Клініко-експертні аспекти оцінювання повсякденного функціонування військовослужбовців з наслідками бойових травм кінцівок та периферичної нервової системи: біопсихосоціальна модель, МКФ та сучасні підходи до експертної оцінки

Ключові слова: МКФ, бойова травма, військовослужбовці, периферична нервова система, оцінювання повсякденного функціонування, біопсихосоціальна модель, інвалідність

Key words: ICF, combat injury, military personnel, peripheral nervous system, assessment of daily functioning, biopsychosocial model, disability

Реферат

Клініко-експертні аспекти оцінювання повсякденного функціонування військовослужбовців з наслідками бойових травм кінцівок та периферичної нервової системи: біопсихосоціальна модель, Міжнародна класифікація функціонування, обмеження життєдіяльності та здоров’я та сучасні підходи до експертної оцінки. Бойові травми кінцівок з ураженням периферичної нервової системи належать до найбільш складних медико-соціальних наслідків сучасної війни, оскільки супроводжуються тривалими порушеннями рухових, сенсорних і вегетативних функцій, обмеженням мобільності, самообслуговування, професійної діяльності та соціальної участі. Для їх клініко-експертної оцінки недостатньо характеристики лише структурного ушкодження, оскільки рівень функціонування визначається також за характером функціонального дефіциту, можливістю виконання повсякденних дій та участю особи в життєвих ситуаціях. Метою роботи був аналіз сучасних підходів до клініко-експертної оцінки функціонування військовослужбовців з наслідками бойових травм кінцівок та ураженням периферичної нервової системи з позицій біопсихосоціальної моделі та Міжнародної класифікації функціонування, обмежень життєдіяльності та здоров'я (МКФ), а також визначення можливості застосування стандартизованих інструментів оцінювання функціонування в сучасній системі оцінювання повсякденного функціонування в Україні. Було виконано наративний огляд 40 джерел: 35 наукових публікацій, двох документів ВООЗ і трьох нормативно-правових актів України. Для тематичного пошуку використано PubMed, Scopus і Web of Science. Search terms: combat limb injury; peripheral nerve injury, functioning; disability, rehabilitation, International classification of functioning, disability and health. До огляду включали публікації 2020-2026 років, базові джерела щодо класифікації та шкал включали незалежно від року. Первинних клінічних даних не збирали. Узагальнення джерел показало, що при наслідках бойових травм кінцівок з ураженням периферичних нервів клінічно значущими є не лише структурні ушкодження, а й моторний, сенсорний та больовий дефіцит, які можуть обмежувати мобільність, самообслуговування та професійну діяльність. МКФ забезпечує структурований опис цих проявів за компонентами функцій і структур організму, активності та участі з урахуванням факторів середовища, у той час як стандартизовані інструменти мають різну спрямованість: індекс Бартел переважно характеризує незалежність у базових повсякденних діях, Rivermead Mobility Index – мобільність, а WHODAS 2.0 – ширший спектр обмежень функціонування та участі. Аналіз нормативної бази України засвідчив концептуальний перехід до оцінювання повсякденного функціонування, що відповідає принципам біопсихосоціального підходу. Наслідки бойових травм кінцівок з ураженням периферичної нервової системи супроводжуються моторними, сенсорними та больовими порушеннями, що зумовлюють обмеження активності й участі військовослужбовців. Застосування біопсихосоціального підходу та МКФ дає змогу комплексно систематизувати ці порушення й оцінювати їх вплив на повсякденне функціонування. Використання стандартизованих інструментів, зокрема WHODAS 2.0, індексу Бартел та індексу мобільності Рівермід, сприяє визначенню кількісної характеристики функціональних обмежень у поєднанні з клінічним оцінюванням тяжкості ураження периферичної нервової системи.

Abstract

Clinical and expert aspects of assessing the daily functioning of military personnel with sequelae of combat-related injuries to the limbs and the peripheral nervous system: the biopsychosocial model, the ICF and modern approaches to expert assessment. Naumenko L.Yu., Rusina G.V., Potapova T.M., Berezovskyi V.M. Combat-related limb injuries involving damage to the peripheral nervous system are among the most complex medical and social consequences of modern warfare, as they are accompanied by long-term impairments of motor, sensory, and autonomic functions, as well as limitations in mobility, self-care, occupational functioning, and social participation. For their clinical and expert assessment, a description of structural damage alone is insufficient, since the level of functioning is also determined by the nature of the functional deficit, the ability to perform daily activities, and the individual’s participation in everyday situations. The aim of this study was to analyze current approaches to the clinical and expert assessment of the functioning of military personnel with the sequelae of combat-related limb injuries and peripheral nervous system damage from the perspective of the biopsychosocial model and the International Classification of Functioning, Disability and Health (ICF), as well as to determine the feasibility of applying standardized functional assessment tools within the current system for evaluating daily functioning in Ukraine.A narrative review of 40 sources was conducted: 35 scientific publications, two documents from the WHO, and three Ukrainian regulatory acts. PubMed, Scopus, and Web of Science were used for the thematic search. Search terms: combat limb injury; peripheral nerve injury; functioning; disability; rehabilitation; International classification of functioning, disability, and health. The review included publications from 2020 to 2026, foundational sources on classification and scales were included regardless of publication year.No primary clinical data were collected.A review of the literature showed that, in cases of combat-related limb injuries involving peripheral nerve damage, not only structural damage but also motor, sensory, and pain deficits are clinically significant, as they can limit mobility, self-care, and occupational functioning. The ICF provides a structured description of these manifestations in terms of the body’s functional and structural components, activity, and participation, taking environmental factors into account. Meanwhile, standardized instruments have different focuses: the Barthel Index primarily characterizes independence in basic activities of daily living, the Rivermead Mobility Index assesses mobility, and the WHODAS 2.0 evaluates a broader spectrum of limitations in functioning and participation. An analysis of Ukraine’s regulatory framework revealed a conceptual shift toward the assessment of daily functioning, consistent with the principles of the biopsychosocial approach.The consequences of combat-related limb injuries involving damage to the peripheral nervous system are accompanied by motor, sensory and pain-related impairments, which lead to limitations in the activity and participation of service personnel. The application of a biopsychosocial approach and the ICF enables these impairments to be systematically categorised and their impact on daily functioning to be assessed. The use of standardised tools, in particular the WHODAS 2.0, the Barthel Index and the Rivermead Mobility Index, facilitates the quantitative characterisation of functional limitations in conjunction with a clinical assessment of the severity of peripheral nervous system damage.

The full-scale war in Ukraine has been accompanied by a significant increase in the number of military personnel suffering from combat-related injuries, with limb injuries being the most common. According to current data, injuries to the upper and lower extremities account for the largest proportion of combat-related surgical trauma and are often accompanied by damage to peripheral nerves, blood vessels, bones, and soft tissues [1, 2].

A distinctive feature of combat injuries is the high energy of the impact, the multiple anatomical structures affected, and the high frequency of combined injuries and complications, which results in a prolonged recovery period [3, 4, 5]. Injuries to the peripheral nervous system are one of the key factors determining the functional prognosis, the duration of rehabilitation, and the soldier’s ability to return to an active life [6, 7]. Even with successful restoration of the limb’s anatomical integrity, motor and sensory deficits, neuropathic pain, and coordination impairments may persist for a long time and significantly limit daily functioning [8-11].

In Ukraine, the implementation of a system for assessing an individual’s daily functioning has become one of the areas of reform in medical and social evaluation. The shift toward assessing functional limitations necessitates the use of approaches that allow for the characterization not only of the diagnosis and structural impairment, but also of their impact on an individual’s daily activities and participation. According to the World Health Organization’s framework, the biopsychosocial approach views functioning as the result of the interaction between health status and individual and environmental factors, whereas the International classification of functioning, disability and health(ICF) provides a standardized system for classifying and describing the relevant components of functioning [12].

For military personnel with the consequences of combat-related limb injuries and damage to the peripheral nervous system, this distinction is of fundamental importance. Structural damage to a limb or peripheral nerve does not automatically determine the degree of limitation in daily functioning, as the latter is shaped by the nature of the functional deficit, pain, mobility impairments, ability to perform activities of daily living, occupational activity, and environmental factors. Therefore, in this study, the ICF is considered not as a method for the primary measurement of functioning, but as a classificatory framework for systematizing its manifestations, whereas standardized scales are used as tools for the quantitative assessment of specific aspects of functioning.

Research objective – to synthesize current scientific data on the assessment of the functional status of military personnel with combat-related limb injuries and peripheral nervous system damage using a biopsychosocial approach and the ICF, to determine the structure of functional limitations according to ICF components, and to characterize the possibilities for applying standardized instruments for their quantitative assessment within the framework of the current system for evaluating daily functioning in Ukraine.

MATERIALS AND METHODS OF RESEARCH

In terms of design, this study is a review and analytical study of a theoretical and methodological nature. A search of the scientific literature was conducted using thematic keywords covering combat injuries to the extremities, peripheral nerve damage, functioning, disability, rehabilitation, and the ICF. We searched for publications indexed in the PubMed, Scopus, and Web of Science databases from 2020 to 2025. The analysis included full-text scientific articles in Ukrainian or English directly related to combat injuries of the extremities, peripheral nerve damage, pain, rehabilitation, or functional assessment. Duplicates, materials without an available full text, and publications lacking relevant functional or clinical-expert data were excluded. Official WHO documents and current Ukrainian regulatory acts were reviewed separately [12-18].

The final thematic synthesis included 40 sources: 35 scientific publications, two methodological documents from the World Health Organization, and three Ukrainian regulatory acts. Since the review was narrative rather than systematic in nature, no separate registry of initially identified and excluded records was created, and the PRISMA guidelines were not applied. The data were grouped into four categories: the consequences of trauma and peripheral nerve injuries; the role of pain and contextual factors; the purpose and limitations of standardized instruments; and the normative model for assessing daily functioning. The ICF was used as a conceptual and classificatory framework for systematizing manifestations of functioning, rather than as a tool for initial quantitative assessment.

The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. The ethical aspects of the study were approved by the biomedical ethics committee of Dnipro State Medical University (report No. 36 March 18, 2026).

RESULTS AND DISCUSSION

Combat injuries to the limbs  remain one of the leading causes of long-term functional impairment among military personnel. A distinctive feature of modern combat injuries is the high frequency of combined damage to the musculoskeletal system, blood vessels, and peripheral nerves, which results in complex, multifactorial functional impairments [19, 20, 21]. It is damage to the peripheral nervous system that is one of the leading factors determining the duration of rehabilitation, the degree of functional limitations, and the prognosis for social reintegration [6, 22, 23, 24].

Traditional clinical approaches are primarily based on the assessment of anatomical defects or individual functional impairments. However, accumulated scientific data indicate that the severity of structural damage does not always correlate directly with a person’s actual level of functioning. Even with a comparable extent of anatomical defect, the degree of limitation in daily living and participation can vary significantly depending on the intensity and nature of pain, the severity of motor and sensory deficits, psychological state, the quality and availability of rehabilitation interventions, as well as the level of social support. Studies of military personnel with combat-related and severe lower-limb injuries demonstrate that pain, psychoemotional disturbances, and psychosocial factors can significantly modify functional outcomes regardless of the severity of the primary anatomical injury [25, 26, 27].

The application of the biopsychosocial approach in the clinical and expert assessment of the consequences of combat-related limb injuries involves going beyond the description of anatomical damage and taking into account its impact on human functioning. In this context, the ICF provides a structured system for describing the functional consequences of health conditions based on interrelated components: body functions and structures, activity, and participation, taking contextual factors into account. For individuals with the consequences of combat-related limb injuries and peripheral nervous system damage, this allows for a systematic characterization of impairments in functions and structures, the associated limitations in activity and participation, as well as environmental factors that may influence the level of functioning. Table 1 presents a systematization of the main functional consequences of such injuries in accordance with the ICF components.

Neuropathic pain plays a particularly significant role in the development of functional limitations; it often persists even after surgical treatment is completed and structural damage has stabilized. Its presence is associated with reduced physical activity, sleep disturbances, the development of anxiety and depressive disorders, and a decline in quality of life. Therefore, the clinical and expert assessment of military personnel with combat-related injuries must go beyond the analysis of anatomical defects and encompass a comprehensive evaluation of all components of functioning [25, 28].

An important tool for the practical implementation of the ICF provisions is the use of standardized functional assessment scales. The Barthel Index of Activities of Daily Living allows for the assessment of the level of independence in performing basic daily activities [16], the Rivermead Mobility Index characterizes a person’s mobility [18], and WHODAS 2.0 provides a comprehensive assessment of activity and participation in accordance with the ICF concept [17]. The combined use of these tools provides a more complete picture of a service member’s level of functioning and their actual rehabilitation needs (Table 2).

The tool that most closely aligns with the ICF concept is the WHODAS 2.0, which allows for the assessment not only of functional impairments but also of their impact on an individual’s participation in social life. The introduction of a new system for assessing daily functioning has become one of the key areas of reform in medical and social assessment in Ukraine; the main feature of the new model is a shift in emphasis from anatomical defects to assessing the actual impact of an injury on a person’s daily life [13] (Table 3).

The analysis shows that the key difference between the current system for assessing daily functioning and the previous model of medical-social evaluation is a shift in emphasis from anatomical defects to the actual impact of health impairments on a person’s daily life. For service members suffering from the consequences of combat-related injuries to the limbs and the peripheral nervous system, this approach is particularly important, as functional limitations are often determined not only by morphological changes but also by the interaction of clinical, psychological, and social factors.

At the same time, the practical implementation of the reform is accompanied by a number of challenges, including insufficient standardization in the description of functional impairments, inconsistent use of validated scales, and a lack of training among certain specialists regarding the practical application of the ICF. These issues are particularly relevant for service members with multiple consequences of combat trauma, where determining the degree of functional limitation requires integrating data from various clinical specialties (Table 4).

The results obtained are consistent with the findings of Ukrainian researchers. In particular, Dorofeeva O.Ye. et al. (2023) demonstrated that in patients with mine-blast injuries to the lower leg, establishing a rehabilitation diagnosis based on the ICF allows for the objective assessment of the profile of activity limitations and the individualization of rehabilitation interventions [29]. Similar approaches have been proposed in studies devoted to physical therapy algorithms for individuals who have undergone lower leg amputation due to mine-blast trauma [9, 10, 23, 30, 31]. This confirms that, within the Ukrainian scientific community, the ICF is increasingly being used as a methodological foundation for clinical-expert and rehabilitation assessments, and our findings build upon these principles with regard to combined injuries of the limbs and the peripheral nervous system.

A promising direction for improving the system is the broader implementation of standardized functional assessment tools, the development of ICF profiles for military personnel with combat-related injuries, and the creation of unified methodological approaches to documenting activity and participation limitations. This will help increase the objectivity of expert decisions, improve the planning of rehabilitation measures, and ensure continuity between the stages of treatment, rehabilitation, and expert assessment. Thus, the application of the biopsychosocial model in combination with the ICF framework allows for a shift from a fragmented assessment of individual impairments to a holistic analysis of functioning, which is particularly relevant for patients with severe, multiple combat-related injuries.

An analysis of the results of a study on the structure and nature of functional limitations in military personnel with combat-related limb injuries and peripheral nervous system damage clearly indicates a total maladjustment in these patients, which goes far beyond a purely anatomical defect. A review of the literature confirms that modern mine- and blast-induced limb trauma is a systemic pathology in which primary tissue destruction triggers a cascade of interrelated disorders that transform the clinical picture into a persistent functional impairment [31-34].

The central factor determining an unfavorable rehabilitation prognosis and a high degree of activity limitation on the Barthel and WHODAS 2.0 scales in military personnel with sequelae of combat-related limb injuries and peripheral nervous system damage is neuropathic pain (ICD code b280). The results demonstrate that even with successful reconstructive and plastic surgery, stable internal fixation, and wound healing, the severity of pain often remains resistant to standard therapy [35, 36].

From the perspective of clinical pharmacology and neurobiology, the development of persistent neuropathic pain following combat trauma is associated with phenomena of peripheral and central sensitization. Direct transection, contusion, or traction injury to nerve trunks caused by a blast wave leads to ectopic impulse generation in the damaged axons. Chronic inflammation at the injury site, nerve ischemia resulting from concomitant vascular damage, and the formation of pathological neuromas alter the architecture of ion channels (in particular, sodium and calcium channels) [37, 28, 39].In practical terms, in cases of combat-related injuries to the lower limbs, this results in the limited effectiveness of traditional analgesics and nonsteroidal anti-inflammatory drugs when there is a pronounced neuropathic component to the pain. Peripheral damage to nerve structures, characteristic of blast, gunshot, and traumatic amputations of the lower limbs, can sustain pathological nociceptive activity and contribute to the development of chronic neuropathic, residual, and phantom pain. Among military personnel following combat-related trauma, the prevalence of such pain syndromes remains high even long after the injury [6, 7, 25, 39, 40]. Therefore, the clinical and expert assessment of patients with severe pain dysfunction (ICF b280) should take into account not only the intensity of pain but also its neuropathic nature, duration, response to pharmacotherapy, and impact on mobility, self-care, physical endurance, and participation in daily life. In the presence of a neuropathic component, patients may require long-term pathogenetically oriented pharmacotherapy, specifically with gabapentinoids and antidepressants with analgesic effects, in combination with comprehensive physical and multidisciplinary rehabilitation. This approach is of direct importance for assessing rehabilitation potential and predicting functional recovery. Particular attention is drawn to damage to the “Body Structures” domain (s730, s750, s760) in combination with ischemic changes. Disruption of major blood flow due to combat trauma, even after staged bypass surgery or autovenous grafting, leads to chronic hypoxia of soft tissues and peripheral nerves. This triggers processes of fibrosis, secondary tunneling of nerve trunks within scar tissue conglomerates, and the development of ischemic neuropathies. As a result, sensory deficits (b265) become persistent, depriving the patient of adequate proprioceptive and tactile feedback, which dramatically lowers scores on the Rivermid Mobility Index (RMI).

When evaluating these results through the lens of reforming the disability assessment system in Ukraine, the fundamental role of implementing the ICF becomes evident. The transition from the outdated nosocentric model of the Medical and Social Expert Commission (MSEC) to a biopsychosocial paradigm for assessing daily functioning is not merely a change in terminology, but a radical transformation of the philosophy underlying the approach to wounded military personnel.

In the traditional system of medical and social assessment, the key focus was on verifying the diagnosis and establishing the presence of an anatomical defect (for example, “consequences of a gunshot fracture of the lower leg bones with damage to the tibial nerve”). The identical nature of the anatomical damage to structure S750 does not automatically determine the degree of functional limitation, as this is shaped by a combination of functional and contextual factors. The modern system for assessing daily functioning, based on the ICF, allows for a clear differentiation between these conditions, emphasizing the assessment of activity (d450, d455, d510) and participation (d850).

This is fully aligned with Ukraine’s current legislative direction, particularly in the context of systemic reforms by the Ministry of Health and the implementation of a comprehensive assessment of daily living for individuals who have suffered injuries as a result of Russian aggression. The new model shifts the focus from “passive disability” to “active recovery and compensation,” where the identification of functional limitations serves as the basis for developing an Individual Rehabilitation Program (IRP), rather than merely as a mechanism for assigning social benefits.The triad of instruments used in this study (the Barthel Index, the Rivermead Mobility Index, and WHODAS 2.0) demonstrated high convergent validity but also revealed specific limitations of each instrument, underscoring the need for their comprehensive combination:

• The Barthel Index is primarily sensitive to severe impairments in activities of daily living (d510). In patients with isolated, albeit severe, trauma to a single upper or lower limb, the Barthel Index may show relatively high scores (moderate or mild dependence), creating a false impression of «well-being».
• The Rivermead Mobility Index (RMI) is significantly better at assessing locomotor deficits, capturing limitations in complex motor tasks (walking on uneven surfaces, climbing stairs, running), which is extremely important for service members planning to return to duty or requiring prosthetics.
• WHODAS 2.0 (36-item version) proved to be the most comprehensive tool, covering the “Participation” domains (d760, d850). It allows for the objective assessment of the cognitive-emotional and social consequences of trauma. Our data show that the greatest limitations on the WHODAS 2.0 are recorded in the domains “Mobility in the World” and “Activities of Daily Living (occupational domain)”, which are directly related to barriers in environmental factors (e115, e580).

An important aspect of the analysis is the “Environmental Factors” domain (e). The availability of high-quality technical rehabilitation aids (e115), barrier-free spaces, and institutional support (e580) can move a patient from the “severe participation limitation” category to “moderate or mild limitation”, even though the anatomical defect in domain s remains unchanged. This demonstrates that expert teams, when assessing daily functioning, must analyze not only the patient but also the environment in which they live.

This approach logically complements and builds upon the work of Ukrainian researchers. For example, the data from Dorofeeva O.Ye. et al. (2023), which emphasize the critical need to establish a rehabilitation diagnosis based exclusively on the ICF for patients with mine- and explosive-related lower leg injuries [29]. Furthermore, our conclusions regarding the significance of locomotor limitations are consistent with studies devoted to the development of algorithms for physical therapy for individuals who have undergone amputations as a result of combat operations [30].

At the same time, it would be advisable to expand this line of research to include patients with a preserved limb but significant neurological and vascular deficits. In such cases, the quantitative assessment of function may be lower than in patients who have undergone elective below-knee amputation, provided that prosthetic fitting is effective. The phenomenon of the «problematic preserved limb» must be adequately reflected during clinical and expert evaluation and in the documentation of functional limitations.

The practical implementation of modern approaches to functional assessment reveals a number of difficulties, among which insufficient methodological support and limited human resources play a significant role (Table 4). Medical documentation, particularly discharge summaries and medical records, often continues to rely primarily on a nosological description of the pathology, while quantitative assessment of functional impairments and limitations in activity and participation using standardized scales is underutilized.

To address these discrepancies and enhance the objectivity of expert assessments, it is critically important to develop and approve, at the national level, national ICF clinical profiles (Core Sets) for combat-related limb injuries and peripheral nervous system injuries. This will standardize the work of multidisciplinary rehabilitation and expert teams, ensuring transparency, evidence-based practice, and a European-oriented approach to the development of Ukraine’s healthcare system.

CONCLUSIONS

1. The consequences of combat-related limb injuries involving damage to the peripheral nervous system are characterized by a combination of motor, sensory, pain-related, and other functional impairments that result in limitations on the activity and participation of military personnel. It is advisable to analyze the structure of these limitations according to the relevant components of theInternational classification of functioning, disability and health, taking into account the nature and severity of the injury.
2. The application of a biopsychosocial approach and the International classification of functioning, disability and healthmakes it possible to systematize the consequences of combat injuries by linking impairments in bodily functions and structures to limitations in activity and participation. This provides a foundation for a comprehensive assessment of military personnel’s daily functioning within the modern expert evaluation system.
3. Standardized assessment tools, including the WHODAS 2.0, the Barthel Index, and the Rivermead Mobility Index, can be used to quantitatively characterize specific aspects of functioning and to objectively assess limitations in activity and mobility. Their use should be combined with a clinical assessment of the nature and severity of peripheral nervous system damage.

Contributors:

Naumenko L.Yu. – conceptualization, validation, supervision;

Rusina G.V. – conceptualization, methodology, writing – original draft;

Potapova T.M. – methodology, writing – review & editing, visualization;

Berezovskyi V.M. – investigation, methodology, project administration.

Funding. This research received no external funding.

Conflict of interests. The authors declare no conflict of interest.

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