.
  21. ↑ 21.0 21.1 21.2 21.3 21.4 21.5 21.6 21.7 21.8 Giesbrecht, J. Principles of Care for Complex Injuries and Multi-System Conditions Course. Plus.2023
  22. ↑ 22.0 22.1 22.2 22.3 22.4 Hutting N, Caneiro JP, Ong'wen OM, Miciak M, Roberts L. Patient-centered care in musculoskeletal practice: Key elements to support clinicians to focus on the person. Musculoskeletal Science and Practice. 2022 Feb 1;57:102434.
  23. ↑ World Health Organisation (WHO). WHO: What is people-centred care? Available from: https://www.youtube.com/watch?v=pj-AvTOdk2Q[last accessed 16/6/2023]
  24. ↑ Jotterand F, Amodio A, Elger BS. Patient education as empowerment and self-rebiasing. Medicine, Health Care and Philosophy. 2016 Dec;19:553-61.
  25. ↑ Meherali S, Punjani NS, Mevawala A. Health literacy interventions to improve health outcomes in low-and middle-income countries. HLRP: Health Literacy Research and Practice. 2020 Dec 11;4(4):e251-66.
  26. ↑ Mukpradab S, Mitchell M, Marshall AP. An Interprofessional Team Approach to Early Mobilisation of Critically Ill Adults: An Integrative Review. International Journal of Nursing Studies. 2022 Feb 18:104210.
  27. ↑ Ferguson, M. Multidisciplinary vs. Interdisciplinary Teamwork: Becoming a More Effective Practitioner. 2014 Available from: http://www.socialworkhelper.com/2014/01/14/multidisciplinary-vs-interdisciplinary-teamwork-becoming-effective-practitioner/ (Accessed 16 June 2023).
  28. ↑ Brown J, Ackley K, Knollman-Porter K. Collaborative goal setting: A clinical approach for adults with mild traumatic brain injury. American Journal of Speech-Language Pathology. 2021 Nov 4;30(6):2394-413.
  29. ↑ 29.0 29.1 NICE Guideline (NG211): Rehabilitation after traumatic injury. Published 18 January 2022.
  30. ↑ World Health Organisation (WHO). Continuity and coordination of care.
  31. ↑ 31.0 31.1 31.2 Ljungholm L, Klinga C, Edin‐Liljegren A, Ekstedt M. What matters in care continuity on the chronic care trajectory for patients and family carers?—A conceptual model. Journal of Clinical Nursing. 2022 May;31(9-10):1327-38.
  32. ↑ 32.0 32.1 Kim MS, Lee SJ, Park MS, Jeong EH, Chang SO. Toward a conceptual framework for the interdisciplinary function‐focused care in nursing homes. Japan Journal of Nursing Science. 2020 Jul;17(3):e12330.
  33. ↑ Leonardi M, Lee H, Kostanjsek N, Fornari A, Raggi A, Martinuzzi A, Yáñez M, Almborg AH, Fresk M, Besstrashnova Y, Shoshmin A, Castro SS, Cordeiro ES, Cuenot M, Haas C, Maart S, Maribo T, Miller J, Mukaino M, Snyman S, Trinks U, Anttila H, Paltamaa J, Saleeby P, Frattura L, Madden R, Sykes C, Gool CHV, Hrkal J, Zvolský M, Sládková P, Vikdal M, Harðardóttir GA, Foubert J, Jakob R, Coenen M, Kraus de Camargo O. 20 Years of ICF-International Classification of Functioning, Disability and Health: Uses and Applications around the World. Int J Environ Res Public Health. 2022 Sep 8;19(18):11321.
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