Challenges in Delivering Rehabilitation in Disasters and Conflicts

Original Editors - Naomi O'Reilly

Top Contributors - Naomi O'Reilly, Kim Jackson, Jess Bell, Uchechukwu Chukwuemeka and Olajumoke Ogunleye      

Introduction[edit | edit source]

Disasters and conflicts often result in damaged infrastructure and disrupted health systems and often occur in remote, underserved areas. In many cases, people are displaced or live in temporary shelters with limited provision for those with disabling injuries, especially when they have impaired mobility.[1] Rehabilitation professionals face unique challenges when working in these settings associated with complex trauma, injury surge and resource scarcity in terms of equipment, infrastructure, and workforce. These occur on an unprecedented scale and outstrip available resources. Rehabilitation professionals are well placed to address these challenges and can add considerable value to patient care. By assisting in discharge planning and identifying local providers for ongoing care, rehabilitation professionals can also help ensure appropriate and efficient patient flow. Understanding and recognising these challenges is vital for rehabilitation professionals to be able to navigate the demands of the emergency medical response in disaster and conflict settings.[2]

Overwhelming Patients and Prioritisation[edit | edit source]

Disaster is a serious disruption of the functioning of a community or society. It involves widespread human, material, economic or environmental impacts that exceed the ability of the affected community or society to cope using its own resources.[3] In the wake of a disaster or conflict, the health infrastructure and workforce can often become overwhelmed, particularly within the early days of the emergency response following a sudden onset disaster, where responders have to cope with an influx of mass casualties presenting to health services. In conflicts and protracted crises with patients presenting over long periods of time, there is a persistent challenge of balancing the needs of new patients requiring early rehabilitation and those with ongoing rehabilitation needs.[4] Other issues arise with this influx which can further impact rehabilitation needs, including family separation, unaccompanied children, and destroyed homes resulting in displacement.

Both of these situations bring significant challenges for the medical team and rehabilitation professionals as it is not always possible to treat everyone optimally. The ability to prioritise becomes vital given the tremendous imbalances between supply and demand for care.[5] Rehabilitation professionals need to both prioritise who they treat and consider their interventions in order to maximise the limited time they have with patients, and ensure the best possible carry over within the constraints of the environment. The field handbook, Early Rehabilitation in Conflicts and Disasters[4] suggests the following priorities for provision of early rehabilitation to enable the best possible outcomes and minimise complications:

  1. Patients whose life may be at risk without rehabilitation input, e.g. new suspected spinal  injuries, brain injury or patients in need of urgent respiratory input.
  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, such  as patients requiring assistive devices, education and a follow-up appointment (e.g.  patients with an upper limb or 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.[4]

There is now recognition that early rehabilitation can facilitate earlier discharge from hospitals thereby improving the overall capacity to treat a higher number of patients. Interventions that have the most value when there are large numbers of patients include patient and caregiver education on:

  • The management of a condition
  • Recognising complications and what to do if they occur so patients can self-manage on discharge

Active treatments including positioning, exercises and functional activities are also key interventions to support management and help to ensure that patients can perform activities of daily living.

International Support[edit | edit source]

While international support often has a role to play, it can create challenges for local responders. A common problem is a lack of coordination with and amongst disaster management organisations.[6] This draws time and resources away from the local response, particularly when international responders are only staying for short periods of time.[4] According to Cranmer and Biddinger “poorly prepared and poorly equipped responders have sometimes ended up depleting needed resources rather than providing solutions. In previous emergency responses, some health care workers have worked outside their scope of practice and licensure. Many have been deployed without food, water, medical-supply chains, or even transportation. Their failure to secure basic logistic arrangements taxes already stressed and fragmented local systems that are attempting to deliver basic necessities to the locally affected population. Failure to coordinate with local response authorities or with international relief agencies results in either duplication of existing capacity or missed opportunities to fill gaps in delivery.”[7][8]

Individuals should only ever travel to disaster zones as part of an established international organisation or as a member of an Emergency Medical Team that is registered as part of the World Health Organisation. They need to be aware of minimum technical standards for rehabilitation in emergencies and should only travel at the request of a locally based organisation. Emergency Medical Teams are now considered a vital aspect of the global health workforce that provide direct clinical care to people affected by disasters and conflicts and support local health systems, particularly in disasters and conflicts where the local health workforce has been decimated and health infrastructure significantly damaged or destroyed. [1][9]

Injury Complexity[edit | edit source]

The type and distribution of injuries caused by disasters and conflicts varies widely according to the type of hazard and a range of other factors. In general though, complex poly-trauma are common with a range of injuries including fracture, limb amputation, spinal cord injury, traumatic brain injury, peripheral nerve injury and burns. These injuries often have to be managed concurrently, which can complicate rehabilitation assessments and interventions.[4]

The Minimum Technical Standards and Recommendations for Rehabilitation - Emergency Medical Teams[1] outlines the following recommendation around injury complexity in emergencies.

  • Minimum Technical Standard;
    • Rehabilitation professionals with an arriving team should be experienced in trauma and medical rehabilitation with experience and/or training to work in austere environments.[1]

Clinical Expertise[edit | edit source]

Trauma specialists with extensive experience of major trauma, and other Clinical Specialists in complex conditions such as spinal cord injury, traumatic brain injury and burns tend to be in short supply in these settings. Given the complexity of injuries seen in disasters and conflicts with the massive surge of patients presenting with poly-trauma, rehabilitation professionals who are going to work in these settings need to be skilled across multiple clinical areas to manage the complexity. They also should have adequate training to ensure that they have the core clinical skills to manage a wide range of presentations in a challenging environment.[4][8] Specialised care teams, such as those for spinal cord injury, burns, and orthoplastics, may also be required to augment local rehabilitation capacity and provide specialist rehabilitation care.

Rehabilitation professionals with specific expertise may have a role in the training and up-skilling of local rehabilitation professionals. This should only be considered where adequate supervision and support will be available to support them in developing and integrating those new skills into their practice. Blanchet and Tataryn[10] have previously reported that "short-term volunteers did not help improve the training, knowledge or clinical practice of local staff. Due to the high turnover rate of volunteers and lack of continuity of practices between the different organisations, there was little uptake of new skills or techniques. Consequently, local staff resorted to what they already knew to avoid confusion between the disparate approaches of transient volunteer teams." Therefore, when staff experienced in major trauma are involved in training, they should be based within Specialised Emergency Medical Teams that spend a longer time in the field to ensure that carry over into practice occurs.[8]

The Minimum Technical Standards and Recommendations for Rehabilitation - Emergency Medical Teams[1] outlines the following recommendations around clinical expertise in emergencies.

  • Recommendations for Optimal Care;
    • Rehabilitation professionals with an arriving team should be experienced in trauma and medical rehabilitation with experience and/or training to work in austere environments.
    • Rehabilitation professionals should comply with the same requirements for practice as in their home country and should work within their scope of practice. [1]

Challenging Environments[edit | edit source]

In large-scale disasters, particularly where there has been significant damage to infrastructure, patients are often treated in a wide variety of settings. It is not unusual to be treating acute patients outside of acute wards, including in hospital corridors, overflow tents in car parks or tents in formal or informal camps. 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 be  adapted, in particular for patients being managed on the floor, and manual handling needs to be  adapted to protect patients, caregivers and staff. [4][11]

Access to Equipment[edit | edit source]

Essential assistive technology, such as wheelchairs, crutches, splints and orthotics are often in short supply during the immediate response and can significantly limit rehabilitation interventions. This lack of assistive technology affects not only those with new injuries, but also those who may have displaced or damaged assistive technology because of the disaster or conflict. This can create bottlenecks in acute centres, result in prolonged bed rest, limit early mobilisation or delay discharge home, which further impacts rehabilitation capacity. [1][4][11]

In many instances, rehabilitation professionals may be involved in the provision of mobility devices, where available, to enable safe discharge. Sometimes, temporary mobility devices are necessary to facilitate smooth, timely discharges. In these situations, the devices should be configured to the user’s needs as closely as possible; meaning it fits them, can be self-propelled (if the person is capable) and can be used in the local terrain. A return policy should be developed where possible to minimise the dumping of devices when they are no longer needed. Where a patient requires an orthotic, prosthetic device or wheelchair long-term, it is important that these devices should be safe, durable, affordable and maintainable in the country of use. It should meet the user’s requirements and environment, with a proper fit, alignment and support that meets sound biomechanical principles. As with any assistive technology, mobility devices should always be provided with appropriate rehabilitation and training. For those who require devices for long-term use, local services should be involved in the prescription so that they can adapt them to the local context and remain available for follow-up, including maintenance and/or replacement. [9][1]

For Emergency Medical Teams, both national and international, the minimum standards for rehabilitation highlight equipment that is essential and non-essential but recommended for initial deployment. However, these standards are minimum and aimed  at field hospitals and so may not always be directly transferable to fixed trauma or rehabilitation facilities.

The Minimum Technical Standards and Recommendations for Rehabilitation - Emergency Medical Teams[1] outlines the following recommendations around assistive technology in emergencies.

  • Minimum Technical Standard;
    • Emergency Medical Teams should bring the essential equipment and consumables for their type of management when they deploy, so that they can be self-sufficient for at least the first 2 weeks of response. Alternatively, they should have a documented agreement with an organisation to provide this equipment rapidly in the event of deployment.
  • Recommendations for Optimal Care;
    • Emergency Medical Teams are encouraged not to expect that equipment will be provided by the host country.
    • Rehabilitation materials should be carefully selected according to the anticipated need, team capacity, local needs and expected case-load.
    • Wheelchairs, orthotics and prosthetics for long-term use should be obtained from a local supplier, where one is available; otherwise, the Emergency Medical Teams should seek guidance from the host Ministry of Health or Coordination Cell.
    • Emergency Medical Teams should maintain an inventory of equipment and consumables and plan for their replenishment on the basis of their case-load and length of stay.[1]

Discharge Planning[edit | edit source]

Coordination of discharge and follow-up care is still one of the greatest challenges in disaster and conflict settings, especially where patients have been transported from remote areas, or displaced as a result of their home being destroyed. Given the surge in patients during the early response, there is often an increased need to move patients out of the acute setting as soon as possible, taking the following into consideration:[4][8]

  1. Discharge Destination
    • It is important to understand where your patients are going on discharge from an acute setting, both in terms of geographic area and accommodation type.
    • Accommodation type might include their own home, home of family or friend, step down facility, rehabilitation facility, or camps for displaced persons with tents or temporary structures.
    • Is the accommodation close to the hospital if follow-up is required, or do they have to travel significant distances? If so, it is important to find options for follow-up care closer to where the patient will be going as the costs and availability of transport may limit their capacity to travel back to the hospital.
    • Challenges patients may face on discharge in emergency settings include sleeping on hard or uneven floors, inaccessible and unsanitary toilet facilities, poor accessibility, poor access to aid distributions, and lack of caregiver support.
    • It may be beneficial to visit discharge settings when safe to do so, particularly for those patients with significant impairment. Having a better understanding of a patient's discharge environment helps rehabilitation professionals to provide appropriate equipment to support a safer discharge and maximise their independence and function.
  2. Early Discharge
    • Given the overwhelming number of patients requiring treatment after disasters and conflicts, inpatient beds are often limited, which results in earlier than expected discharges once a patient is stable post-operatively.
    • This increases pressure on rehabilitation professionals to ensure:
      • They have discharge plans in place
      • Have adequately assessed patients prior to discharge
      • Are maintaining a database including follow-up requirements, so that patients are not lost to follow-up
      • They have made onward referrals
      • They have emphasised patient and caregiver education, to ensure they can manage their injuries and recognise any complications
    • Where possible, establishing rehabilitation criteria and emergency care pathways as part of disaster preparedness, can help to limit the risk that patients will be discharged to an unsafe environment. 
  3. Family and/or Community Support
    • Family and community support may be severely impacted, as those affected by the disaster or conflict may have also lost their own families, friends, homes and livelihoods. It is important to be aware of vulnerable groups, such as children, women, older persons and persons with a disability who may have inadequate support structures and require onward referral to organisations to help with integration back into their communities. Having an understanding of cultural perspective is also important, and can impact the type of support that is available. Personal factors such as coping mechanisms in the face of bereavement or overall behavioural patterns equally need to be taken into consideration to ensure the well-being of patients on discharge back home.
  4. Follow-up
    • Disasters often affect rural and isolated communities, resulting in damage and disruption to transport infrastructure and terrain. This may impact access to medical care, particularly follow-up care and rehabilitation.
    • In conflict situations, it is rare to provide rehabilitation for civilians on the frontline, but rather patients are stabilised and transported to access further care. Length of stay during conflicts is often short because of safety and security concerns. Displacement is also common. All these factors can reduce access to follow-up care and affect continuity of care.
    • Ideally, follow-up should occur in the hospital where treatment was completed, but in emergencies, this is not always possible. Thus, follow-up is often referred out to other services in the community.
    • Uncertainty about services and facilities for long-term rehabilitation is frequent in the early phase following disasters and throughout conflict situations. This often results in delayed access to ongoing rehabilitation following discharge.
    • Safety, security issues and sheer volume of patients can significantly impact community follow-up.
  5. Onward Referral  
    • Rehabilitation professionals play a pivotal role in identifying rehabilitation needs and establishing referral mechanisms and protocols, linking emergency response services with hospital and community-based rehabilitation facilities.
    • To avoid duplication of services, coordination should be completed through existing mechanisms where available, or where not available, may be completed through the Health Cluster or Emergency Medical Team Coordination Cell.
    • Rehabilitation professionals have played a key role in coordination of services in recent sudden onset disasters. [4][8]

Successful rehabilitation is, therefore, intrinsically linked to effective discharge, which allows a patient to function optimally in his/her environment with the necessary tools for proper management and self-care at home, inherent to the quality of life and empowerment of the patient. Discharge planning is an important element in preventing adverse events post-discharge. By involving the patient and family in discharge planning, patient outcomes can be improved and readmissions reduced.

The Minimum Technical Standards and Recommendations for Rehabilitation - Emergency Medical Teams[1] outlines the following recommendations around discharge and referral in emergencies.

  • Recommendations for Optimal Care;
    1. EMTs should plan for discharge and referral from the early stages of care in order to identify service gaps, which should be promptly communicated to the host ministry of health/coordination cell.
    2. To ensure that referrals for rehabilitation are managed effectively, the patient and the referring EMT should both keep a copy of the referral, which should contain the following information, at a minimum;
      • required assistive devices provided;
      • functional status, including mobility and precautions; and
      • requirements for follow-up with the referral team (e g for surgical review, removal of an external fixator or follow-up X-ray).
    3. EMTs should endeavour to discharge patients only when they can safely access their discharge destination (with or without assistance) and when they have adequate support to cope.
    4. Patients who require care after the treating EMT leaves should be referred to another EMT, a step-down facility or a local service provider. EMTs should keep an updated list of all patients who require rehabilitation follow-up after discharge or after the departure of the EMT and communicate the list to the host ministry of health/ coordinating cell as requested. The list should include, at a minimum, the patient’s name, a telephone number (if available), the diagnosis, the discharge destination and the reason for follow-up.
    5. Patients should be referred for follow-up as close to home as possible
    6. EMTs should maximize opportunities to prepare patients, their families and care providers for discharge by education and functional retraining.[1]

Resources[edit | edit source]

Guidelines[edit | edit source]

Field Handbook[edit | edit source]

References [edit | edit source]

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 World Health Organization (WHO). Minimum Technical Standards and Recommendations for Rehabilitation–Emergency Medical Teams. 2016. Available from: [Accessed 26th February 2022]
  2. Howitt AM, Leonard HB. Katrina and the Core Challenges of Disaster Response. Fletcher F. World Aff.. 2006;30:215.
  3. United Nations Office for Disaster Risk Reduction. Terminology. Available from [Accessed 29 Nov 2016]
  4. 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 Lathia C, Skelton P, Clift Z. Early rehabilitation in conflicts and disasters. Handicap International: London, UK. 2020.
  5. Landry MD, Salvador EC, Sheppard PS, Raman SR. Rehabilitation following natural disasters: Three important lessons from the 2015 earthquake in Nepal. Physiotherapy Practice and Research. 2016 Jan 1;37(2):69-72.
  6. Khan F, Amatya B, Rathore FA, Galea M. Medical rehabilitation in natural disasters in the Asia-Pacific region: the way forward. Int J Natural Disaster Health Secur. 2015 Dec 7;2(2):6-12.
  7. Cranmer H, Biddinger P. Typhoon Haiyan and the Professionalization of Disaster Response. N Engl J Med [Internet]. 2014 [cited 2014 Mar 11];1–3. Available from:
  8. 8.0 8.1 8.2 8.3 8.4 World Confederation for Physical Therapy. WCPT report: The role of physical therapists in disaster management. London, UK: WCPT; 2016
  9. 9.0 9.1 World Health Organization (WHO). Classification and Minimum Standards for Emergency Medical Teams. 2021 Available from: [Accessed 25th February 2022]
  10. Tataryn M, Blanchet K. Evaluation of Post-Earthquake Physical Rehabilitation Response in Haiti, 2010 – a systems analysis. 2012.
  11. 11.0 11.1 Maghsoudi A, Moshtari M. Challenges in disaster relief operations: evidence from the 2017 Kermanshah earthquake. Journal of Humanitarian Logistics and Supply Chain Management. 2020 Dec 24.
  12. Early Rehabilitation in Conflicts and Disasters. Cox Bazar - challenging discharge environments. Available from:[last accessed 20/03/22]
  13. Early Rehabilitation in Conflicts and Disasters. Cox Bazar - challenging discharge environments. Available from:[last accessed 20/03/22]