With Russia's full-scale invasion of Ukraine in February 2022, Ukraine has become the most heavily mined country globally; a title that no nation desires. The State Emergency Service of Ukraine estimates that around 30 per cent of its territory (170,000 square kilometres) may be contaminated with landmines and unexploded ordnance.
Hospitals have seen a significant influx of patients, particularly in the eastern and southern regions of Donetsk, Kherson, and Kharkiv, where active fighting occurs and the spread of landmines is most prevalent. In these hospitals, initial emergency care is provided, and patients are stabilised. If necessary, surgical interventions are performed.
To alleviate the strain on these healthcare facilities, patients are subsequently transported to hospitals in relatively secure regions like Kyiv and Vinnytsia for further treatment and rehabilitation.
The surge in patients with amputations and complex injuries has generated a critical need for medical specialists, especially physiotherapists to provide post-operative rehabilitation care. As per the Ministry of Social Policy, since the escalation of the war in February 2022, the number of Ukrainians with disabilities has increased by 300,000, doubling the demand for physiotherapists experienced in treating acute or chronic injuries.
The injuries we are treating are amputations, multiple traumas, and nerve injuries... I have never encountered such war-related traumas before.Viktoriia Vantsarovska, MSF physiotherapist
In response to this need, in mid-2022, Médecins Sans Frontières (MSF) launched a project focused on early rehabilitation of war-wounded patients at hospitals in Vinnytsia and Kyiv, where patients are evacuated from the most conflict-affected areas of Ukraine.
Collaborating with the Ministry of Health and Ministry of Internal Affairs, MSF medical teams started implementing new and evidence-based approaches to rehabilitation, aiding the recovery of injured patients.
“Physio is not well developed in Ukraine. There are not enough physiotherapists,” says Viktoriia Vantsarovska, MSF physiotherapist. “The injuries we are treating are amputations, multiple traumas, and nerve injuries. At first it was very difficult to accept what I was seeing. I have never encountered such war-related traumas before.”
To support the training and capacity building of local medical staff and university students, MSF invited physiotherapists with prior experience in international armed conflicts, such as Afghanistan, Yemen, Gaza and Sudan, to share experiences about the latest techniques in physiotherapy. We have also conducted dozens of trainings to teach evidence-based and progressive methods of physical rehabilitation.
“The international staff helped us a lot with their teaching and providing us with knowledge. For example, we have learnt how to provide treatment for patients' stumps in preparation for prosthetics,” says Vantsarovska.
Our physiotherapy team began employing a range of techniques with patients, such as stretches and exercises using equipment including parallel bars, fitness balls, and the Swedish Wall.
Many patients also experience acute and chronic pain as a result of damage to nerve endings in their affected limbs. A method of electrical stimulation called transcutaneous electrical nerve stimulation (TENS) was implemented to alleviate this and provide patients with symptomatic pain relief.
“We explain to our patients that if they follow our exercises, they will be able to become independent again. When you see progress and the patient is not giving up, you want to continue to help them,” says Vantsarovska. “When they come back wearing a prothesis I realise that my job is not in vain and I become really happy.”
Since the rehabilitation project commenced, MSF has provided more than 19,000 physiotherapy sessions with 668 patients. One of these patients is Andrii, who has been receiving treatment at the hospital in Vinnytsia.
“I stepped on a landmine in Donetsk region in July and since then I’ve had six surgeries. My right leg was amputated, and I also have nerve damage in my left arm. The physiotherapists always try new activities and approaches to help me. I would be immobilised without physio,” says Andrii.
As part of the rehabilitation project, our teams also provide patients with psychological care. The counselling services help patients process their traumatic experiences, gain motivation to maintain their physiotherapy, and better adapt to their new body and living conditions. A total of 2,638 psychological sessions have been provided to 508 patients, as well as 110 psycho-social group activities.
One particularly innovative component of the psychological services provided to amputee patients involves a mirroring exercise, which is performed by putting a mirror between their surviving leg and stump. The patient sees their leg in the reflection of the mirror and moves it; creating the perception that they are moving both limbs.
During this time, MSF psychologists support patients, engaging in discussions about the perception of movements. Patients can also share their fears and worries about their new body. This exercise contributes to the acceptance of the prosthesis.
The mirroring exercise is also used to address phantom pains in the missing limb, whereby the patient can address the imaginary pain by rubbing or moving the existing limb whilst looking at the mirror.
Patients with war-related trauma receive early and comprehensive treatment from our multidisciplinary team, who provide physiotherapy, mental health support and nursing care.Katerina Serbina, MSF project coordinator for Cherkasy and Zhytomyr
The process of treatment and rehabilitation can be quite lengthy, and some patients with serious injuries remain in the hospital for many months. Psychosocial activities and a change of environment are therefore essential for their mental health.
Our psychologists and social workers organise recreational trips to places such as the zoo and cinema, or take patients on fishing trips. In addition, there are regular excursions to the prosthetic and orthopaedic enterprise, where doctors explain the types of prostheses available and how to choose them correctly.
We also bring these activities to patients who can't make such trips because of their condition. Art activities are organised on a weekly basis, and special events such as barbecues, and visits from trainers with horses and dogs are set up in the hospital gardens.
These activities not only allow patients to have some respite, but also build their confidence in showing them that they are still capable of doing many of the things they did before they were injured.
After setting up the rehabilitation facilities and services in Vinnytsia and Kyiv, and providing 18 months of patient care and capacity building of staff, in December 2023, MSF handed over these projects to Mehad, a French NGO managing health and development projects.
All the Ukrainian health specialists – including the physiotherapists and psychologists – are being retained by Mehad, and we have donated our medical and office equipment, as well as two vehicles, to support the continuation of the rehabilitation activities.
With the ongoing war in Ukraine, injuries from landmines, explosions and shelling are still constant, and the need for rehabilitation services remains high. MSF is continuing to support the Ministry of Health by providing physiotherapy training and technical support to hospitals in Zhytomyr region, as well implementing a new rehabilitation project with war-wounded patients in Cherkasy.
As Cherkasy sits in the centre of Ukraine and is quite close to the frontline, many of the patients arrive within the first days of being injured. Our teams commence rehabilitation shortly after surgery or limb amputation, which is crucial to the recovery process. If physiotherapy is delayed, joints can become immobilised, which can make the use of prosthetics impossible in the future.
“Patients with war-related trauma receive early and comprehensive treatment from our multidisciplinary team, who provide physiotherapy, mental health support and nursing care,” says Katerina Serbina, MSF project coordinator for Cherkasy and Zhytomyr.