Early Initiation Of Rehabilitation Research Articles

Arthroscopy-Assisted Open Fabella Excision With Medial Meniscus Revision Repair

Background: The fabella is a sesamoid bone that is a normal anatomic variant yet a rare cause of pathology in the posterolateral portion of the knee. The fabella can cause chronic knee pain in patients with knee osteoarthritis and athletes at all levels and in rare cases can cause neuropathy. Initially, treatment for a painful fabella includes conservative measures, with surgical intervention after conservative treatments have failed. This technique describes our arthroscopic-assisted fabella removal technique with a concomitant medial meniscus revision repair. Indications: The goal of treatment is to relieve pain and numbness. Conservative measures (i.e., nonsteroidal anti-inflammatory drugs [NSAIDs], range of motion exercises, heel cord stretching, etc.) are the initial step in treatment. Patients are treated surgically after conservative measures have failed. The surgical approach involves an open incision, arthroscopy, or a combination. Technique Description: With the patient in the supine position, a physical examination is performed under anesthesia to compare to validate clinical findings. An open lateral knee approach helps to locate the fabella which is grasped with an Alice clap. An arthroscopy is performed, and viewing posterolaterally will confirm that the fabella is within the grips of the Alice clamp. After repair of the meniscus, the surgical bed is repositioned to identify the fabella properly. Excision of the fabella is performed sharply from the lateral gastrocnemius tendon, and palpation is demonstrated to ensure complete removal. Caution is essential to avoid complications including damage to nearby anatomic structures, such as the lateral gastrocnemius tendon, and incomplete fabella removal. Results: A clinical study by Dekker et al reported that 80% of patients were able to return to full activities and postoperative patient-reported outcomes improved from preoperative to postoperative. Fabella excision is recommended for patients with fabella pain who do not respond to conservative treatment. Discussion: We describe a technique for removing the fabella with arthroscopic assistance. Patients who have not responded appropriately to conservative treatment for a painful fabella should consider surgical intervention. With the early initiation of rehabilitation, patients will have an increased likelihood of decreased pain, resolution of symptoms, and reduced knee stiffness. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Abstract TMP30: The Impact of Social Influences on Rehabilitation Services Utilization After Stroke

Introduction: Evidence supports that early initiation of rehabilitation is important for patient outcomes after stroke. Thus, determination of patients needing rehabilitation during their acute hospitalization is critical. We assessed the impact of demographic, clinical, and county-level social influences on rate of transfer to a rehabilitation facility after acute stroke hospitalizations. Methods: Using Get with the Guidelines-Stroke registry data and Institute for Health Metrics and Evaluation data, we fitted univariate and multivariate generalized linear mixed models (GLMM) with demographic, clinical, and social variables to determine how social influences of health impacted variances in transfers to rehabilitation facilities. Specific county-level variables assessed were related to education, income, employment, home ownership, and being foreign born. Results: Among 912,488 patients who were assessed or received rehabilitation services due to acute ischemic or intracerebral hemorrhagic stroke, 33.4% of them were transferred to rehabilitation facilities. Multivariate analyses of patient-level demographic and clinical variables achieved an Akaike Information Criterion (AIC) of 925780 (21.0% reduction from the base model) largely driven by clinical factors (mRS at discharge, initial NIHSS, and initial exam findings). When county-level variables related to social influences of health were incorporated, AIC decreased by 23.4% to 871806, indicating a better model fit largely driven by education level. Conclusions: Social influences of health impact transfer to rehabilitation facilities after acute stroke hospitalization. Future studies should focus on individual (versus county-level) metrics of social influences of health and their impact on access to rehabilitation. This information should be used to develop interventions to improve the equity of rehabilitation utilization after stroke.

Comprehensive Rehabilitation After Reconstruction of the Anterior Cruciate Ligament

Introduction: The knee joint is the second most frequently injured joint. Anterior cruciate ligament (ACL) injury is a relatively common injury to the inner part of the knee joint, mainly related to contact sports. Its rupture leads to instability of the entire joint. Two treatment options are possible: operative or conservative. Each of them is related to an appropriate rehabilitation process. The aim of this study was to define a comprehensive rehabilitation plan in patients after ACL rupture and meniscal suturing.Materials and methods: The work was written based on the medical history of the patient who was diagnosed with complete rupture of ACL, and then reconstruction was performed with the harvesting of a semitendinous and slender muscle graft.Results: The rehabilitation process can be divided into two stages: hospital and post-hospital. Rehabilitation in hospital conditions begins on the zero day after arthroscopy. The main goals of rehabilitation include: increasing the range of mobility, no myofascial dysfunctions, no thromboembolic complications, and the ability to self-service.Conclusion: Rehabilitation is an indispensable element of the treatment of patients after ACL reconstruction. Early initiation of rehabilitation brings tangible benefits during treatment and return to full physical fitness.

In the Aftermath of Acute Hospitalization for Traumatic Brain Injury: Factors Associated with the Direct Pathway into Specialized Rehabilitation.

Previous research has demonstrated that early initiation of rehabilitation and direct care pathways improve outcomes for patients with severe traumatic brain injury (TBI). Despite this knowledge, there is a concern that a number of patients are still not included in the direct care pathway. The study aim was to provide an updated overview of discharge to rehabilitation following acute care and identify factors associated with the direct pathway. We analyzed data from the Oslo TBI Registry—Neurosurgery over a five-year period (2015–2019) and included 1724 adults with intracranial injuries. We described the patient population and applied multivariable logistic regression to investigate factors associated with the probability of entering the direct pathway. In total, 289 patients followed the direct pathway. For patients with moderate–severe TBI, the proportion increased from 22% to 35% during the study period. Significant predictors were younger age, low preinjury comorbidities, moderate–severe TBI and disability due to TBI at the time of discharge. In patients aged 18–29 years, 53% followed the direct pathway, in contrast to 10% of patients aged 65–79 years (moderate–severe TBI). This study highlights the need for further emphasis on entering the direct pathway to rehabilitation, particularly for patients aged >64 years.

Effects of Cyanoacrylate in Rabbits with Induced Achilles Tendon Rupture.

BackgroundIn this study, we aimed to investigate the effects of N-butyl-2-cyanoacrylate (cyanoacrylate) on the biomechanical and histopathological aspects of tendon healing in a rabbit model of Achilles tendon injury.Material/MethodsIn total, 36 rabbits were randomized to experimental (cyanoacrylate) and control groups (n=36 tendons in each group). A simple suture was used in the control group and a simple suture plus cyanoacrylate was used in the experimental group.Nine rabbits from each group were euthanized at week 4 and week 6 after surgery for histopathological and biomechanical testing.ResultsGranulation tissue formation was significantly greater in the experimental group in week 4 and week 6 than in the control group. Foreign body giant cell formation was significantly higher in the experimental group in week 4 and week 6. The maximum rupture force was significantly higher in the experimental group in week 4 and week 6 than in the control group. Elasticity and stiffness were comparable between groups in week 4; however, stiffness, but not elasticity, was significantly higher in the experimental group in week 6.ConclusionsIn the short term, cyanoacrylate enhanced tendon endurance in both a histopathological and biomechanical manner. We conclude that the early initiation of rehabilitation in patients may be safe in cases of cyanoacrylate use for surgical repair of tendon injury.

Correlation of Magnetic Resonance Imaging and Magnetic Resonance Spectroscopy of Basal Ganglia with APGAR Score in Perinatal Asphyxia: A Cross-sectional Study

Introduction: Birth asphyxia is leading cause of perinatal and neonatal mortality and morbidity especially in developing countries. Around 20% of neonatal deaths in India are due to birth asphyxia. There are around one million cases of birth asphyxia per year worldwide. Majority of deaths and disabilities can be prevented by timely identification of pathologies and early initiation of rehabilitation. Magnetic Resonance Imaging (MRI) and Magnetic Resonance Spectroscopy (MRS) plays a vital role by helping in identification of such pathologies. Aim: To assess the severity of injury to brain in hypoxic ischaemic encephalopathy infants using MRI and MRS which helps in prognosticating the disease outcome. Materials and Methods: A cross-sectional study was conducted on 30 term infants with low Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) score in the Department of Radiodiagnosis, from all the Hospitals attached to Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India from November 2018 to May 2020. Patients were subjected to brain MRI and basal ganglia MRS. All MR imaging examinations were performed on a SIEMENS magneto Avanto 1.5 Tesla system. Conventional MR imaging findings were documented and MR spectroscopy values of Basal Ganglia (BG) N-Acetyl Aspartate (NAA), Creatinine (Cr), Choline (Cho) and lactate were obtained. Metabolite levels were correlated with APGAR scores by performing Pearson correlation. Chi-square test was applied with Fisher’s-exact correction to see the association between lactate peak and diffusion changes in brain. Results: A total of 30 term neonates with low APGAR score at birth were selected, of which 12 were females and 18 were males. Babies with APGAR score of 2 at one minute showed only subcortical and parasagittal areas of diffusion restriction. Basal ganglia diffusion restriction is noted only in babies with very low APGAR score of 1 at one minute. Positive correlation was noted between APGAR score and BG-NAA and BG-Cr. Negative correlation was noted between BG-Cho and APGAR score. Hence, BG-NAA:Cr, NAA:Cho and Cho:Cr can be used to assess severity of hypoxic ischaemic encephalopathy (p-value <0.001). Conclusion: Basal ganglia is a sensitive region in defining asphyxia related metabolite abnormalities. Involvement of basal ganglia and thalamus indicates severe asphyxia. BG metabolite levels may alter even in the absence of brain changes on MR imaging. Presence of lactate peak indicates severe asphyxia. Thus, MRS helps in early diagnosis of birth asphyxia, grading of its severity and prognostication.

Keratoconus: a potential risk factor for osteoarthritis

This study was undertaken to compare the distal femoral cartilage thickness in patients with keratoconus (KC) with that of age- and sex-matched healthy controls, in order to identify a potential risk factor for early osteoarthritis in patients with KC and to allow initiation of early rehabilitation. Thirty-six KC patients between 18 and 35 years of age and 36 healthy controls were included in this study. Keratometry readings (K1, K2), central corneal thickness (CCT), anterior chamber depth (ACD), iridocorneal angle (ICA), and corneal volumes (CV) were measured using a Sirius imaging system (Costruzioni Strumenti Oftalmici, Italy). Also, the distal femoral cartilage thickness (DFCT) was assessed bilaterally using ultrasound by the same physiatrist. Lateral femoral condyle (LFC), intercondylar area (ICA), medial femoral condyle (MFC), and body mass index (BMI) values were recorded. Patient and control groups were comparable in terms of age, gender, and BMI. On the other hand, patients with KC had a significant reduction in right LFC, MFC thickness and left ICA, MFC as compared to controls (p < 0.05). In the corneal topographic evaluation of the groups, it was observed that K1, K2, CCT, and ACD values differed significantly. Detection of thinner DFCT in KC patients suggests that these patients may be future candidates of osteoarthritis.

The Best Time to Start Stroke Rehabilitation: A Review of the Evidence in ResourceAdequate and Resource Constrained Settings

Background: Stroke is a global health problem and one of the major causes of death, disability and impairment among adults worldwide. Post-stroke outcomes vary widely, between and within world regions depending on a range of factors including demographic profile, stroke type, severity and immediate and long-term post stroke care. It has been reported that early initiation of rehabilitation following stroke promotes better long-term outcomes than delayed rehabilitation, although this has been disputed by some researchers in the AVERT (A very early rehabilitation trial) study. Purpose of Review: To evaluate the best time to start stroke rehabilitation with good outcomes Results of the Review: There is limited evidence to show that later rehabilitation is better than early rehabilitation. It also remains unclear whether early mobilization is more effective than mobilization at a later stage, due to insufficient statistical power of the studies that have examined this practice because clinicians around the world are practicing this model to this day. Furthermore, some trial limitations of the AVERT study in line with the uncertainty of the external validity of the results, make generalizability something to be concerned about. Conclusion: The best time to start stroke rehabilitation is as soon as the patient is clinically stable i.e; as early as possible. The results of the poor outcomes of the AVERT study in providing evidence of the impact of early stroke rehabilitation, should not be interpreted as proof of the ineffectiveness of early physical rehabilitation. Every stroke is different from one person to another because the impact of the damage to the brain is associated with the different functions of several parts of the brain making generalizability quite difficult. Therefore, in the absence of provision of high quality evidence, clinicians like physiotherapists should base their decisions on clinical experience, individual circumstances and patient preferences as appropriate. It is extremely important to develop evidence-based practice protocols that can guide clinical practice on the best time to start stroke rehabilitation and also enhancing plasticity and reducing the negative impact of stroke through pharmacotherapy, especially for

Postoperative analgesia with the use of peripheral nerve block of the foot and ankle

Category: Basic Sciences/Biologics Introduction/Purpose: Peripheral nerve block in the foot and ankle is usually used for anesthesia in forefoot and midfoot surgeries. However, since the postoperative analgesia obtained is prolonged, we can expand its use, as an adjuvant after the end of the spinal or general anesthesia. The aim of this study was to evaluate the use of peripheral nerve block of the foot and ankle as a method of postoperative analgesia. Methods: A prospective, randomized, blinding study was performed. The study group included 30 patients (32 feet) submitted to peripheral anesthetic block after surgery with spinal anesthesia and the control group (30 patients, 31 feet) were patients not submitted to nerve block. The inclusion criterion was: patients submitted to foot and ankle surgery at our institution. Patients answered the questionnaire postoperatively, with the measurement of pain intensity by the Visual Analog Scale (VAS) and the time of onset of pain. All local peripheral block was performed by the same orthopedic team with 20 mL of Ropivacaine at a concentration of 7.5 mg / mL (0.75%). Results: The mean patient age was 52,5 years, and the majority of patients were women (66%). The results showed a statistically significant difference between the control group and the study group, with a longer time of postoperative analgesia (p &lt;0.001) and lower pain intensity in the immediate postoperative period (p &lt;0.001) in patients submitted to blockade anesthetic. There was no statistical difference between the two groups regarding pain intensity on the first and second postoperative day. Conclusion: In the study group, the mean postoperative pain (six hours after surgery) was lower when compared to the control group, with statistical significance. This result showed that the ankle block helped to control pain, in a safe and effective mode. The use of ropivacaine presents a sensitive block similar to bupivacaine, but with shorter motor block, allowing early initiation of rehabilitation. The study demonstrated that peripheral nerve block in the foot and ankle region can be used effectively in postoperative analgesia, reducing pain intensity in the immediate postoperative period and also prolonging analgesia and thus maximizing physiotherapy postoperative period.

Health care for patients with stroke - a challenge for rehabilitation at home environment

The process of rehabilitation in patients who have experienced stroke is complex and lengthy and needs to begin immediately after the incident. The procedures are to be carried out systematically and continuously over time to achieve the desired results. Moreover, the rehabilitation of stroke patients typically requires compiling specific and highly individualized program for each of teamwork and cooperation efforts of all medical and non-medical professionals. On the other hand, early initiation of rehabilitation and its duration and consistency of clinical, ambulatory and home conditions is particularly important to reduce disability that inevitably accompanies patients whose rehabilitation is not conducted with the required duration. The conditions offered by the NHIF, however are primarily focused on the recovery of patients in a hospital environment. The need to cover the existing deficit of rehabilitative care reveals untapped opportunities to create a center for rehabilitation care provided at home. The disclosure of the limitations that puts the health system for patients who have experienced stroke and the creation of mechanisms to overcome them ensures good health and social policies. The expected benefits of development and expansion of this type of personalized health care aimed at recovery of locomotor activity of this vulnerable population group are associated with improved quality of life and early social inclusion.

Improving practice with integration of patient directed activity during inpatient rehabilitation

Background: Early initiation of rehabilitation following stroke promotes better long-term outcomes than delayed onset, emphasizing the importance of inpatient therapy. However, literature indicates that following stroke individuals in inpatient rehabilitation spend the majority of their day in their bedroom and inactive. Consequently, since amount of functional activity is posited to relate to outcomes, the current rehabilitation model needs to be challenged with innovative solutions to maximize recovery. Rationale: In an attempt to promote greater activity and higher doses of therapy during inpatient rehabilitation, we implemented the “Patient Directed Activity Program” to facilitate specific movement and improve outcomes for patients post stroke. Our interdisciplinary activity program was conceptualized on a theoretical model for stroke recovery and principles of experience-dependent neural plasticity. Main features: The “Patient Directed Activity Program” includes distinct activity stations designed to increase repetition, stimulation, attention, and activity of the affected upper extremities, lower extremities, and trunk. Each task-specific activity was easily graded to achieve moderate- to high-intensity. The activity program prescribed individuals up to three additional 30-minute bouts of activities daily that were to be completed independently, and in addition to standard of care. Clinical application: After implementing this program in our facility for one year as a quality improvement project, the intervention has been delivered as an Institutional Review Board approved randomized controlled trial (Clinical Trial #NCT02446197). Challenges with people and facilities have been overcome, resulting in a feasible program that can be delivered in an inpatient setting. High satisfaction has been reported by patients and clinicians.

A clinical perspective of sepsis-associated delirium.

The term sepsis-associated encephalopathy (SAE) has been applied to animal models, postmortem studies in patients, and severe cases of sepsis. SAE is considered to include all types of brain dysfunction, including delirium, coma, seizure, and focal neurological signs. Clinical data for sepsis-associated delirium (SAD) have been accumulating since the establishment of definitions of coma or delirium and the introduction of validated screening tools. Some preliminary studies have examined the etiology of SAD. Neuroinflammation, abnormal cerebral perfusion, and neurotransmitter imbalances are the main mechanisms underlying the development of SAD. However, there are still no specific diagnostic blood, electrophysiological, or imaging tests or treatments specific for SAD. The duration of delirium in intensive care patients is associated with long-term functional disability and cognitive impairment, although this syndrome usually reverses after the successful treatment of sepsis. Once the respiratory and hemodynamic states are stabilized, patients with severe sepsis or septic shock should receive rehabilitation as soon as possible because early initiation of rehabilitation can reduce the duration of delirium. We expect to see further pathophysiological data and the development of novel treatments for SAD now that reliable and consistent definitions of SAD have been established.

Rehabilitation following rotator cuff repair: a systematic review.

The aim of this systematic review was to evaluate the effectiveness of rehabilitation programmes following surgical repair of the rotator cuff with emphasis upon length of immobilisation and timing of introduction of load. An electronic search of CENTRAL, MEDLINE and PEDro was undertaken to August 2014 and supplemented by hand searching. Randomised controlled trials were included, quality appraised using the PEDro scale and synthesised via meta-analysis or narrative synthesis, based upon levels of evidence, where appropriate. Twelve studies were included. There is strong evidence that early initiation of rehabilitation does not adversely affect clinical outcome but there is a marginally higher, statistically non-significant, incidence of tendon re-tear (OR 1.3; 95% CI 0.72 to 2.2). There is strong evidence that initiation of functional loading early in the rehabilitation programme does not adversely affect clinical outcome. Concern about early initiation of rehabilitation and introduction of gradual functional load does not appear warranted but this should be considered in a context of potential for Type II error. There is further need to evaluate approaches that foster early initiation of rehabilitation and gradual introduction of functional load as well as considering key outcomes such as return to work.

Association between Very Early Initiation of Rehabilitation and Rehabilitation Provision System for Stroke Patients: Analysis According to Day of Admission

Association between Very Early Initiation of Rehabilitation and Rehabilitation Provision System for Stroke Patients: Analysis According to Day of Admission

Association between Very Early Initiation of Rehabilitation and Rehabilitation Provision System for Stroke Patients : Analysis According to Day of Admission

Association between Very Early Initiation of Rehabilitation and Rehabilitation Provision System for Stroke Patients : Analysis According to Day of Admission

Effects of prolonged robot-assisted training on upper limb motor recovery in subacute stroke

High intensity and early initiation of rehabilitation have been extensively demonstrated to enhance neural plasticity and motor recovery after stroke. However, the optimal duration of rehabilitation programs in order to have the highest impact on motor outcomes has not been established. To evaluate motor outcomes in subacute stroke survivors with moderate to severe upper limb paresis over an extended period of rehabilitation consisting of usual care augmented with a large number of upper limb robot-assisted sessions (54 ± 13 sessions). Retrospective study in 10 inpatients. The results showed a gradual decrease in motor and functional impairments throughout the training period with a clinically meaningful increase in the Fugl-Meyer Assessment scores and in the Motor Status Scores (1st vs 37th day of the training, FMA,+ 48%, p = 0.018, MSS,+ 64%, p = 0.012; 37th vs. 79th day, FMA,+ 23%, p = 0.012, MSS,+ 30%, p = 0.017). In addition, there were improvements in hand kinematics recorded by the robot during a pointing task, with quantitative improvement (1st vs 40th day, movement efficacy,+ 97%, p = 0.0499; hand velocity,+ 335%, p = 0.013) prior to qualitative improvement (1st vs 80th day, number of hand trajectory reversals, -50%, p = 0.028; root mean square error of the trajectory/linear displacement, -52%, p = 0.059). Although this study was a retrospective analysis of a small sample of patients, the results suggested that a prolonged period of intensive upper limb rehabilitation, including robot-assisted training incorporated into a multidisciplinary program throughout the subacute phase after stroke resulted in significant improvements in patients with moderate to severe motor impairments.

Physiotherapy led early rehabilitation of the patient with critical illness

Background: Studies revealing the effectiveness of physical rehabilitation techniques provided during a critical care admission have been hampered by experimental control issues and ethical constraints. However, because of worldwide variations in physiotherapy practice, differences in patient outcomes can be investigated when physical rehabilitation is provided immediately upon critical care admission compared to rehabilitation initiated after extubation, after withdrawal of mechanical ventilation, after discharge from the acute environment or not at all.Objectives: The purpose of this review is to examine reports describing the effects of physical rehabilitation which is commenced immediately on critical care admission compared to rehabilitation which is delayed.Major findings: Overall, early initiation of rehabilitation reveals an increased incidence of physiotherapy consultation, decreased time to achieve activity milestones, improved functional outcomes at intensive care unit and hospital discharge and reduced direct patient costs. Where early rehabilitation is already a key component of care for critically ill patients, research has concentrated on determining the acute physiological effects of interventions, or the impact of providing additional specific therapies to overall functional and administrative outcomes.Conclusions: Early physiotherapy led rehabilitation of the critically ill patient has the potential to dramatically influence recovery and functional outcomes in this vulnerable patient group.

Rehabilitation of the injured child

Several recent surveys have highlighted the significant risks of disability experienced by injured children.1 While the distinction is inadequately captured in most databases, disability results from the interaction between the injured child and their environment, and encompasses impairments in body functions and structures as well as limitations in activities and participation.2 The major impact on the lives of injured children is typically compounded by the adverse psychosocial and financial consequences for their families.3 The “injury poverty trap” is an inevitable outcome for many low-income households.1 Rehabilitation is a process designed to assist the injured child, who is experiencing or likely to experience disability, to achieve and maintain optimal functioning in interaction with their environment. By addressing evolving needs and building on the strengths and resources of the child and their family, early initiation of rehabilitation can reduce acute health care costs and prevent disability.2 In addition to the goals of trauma rehabilitation programmes in general (e.g. facilitating recovery of pre-injury health), child-oriented programmes must also actively consider: the physical and psychosocial developmental needs of children, increasing levels of autonomy with regard to care and decision-making as they transition through adolescence; as well as their relationships with families, peers, schools and vocational settings. For many injured children living with disabilities, assistive devices (e.g. crutches, wheelchairs, prostheses and computer aids) can play a vital role enabling mobility, education and social engagement.4 Adequate provision of assistive devices usually requires trained professionals such as prosthetic and orthotic technicians, occupational therapists and physical therapists. However, a wheelchair cannot facilitate access to an inaccessible school. Changes are also required in the child’s environment if they are to use technologies effectively (e.g. availability of ramps and accessible toilets). The 2008 Convention on the Rights of Persons with Disabilities is the first legally binding treaty that reaffirms that all persons with all types of disabilities must enjoy all human rights and fundamental freedoms.5 The Convention underscores the need for interdisciplinary collaborative efforts at local, national and global levels to enhance the quality of life of children with disabilities, promote their rights and protect their dignity. It is estimated, however, that only 3% of individuals who need rehabilitation, globally, receive any kind of support,6 the reasons for this include inadequate primary care, a lack of trained personnel, prohibitive costs, limited availability of transport and difficulties in accessing health-related rehabilitation. A study undertaken in Ghana, India, Mexico and Viet Nam found that human resources for rehabilitation were less-developed than for acute care, with specialized services such as speech pathology virtually absent while physiotherapy services were more likely to be available.7 Donated or mass-produced assistive devices can pose particular difficulties as they are often not child-sized, customized or provided with appropriate support services. Rehabilitation services for children may be funded through a variety of sources including government budgets, health and social insurance, external funding, private sources, including nongovernmental arrangements, and out-of-pocket payments. Of the 114 countries providing data to the global survey on government action in 2005,8 only 73 countries (64%) allocated budgets for rehabilitation services. In 66 (58%) of countries surveyed, no government funding was allocated to make the physical environment accessible to persons with disabilities, and 43 countries (38%) provided no support for children with disabilities with regard to assistive devices and support services. In a representative national survey in India, two-thirds of recipients of assistive devices paid for their devices themselves.9 Third payer and insurance schemes in high-income countries can also influence the type, amount and extent of rehabilitation services for injured children.3 In the context of these constraints and unmet needs, some promising strategies designed to maximize the availability and outreach of rehabilitation services have emerged. These include more flexible and community-based services (e.g. home and school-based programmes), and training of primary health care workers, family members or community rehabilitation workers in core elements of rehabilitation. Community-based rehabilitation aims to utilize resources available in the prevailing social context while motivating communities to work with persons with disabilities to identify and remove barriers to participation and inclusion.10 Rehabilitation professionals in several south east European countries are collaborating with associations of persons with disabilities to develop alternative rehabilitation services based on holistic and individualized approaches.11 WHO is currently implementing its Disability and rehabilitation action plan 2006–2011, which provides the impetus to bring about change in key areas including strengthening community-based and medical rehabilitation (and access to it), improving data collection and supporting policy development in accordance with the principles of the Convention on the Rights of Persons with Disabilities.12 While much remains to be learned about the effectiveness of these approaches, they signal the potential to actualize the full and meaningful participation of young people who experience disability following an injury. ■

Treatment of Complex Below-the-Elbow Gunshot Wounds

Firearm injuries, many of which involve the hand, wrist, or forearm, pose a serious public health concern in the United States in both medical and economic terms. Despite the preponderance of low-velocity weapons, complex below-the-elbow gunshot injuries are commonly seen. A successful approach to these patients requires efficient treatment and early initiation of rehabilitation. Unfortunately, this goal is often not met because of multiple factors including wound infections, the need to coordinate multiple surgical specialties, long hospital stays, and delayed definitive reconstruction. At our institution, the plastic surgery hand service is able to treat all aspects of below-the-elbow trauma. A protocol of early aggressive debridement and skeletal stabilization, with definitive reconstruction within 1 week of injury, is used. We retrospectively reviewed all complex below-the-elbow gunshot injuries treated by the senior author between 1996 and 2003. Eighteen such patients were identified. All limbs were salvaged and all patients regained functional use of the extremity. There was no incidence of wound infection. The average length of inpatient stay was 8.9 days (median, 7 days). The use of this protocol by a single surgical specialty allows efficient reconstruction, short hospital stays, and early initiation of rehabilitation.

Treatment of Complex Below-the-Elbow Gunshot Wounds

Firearm injuries, many of which involve the hand, wrist, or forearm, pose a serious public health concern in the United States in both medical and economic terms. Despite the preponderance of low-velocity weapons, complex below-the-elbow gunshot injuries are commonly seen. A successful approach to these patients requires efficient treatment and early initiation of rehabilitation. Unfortunately, this goal is often not met because of multiple factors including wound infections, the need to coordinate multiple surgical specialties, long hospital stays, and delayed definitive reconstruction. At our institution, the plastic surgery hand service is able to treat all aspects of below-the-elbow trauma. A protocol of early aggressive debridement and skeletal stabilization, with definitive reconstruction within 1 week of injury, is used. We retrospectively reviewed all complex below-the-elbow gunshot injuries treated by the senior author between 1996 and 2003. Eighteen such patients were identified. All limbs were salvaged and all patients regained functional use of the extremity. There was no incidence of wound infection. The average length of inpatient stay was 8.9 days (median, 7 days). The use of this protocol by a single surgical specialty allows efficient reconstruction, short hospital stays, and early initiation of rehabilitation.