According to Recovery, a network of rehabilitation centers for war veterans created by Viktor and Olena Pinchuk, rehabilitation isn’t about relaxing in a sanatorium. It’s a process that requires hard work and a systematic approach. Though no exact number is available, Recovery estimates that at least 100,000 military personnel require rehabilitation. 

The current understanding of and culture around rehabilitation in Ukraine is relatively recent: in the past, rehabilitation was seen as a form of rest and recreation and associated with stays in countryside sanatoriums.

The Village Ukraine talks to Svitlana Grytsenko, Director of the Recovery project in Ukraine, Rostyslav Andrusenko, head of a rehabilitation center, and psychologist Hanna Barylo about how to identify who needs to undergo rehabilitation, how much it costs, and what the process is like.

On 7 December 2023, Ukraine’s Defense Ministry issued a memorandum on working together with the Recovery project, which aims to use existing state hospitals in seven Ukrainian oblasts to create a network of rehabilitation centers. Together, they will also set up a rehabilitation center with one of the largest capacities in Ukraine, able to accommodate more than 100 military personnel undergoing rehabilitation. Over 5,000 people have already gone through Recovery’s rehabilitation programs.

Цей текст також можна прочитати українською.

 

Rostyslav Andrusenko

 Svitlana Grytsenko

 

Who needs rehabilitation?

The Ukrainian Defense Ministry determines who might need to undergo a formal rehabilitation program. The exact number has not been disclosed, but Svitlana Grytsenko estimates that at least 100,000 soldiers are currently undergoing rehabilitation.

Rehabilitation can take one of two forms: the process can be relatively quick, with the person eventually resuming military service, or it can be a longer, more profound rehabilitation process that is required for serious injuries – injuries that will most likely prevent the person from resuming service. In the latter case, the rehabilitation process is aimed at wholly or partially restoring the person’s health.

Military personnel can undergo rehabilitation in private or public hospitals and medical centers. Either they are issued a referral for a specific hospital, or they can ask for a referral to a facility where they would like to undergo rehabilitation. If someone chooses to appeal directly to a Recovery center, the request is reviewed by the centers’ medical staff.

Rehabilitation departments are currently working at over 100% capacity and veterans have to sometimes wait for months for a spot. Recovery centers have been integrated into existing public healthcare facilities and operate in eight civilian hospitals in seven Ukrainian cities; 2024 will see the opening of another eight centers. In the future, rehabilitation hubs will also exist as part of military hospitals.

After the remaining Recovery rehabilitation centers launch in 2024, the network will be able to support 20,000 patients a year. But that’s still not enough. “There will be millions of patients with time,” Grytsenko says, adding that many soldiers are serving with existing injuries (including concussions) that require rehabilitation that is currently unavailable to them.

 

The price of rehabilitation

Ukraine’s National Health Service pays for veterans’ rehabilitation. It also sets standards for medical facilities offering rehabilitation, such as the types of experts they should employ and the kinds of equipment they should offer. The most comprehensive care plan available is for patients who have suffered multiple injuries, and covers 33,000 hryvnias worth of expenses (approximately US$880). Smaller plans are available too. Patients undergo rehabilitation at public health facilities and Recovery centers free of charge, though the price may vary across private medical facilities.

 

What are Recovery rehabilitation centers like?

When the Recovery team arrives in a new region, they inspect all major healthcare facilities that are suitable for hosting rehabilitation programs, eventually deciding on one hospital or center. They carry out major repairs, make the premises completely accessible, train hospital staff, purchase equipment on behalf of the state, and finally launch the rehabilitation center. Rehabilitation center staff get additional training during seminars and courses that focus on specific challenges they might encounter in their work.

 

What the rehabilitation process is like

When a patient is first admitted to a rehabilitation center, they undergo an exam, after which they’re issued their personalized rehabilitation plan. Ukrainian law requires that rehabilitation always be overseen by a multidisciplinary team: each patient works with a team of doctors who together decide on the rehabilitation course. These teams include occupational therapists, psychologists, physical and rehabilitation medicine doctors, and speech therapists. The composition of each team reflects each particular person’s needs. Each patient receives a daily chart that sets out how many hours they get to work with each specialist.

Grytsenko says that the legal framework for the rehabilitation process is now quite efficient – the difficulty is in consistently implementing it throughout all of Ukraine. Medical personnel trained during Soviet times, under a totally different system, are not going to change overnight. The entire healthcare system is undergoing a major transformation.

Recovery says the main challenge that it faces is a critical lack of specialists and their level of training: “That’s a challenge for both our project and the country overall, because it’s not the comfortable facilities or even the equipment that rehabilitates you, but the doctors.” Ukraine’s main goal right now is training such specialists.

Junior medical staff play a crucial role in rehabilitation too – of whom there is also a shortage. Medical equipment doesn’t just directly affect the patients’ health, but also makes the work of medical staff easier. Where before, three people were needed to help a patient get up, now it can be done by a single piece of equipment.

 

 

Modern rehabilitation practice, equipment, and procedures

Modern rehabilitation equipment often draws on virtual reality technology, such as special gloves which help people move and exercise the muscles of an injured hand, or game-based muscle and joint strengthening exercises. These resources can speed up the rehabilitation process.

Rostyslav Andrusenko, director of the Recovery center in Kyiv, says that the most commonly used piece of equipment in rehabilitation is a ceiling lift, as there is a general need to help soldiers stand early in the recovery process. Ceiling lifts can also help people regain their walking skills and are helpful in teaching a person using a prosthesis to walk. Virtual reality continues to be effective in improving physical and emotional wellbeing and reducing phantom pain. An exoskeleton – an external support system that follows a person’s movements to enhance muscle effort – is most often used in severe cases, when a person requires full or partial assistance in performing certain motor functions.

There are state protocols for how the rehabilitation process should unfold in certain areas, but Recovery staff observe that each hospital adapts them based on the equipment and staff available. The World Health Organization has also been involved in devising rehabilitation protocols – all of them can be accessed in Ukraine. Recovery centers also keep up to date on and implement the latest international developments in the field.

The Recovery team believes that there should be rehabilitation centers across all of Ukraine, citing that it would enable veterans to undergo rehabilitation close to their families and loved ones. In addition to improving the physical aspects of the rehabilitation process, loved ones can help in an emotional capacity – and that’s an important part of recovery.

“Rehabilitation can be a one-off event, though some people will require rehabilitation services – such as psychological support – for all of their life,” Grytsenko says.

 

What makes for a successful rehabilitation case?

The latest research on rehabilitation focuses on new approaches to the initial patient examination, in order to assess which functions can be restored and how long the process might take. The director of the Kyiv Recovery center says that this is particularly important for people who have had their limbs amputated, those with brain and skull injuries, and those with spinal cord injuries. All these conditions require patient rehabilitation and a clear understanding of which functions may come back and which will not.

The outcome of rehabilitation depends on the patient’s health, their mindset, and the effort they put in. The most important things are:

  • a comprehensive approach (physical, social, and psychological rehabilitation all taking place at the same time);
  • a patient-centric approach (taking the patient’s needs, abilities, and wishes into account);
  • a goal-oriented approach (working towards a particular goal or result);
  • a timely approach (rehabilitation has to begin as soon as the patient’s condition has stabilized following the initial injury);
  • a methodical approach (with each stage of rehabilitation connected to and flowing from one another).

“Joint, systematic work by all rehabilitation specialists, the veteran’s desire and motivation, and psychological recovery work are all factors that contribute to quality rehabilitation,” Andrusenko sums up.

 

 

The importance of psychological rehabilitation

A psychologist is an integral part of a multidisciplinary rehabilitation team. They are almost always involved from the very first days of the rehabilitation process, when the patient is going through the critical phases of physical and medical rehabilitation. Today’s rehabilitation centers rarely deal with cases of purely psychological trauma; usually they come in tandem with physical trauma.

Hanna Barylo, a psychologist at the Kyiv Recovery center, explains that psychological rehabilitation is important, not least because people are less able to focus their efforts on physical rehabilitation when they are depressed or  anxious. A person’s psychological and emotional state also affects hormone regulation in the body, which directly affects the time it takes for tissues to heal, and for muscles and the body as a whole to recover. Psychological assistance is one of the most important components of the rehabilitation process because a psychologist helps the patient focus on their recovery.

At Recovery centers, patients start working with a psychologist as soon as they are admitted. Early on, the patient undergoes a number of psychological tests, learns about the range of work that psychologists can do, and then together they decide what they will focus on during the particular stage of rehabilitation the patient is in. “I usually visit all of my patients every day. We have set days when we meet for one-on-one sessions with each person, but we can also agree to meet outside of that schedule as part of the rehabilitation program. Psychologists help doctors find the right approach to the patient, to ensure the most effective rehabilitation possible,” Barylo says.

A person’s psychological and emotional state doesn’t just depend on internal factors. Anything happening in the person’s family, in the society at large, in their military unit, and in the rehabilitation center itself could affect the pace of rehabilitation and the patient’s overall state.

Barylo says that the most common challenges she faces in her work are anxiety and depression, sleep disturbances, loss of appetite, and the aftereffects of shell shock, such as impaired attention, memory, decreased – or increased – motivation, and sometimes a sense of guilt. Patients feel guilt both towards their fellow soldiers and their families, because they can no longer provide for them as before.

“The soldiers I worked with might find it difficult to accept the way their bodies look after injuries or the loss of limbs. Every single one of them told me that after they got injured the first thing they did was make sure their penis was still there,” Barylo says. Resuming sexual life after injury is another key issue. This is often a separate part of the rehabilitation process, or something that takes place after rehabilitation – and it is almost always painstaking long-term work. “These issues don’t get solved in two weeks or even a month, though we can find an approach,” Barylo adds.

Recovery director Svitlana Grytsenko says that offering psychological help to military personnel in need of rehabilitation is crucial, but it is no less important to ensure that medical staff also have adequate support. There is a high risk of burnout for doctors doing this work, and that has proved to be one of the major challenges. Therapists have to be trained to work with the veterans and to understand the particularity of the military affairs – not every soldier is prepared to talk to a civilian therapist.

Recovery centers and local rehabilitation teams are working with universities, meeting students and inviting them to train there, and often eventually offering those students jobs.

 

How to treat veterans undergoing rehabilitation

The most important thing is to remember that a soldier is first and foremost a human being. You have to take into account their personal preferences in terms of the types of support they want or need.

Hanna Barylo, a Recovery psychologist, advises the following:

  • Avoid performing tasks for a patient unless they explicitly ask you to. If you want to help, ask their permission: performing a task for them  takes away their sense of agency and independence.
  • Don’t be afraid to talk to patients: they often want to talk rather than listen. If you find it difficult to hear about their experiences, you should tell them – instead of listening “out of respect”. Therapists are there to offer quality listening, because they know how to process the information they hear about. Family, loved ones, and friends serve different social functions – and that’s alright. “Talk about anything that has to do with being alive, new discoveries, and anything you’re interested in,” Barylo advises.
  • Don’t be embarrassed. It’s okay to look at someone’s prosthesis, but it’s not okay to comment on it, or to look away and tell children who might be looking at it to look away. Just tell the kids that this is a veteran who defends us, and convey your gratitude to this person with a gesture or a couple of words.
  • Smile at the soldiers you might see on the street: “It’s always nicer when people smile at you than when they avert their eyes,” Barylo says.

Barylo believes it is wrong when the public offers different types of psychological and emotional support for veterans and for people who are not veterans. Being a veteran is just one of a person’s social roles – and it might not be the one they want to foreground. Veterans want to be part of society, not an external feature. They want to go back to normal life, to the life that everyone else is living – and not to an artificially generated and specially tailored reality.