There is no universally accepted definition of QOL. Socrates stated in an Athenian court that he feared some things more than death, and that it was not merely life itself but the QOL that counted most (Eales et al., 2004). The World Health Organisation (WHO) described QOL as ‘an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns’ (WHO QOL Group, 1995). The WHO went further and described health-related QOL to be ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ (WHO QOL Group, 1997).

People worldwide who have survived an episode of critical illness, sepsis or multiple organ dysfunction syndrome or even acute respiratory distress syndrome (ARDS) have reported limitations in physical components of health-related QOL in the early months (three to six months) following discharge from hospital (Herridge et al., 2003; Wehler et al., 2003; Granja et al., 2004; Cuthbertson et al., 2005; Hofhuis et al., 2008). A slow improvement in the physical aspects of health-related QOL has been reported during the course of the 12 months following discharge (Herridge et al., 2003; Cuthbertson et al., 2005); however, these limitations may persist for a period of two to five years after hospital discharge (Heyland et al., 2000; Jagodic et al., 2006; Cuthbertson et al., 2010; Herridge et al., 2011).

Compared with individuals who never suffered critical illness, the physical function-related aspects of QOL for critical care survivors remain below the norms reported in various countries at all time points at which health-related QOL was assessed (Heyland et al., 2000; Dowdy et al., 2005; Hofhuis et al., 2008; Cuthbertson et al., 2010). Critical illness leads to a sharp decline in all aspects of health-related QOL when measured on admission to the ICU; however, there is an improvement in reported health-related QOL that already starts at discharge from the ICU and continues after discharge from the hospital (Hofhuis et al., 2008). Hofhuis et al. (2008) emphasised that rehabilitation should start early in the ICU and be continued even after hospital discharge. The long-term negative impact that critical illness has on physical function, as mentioned previously, should be managed along the same lines as other chronic medical conditions; in other words, with rehabilitation that continues long after discharge from the hospital setting.

Limitations in the mental health aspects of health-related QOL after critical illness occur in the first few months after discharge from the ICU but tend to recover to levels comparable with that reported for healthy populations by six months after discharge (Herridge et al., 2003; Cuthbertson et al., 2005, 2010; Hofhuis et al., 2008). Some speculate that the unexpectedly good levels of mental health reported by ICU survivors might be attributed to a mental ‘high’ as subjects feel that they managed to ‘cheat’ death (Cuthbertson et al., 2005; Livingston et al., 2009). Other authors, however, have reported that mental health aspects of health-related QOL for their patients had remained low when compared to general population norms even up to 16 months after discharge (Heyland et al., 2000; Dowdy et al., 2005). Factors such as an inability to work after critical illness, posttraumatic stress disorder (PTSD), cognitive dysfunction and depression can contribute to a decreased level of mental health-related QOL (Wunsch and Angus, 2010).

Traumatic events or injury may give rise to the development of emotional illnesses such as PTSD. People who suffer from this disorder re-experience the traumatic event or injury, tend to avoid people or things that remind them of the event and are very sensitive to normal life experiences. These people suffer from avoidance and hyperarousal behavioural patterns. The prevalence of PTSD in the general ICU population has always been thought to be low, but recently new evidence has come to light that PTSD prevalence could be as high as 19–22% and that symptoms persist over time (Davydow et al., 2008). Risk factors for the development of PTSD after critical illness include pre-ICU psychopathology, high dosages of benzodiazepine sedative medication and post-ICU memories of in-ICU frightening or psychotic experiences (Davydow et al., 2008; Hough and Herridge, 2012). Other general risk factors for the development of PTSD in survivors of critical illness include female gender and younger age (Davydow et al., 2008; Hough and Herridge, 2012).

Survivors of blunt or penetrating trauma in Sweden had lower health-related QOL in all domains of physical function compared to an age- and sex-matched group from the general Swedish population even at five years after the traumatic event (Sluys et al., 2005). Older age, number of inhospital complications, number of surgical procedures performed and prolonged ICU and hospital stay were associated with the observed decrease in health-related QOL. Those subjects who were in full employment or had part-time work five years after the event had a higher level of health-related QOL than those who were still on sick leave or who received a disability grant. A sense of abandonment after discharge from the hospital, as reported by some subjects, was found to have a negative impact on their health-related QOL. Inadequate pain management in the ICU or surgical ward was also associated with a reduction in health-related QOL at five years after discharge. Interestingly, the authors reported that blunt trauma led to a lower health-related QOL related to physical function and that penetrating trauma led to a lower health-related QOL related to mental health (Sluys et al., 2005).

The reader is referred to the discussion in the multiple orthopaedic trauma section.

Anzarut et al. (2005) assessed QOL in survivors of severe burn injuries (more than 50% total body surface area) in Canada. They found that the strongest independent predictors of physical components of QOL were the total amount of full-thickness burn injury and hand function. Hand burn injury that was severe enough to necessitate grafting lead to significant reductions in reported physical component summary (PCS) scores on the SF-36.

The physiological changes to the lung which occur as a result of inhalation burns do not result in long-term pulmonary dysfunction in the majority of burn survivors; however, cases of compromised lung function, decreased aerobic capacity and reduced participation in leisure-related physical activity have been documented up to five years after inhalation injury (Willis et al., 2011).

These poor long-term outcomes of burn survivors should be an impetus for the development of more integrated rehabilitation approaches (Esselman et al., 2006). Early data suggests that targeted exercise prescription can improve outcomes in the burn-injured population (Al-Mousawi et al., 2010; Grisbrook et al., 2012; Tan et al., 2012). An individualised rehabilitation programme which focuses on strength and endurance training should be available for all burn survivors (Celis et al., 2003). Such a programme should start in hospital but should also be offered after hospital discharge.

Another study by Weedon and Potterton (2011) set out to establish QOL in children aged two to 12 years with burn injury one week and three months after discharge from a hospital in South Africa using the PedsQL. They reported that overall QOL was 10% short of ‘optimal’, as reported from developed countries, at three months. The largest improvements were seen in physical aspects of health-related QOL as the children became more active as their wounds healed. They postulated that the speedy improvement in QOL observed could be attributed to the fact that young children have a faster rate of recovery from injury than adults. They also acknowledged that if QOL is assessed over a longer time period after discharge, a reduction in scores might be observed, as burn survivors are at an increased risk of developing long-term complications (Weedon and Potterton, 2011).

Patients who suffered multiple fractures or fractures sustained due to high-energy transfer present with prolonged disability, which has a negative impact on return to work after discharge (Livingston et al., 2009). Reasons put forward for these findings include a longer ICU stay with the risk of numerous complications due to the severity of injury, which would contribute to significant loss of muscle mass and subsequently result in poor QOL related to physical function (Livingston et al., 2009). Lower extremity fractures are reported to negatively impact physical function-related QOL in the first six months after hospital discharge; more so than injury to other body regions (except the spine) (Aitken et al., 2012).

Patients who sustained pelvis or isolated acetabular fractures as a result of trauma suffer from pain years after the event. Gerbershagen et al. (2010) showed that 64% of patients reported high-intensity posttraumatic pelvic pain when surveyed four years after the incident. Those who sustained type B or C pelvic fractures or isolated acetabular fractures reported higher pain intensity than those who sustained type A pelvic fractures. As a result, physical function-related QOL was very low in those with high pain intensity (Gerbershagen et al., 2010).

Adolescents who suffered major trauma were assessed for QOL at various time points over the first two years after discharge. They showed progressive improvement in QOL but, compared to normative population-based data, their QOL scores remained well below the norm at all time points of assessment (Holbrook et al., 2007). Older adolescents reported lower QOL compared to younger adolescents up to two years after suffering major traumatic injury. A possible explanation offered by the authors is that older children’s responses to injury mature into adult responses to injury, hence the lower reported QOL (Holbrook et al., 2007). Injury to multiple body regions is associated with deficits in health-related QOL for adolescents up to two years after the incident (Holbrook et al., 2007).

Spinal cord injury (SCI) leads to severe physical disability and people with SCI and neurological deficit may develop secondary complications (e.g. bladder and bowel dysfunction, chronic pain or depression) that significantly impact their already lowered sense of life satisfaction and well-being (Van Koppenhagen et al., 2008; Wijesuriya et al., 2012). Quality of life research shows that people with SCI and neurological deficit have significantly lower levels of QOL compared to healthy controls or normative population data (Middleton et al., 2007; Boakye et al., 2012; Schouten et al., 2013). Domains of QOL, as measured with the SF-36, that seem to be more severely affected by SCI are those related to PF, RP and bodily pain (Middleton et al., 2007; Boakye et al., 2012). As can be expected, people with tetraplegia seem to have reduced QOL related to PF and bodily pain compared to those with paraplegia (Middleton et al., 2007; Boakye et al., 2012).

Those with SCI without neurological deficit report a QOL that is similar to that of normative population data and have a high rate of return to work (Schouten et al., 2013).

There is a dearth of information on the effect of SCI on physical function-related QOL in the paediatric population. The only report found showed that youth with paraplegia participated in more activities more frequently than youth with tetraplegia (Riordan et al., 2013).

As can be expected, health-related QOL of patients who suffered moderate to severe TBI is reported to be significantly affected when compared to that reported by a healthy population (Hawthorne et al., 2009; Arango-Lasprilla et al., 2012; Hu et al., 2012). Various domains of physical function-related QOL (RP, bodily pain and GH) seem to be affected by TBI (Hawthorne et al., 2009; Arango-Lasprilla et al., 2012). Elevated levels of fatigue and decreased vitality are complaints often reported by people with TBI (Wijesuriya et al., 2012). Two years after the traumatic event, patients diagnosed with severe TBI still exhibited significantly lower scores for PCS as measured with the SF-36 than those diagnosed with moderate TBI (Hu et al., 2012).

Functional ability of children aged between six and 14 years who suffered TBI is negatively influenced by the severity of injury (Anderson et al., 2012). These authors also found that the child’s pre-injury functional level was a greater predictor of post-injury functional ability than the severity of TBI.

Intensive care unit delirium has been reported in a small percentage of trauma survivors (up to 75% of general ICU survivors have reported delusional memories) who were assessed six to 18 months after discharge from the ICU (Ringdal et al., 2009). Delirium is characterised by cerebral dysfunction that can develop due to electrolyte abnormalities, sepsis, fever, shock, certain medications (benzodiazepines, opiates or anticholenergics), infection, hypertension or anemia (Cavallazzi et al., 2012). Symptoms of delirium that subjects might exhibit include hallucinations, dreams, nightmares experienced in the ICU or the incorrect perception that ICU staff are trying to hurt them. It seems to be more common in younger patients who have a prolonged ICU stay, and hence longer periods of MV, higher injury severity and greater morbidity, than other trauma sufferers. These patients reported poor health-related QOL and higher levels of anxiety and signs of depression than trauma patients who had no delusional memories (Ringdal et al., 2009).

Limitations in mental health-related QOL that various groups of trauma survivors experience in the short and long term after discharge from the acute care setting are discussed below.

Mental health-related QOL of survivors of penetrating trunk trauma who received prolonged MV was similar to that of a healthy group and the group who received a short period of MV at six months after discharge (Van Aswegen et al., 2011). The majority of these subjects were male and reported that they were grateful to be alive, which might have contributed to the higher than expected scores. Fu et al. (2011) reported that female survivors of blunt trauma reported lower levels of mental health-related QOL than male survivors and that subjects with head injuries had lower levels of mental health than other blunt trauma survivors.

Anzarut et al. (2005) reported that age at the time of injury and the level of social support that survivors had at home after discharge from the burn centre were the strongest independent predictors of mental health component summary (MCS) scores on the SF-36. The younger the survivor, the higher their reported MH score on the SF-36 questionnaire. Interestingly, these authors found no association between facial burns requiring grafting and QOL; however, the majority of their study population was male and their results might have been different if more females participated in the study (Anzarut et al., 2005).

Not all patients who suffer SCI present with limitations in QOL due to MH or RE problems. There does seem to be a smaller group of SCI sufferers who are at increased risk of developing psychological disease following the injury. These people may suffer from lowered QOL due to MH, RE and SF limitations (Middleton et al., 2007; Wijesuriya et al., 2012). Women seem to experience lower levels of QOL after traumatic SCI than men (Middleton et al., 2007). A possible explanation for this finding is that men are more frequently involved in trauma and thus the unbalanced gender sample sizes of QOL research studies could contribute to this unusual finding (Middleton et al., 2007). A person with SCI who has a strong sense of self-efficacy (belief that they can do a particular task successfully in the future) is likely to have a better level of QOL compared to someone with a low sense of self-efficacy (Middleton et al., 2007).

Children with SCI are at a higher risk for developing depression or anxiety disorders than those without SCI. Those who develop depression or anxiety disorders have lower levels of QOL in the long term following SCI (Garma et al., 2011). Children with SCI under the age of 18 years old report significantly lower levels of QOL one year after the injury, compared with QOL reported by a healthy group without SCI (Garma et al., 2011). One year after SCI the reported mental health-related QOL of children with tetraplegia and those with paraplegia is not significantly different. This suggests that the level of SCI does not directly influence QOL in children in the long term (Oladeji et al., 2007).

Psychiatric disorders tend to develop in up to a third of patients after severe TBI and affects these patients’ QOL (Diaz et al., 2012). These authors observed the development of psychiatric disorders in patients after severe TBI over an 18-month period. Major depressive disorder, anxiety disorder and personality changes were reported to develop in a third of the study population. Patients with severe TBI and personality changes had a significant decline in general health, as well as impairments in PF and SF domains, compared to those with TBI without personality changes (Diaz et al., 2012). Subjects with severe TBI and depression had significantly lower health-related QOL in all domains of the SF-36 over the 18-month period compared to those with TBI without depression (Diaz et al., 2012).

The severity of TBI continues to be a major contributor to poor mental health two years after injury, as patients with severe injury exhibit significantly lower scores in MCS as measured with the SF-36 than those diagnosed with moderate TBI (Hu et al., 2012). This difference in mental health-related QOL measures in patients with moderate and severe TBI seems to disappear at 10 years after the injury (Andelic et al., 2009).

Children with orthopaedic injuries and severe TBI have more limitations in neuropsychological, behavioural and adaptive functioning than those with orthopaedic injuries without TBI (Winthrop, 2010). Finally, the impact of caregivers’ strain on the health-related QOL of survivors of TBI should not be dismissed (Winthrop, 2010).

Symptoms of PTSD diagnosed in survivors of burn injury at one month after hospital discharge has a significantly negative impact on physical functioning at two years follow up. Furthermore, PTSD at six, 12 and 24 months after discharge is reported to interfere greatly with psychosocial aspects of QOL in burn survivors (Corry et al., 2010).

Subjects who suffered mild TBI are at increased risk for developing PTSD compared to others. Posttraumatic stress disorder can develop years after the TBI event. In those that do develop PTSD, impairments related to physical and cognitive function and control of emotions are reported (Vanderploeg et al., 2009).

Acute stress disorder (ASD) and the consequent development of PTSD are also reported in adolescents and children who have suffered major traumatic injury. Perceived threat to life, intentional injury and pre-trauma psychopathology are the most significant predictors of the development of ASD and PTSD in children and adolescents following trauma (Holbrook et al., 2005; Winthrop, 2010). Female adolescents who suffered major traumatic injury seem to have a higher risk for developing ASD than male adolescents, but the reasons for this finding are still unclear (Holbrook et al., 2005). Low health-related QOL at one year after trauma is associated with the presence of posttraumatic stress symptoms as early as one month after the injury.

Mild to severe TBI in children aged between six and 15 years is associated with an increased risk for PTSD (Brown et al., 2014). The authors reported that the presence of pain was higher in those diagnosed with PTSD even at 18 months following the injury compared to those with TBI but no PTSD.

Despite the fact that the health benefits derived from regular exercise is well known, there is a dearth of literature on the effect of exercise therapy on health-related QOL in survivors of critical illness following discharge from the hospital.

Jones et al. (2003) tested the effectiveness of a rehabilitation programme on the recovery of survivors of critical illness using a randomised controlled study design in the UK. They compiled a 93-page rehabilitation package that consisted of a self-directed exercise programme, diagrams and illustrations. The manual also contained advice on a wide range of psychological, psychosocial and physical problems that the ICU survivor could expect to encounter after they had recovered from critical illness. Subjects were contacted by telephone three times per week after discharge to monitor progress; subjects in the experimental group were also encouraged to use the self-help rehabilitation manual. All subjects were tested at follow-up clinics at eight weeks and six months after discharge. The authors found that the SF-36 PF score for subjects in the experimental group was closer to normal and significantly different from those in the control group (Jones et al., 2003). Some critique on this study includes the fact that the authors did not objectively measure muscle strength or exercise capacity in their subjects and therefore it is difficult to draw conclusions regarding the effect of the rehabilitation manual on their musculoskeletal system recovery after critical illness.

Despite the slightly discouraging reports on the effects of exercise rehabilitation in survivors of critical illness, the importance of rehabilitation that starts in the ICU and is carried through to post-ICU care into the community setting is still emphasised in the literature (Hough and Herridge, 2012).

Ongoing structured rehabilitation protocols and programmes for patients with burns, orthopaedic injury, SCI or TBI after discharge from the acute care setting are well known and well established in most countries. Patients who suffered blunt or penetrating trauma, especially to the chest or trunk, regularly receive rehabilitative care during their stay in the acute care setting, but rehabilitation often ceases at discharge as the need for intensive ongoing exercise therapy in the community setting is not recognised by the patient, the physiotherapist or both. A search of the available literature revealed no studies that investigated the effects of exercise rehabilitation on the recovery of survivors of blunt or penetrating trauma. In light of the significant long-term limitations to physical function-related QOL that trauma survivors suffer, especially those who had a complicated and prolonged ICU stay, exercise rehabilitation after discharge is of great importance. The suggestions made below regarding exercise rehabilitation interventions in the community setting are aimed at this specific group of trauma survivors, but can also be applied to those recovering from burn injuries or orthopaedic injuries.