[Long-term results after multiple trauma with ISS ≥ 25. Outcome and predictors of quality of life]

Implementation of health-related quality of life in the German TraumaRegister DGU® - first results of a pilot study

BACKGROUND

Approximately 30,000 people are affected by severe injuries in Germany each year. Continuous progress in prehospital and hospital care has significantly reduced the mortality of polytrauma patients. With increasing survival rates, the functional outcome, health-related quality (hrQoL) of life and ability to work are now gaining importance. Aim of the study is, the presentation of the response behavior of seriously injured patients on the one hand and the examination of the factors influencing the quality of life and ability to work 12 months after major trauma on the other hand. Building on these initial results, a standard outcome tool shall be integrated in the established TraumaRegister DGU® in the future.

METHODS

In 2018, patients [Injury Severity Score (ISS) ≥ 16; age:18-75 years] underwent multicenter one-year posttraumatic follow-up in six study hospitals. In addition to assessing hrQoL by using the Short-Form Health Survey (SF-12), five additional questions (treatment satisfaction; ability to work; trauma-related medical treatment; relevant physical disability, hrQoL as compared with the prior to injury status) were applied.

RESULTS

Of the 1,162 patients contacted, 594 responded and were included in the analysis. The post-injury hrQoL does not show statistically significant differences between the sexes. Regarding age, however, the younger the patient at injury, the better the SF-12 physical sum score. Furthermore, the physically perceived quality of life decreases statistically significantly in relation to the severity of the trauma as measured by the ISS, whereas the mentally perceived quality of life shows no differences in terms of injury severity. A large proportion of severely injured patients were very satisfied (42.2%) or satisfied (39.9%) with the treatment outcome. It should be emphasized that patients with a high injury severity (ISS > 50) were on average more often very satisfied with the treatment outcome (46.7%). A total of 429 patients provided information on their ability to work 12 months post-injury. Here, 194 (45.2%) patients had a full employment, and 58 (13.5%) patients were had a restricted employment.

CONCLUSION

The present results show the importance of a structured assessment of the postinjury hrQoL and the ability to work after polytrauma. Further studies on the detection of influenceable risk factors on hrQoL and ability to work in the intersectoral course of treatment should follow to enable the best possible outcome of polytrauma survivors.

Clinical outcome after dorso-ventral stabilization of the thoracolumbar and lumbar spine with vertebral body replacement and dorsal stabilization

PURPOSE

Surgical stabilization of the spine by vertebral body replacement (VBR) is used for spinal disorders such as traumatic fractures to provide an anatomical re-adjustment of the spine to prevent late detrimental effects and pain [1-4]. This study addresses the clinical outcome after a ventral intervention with VBR and bisegmental fusion.

METHODS

The study includes 76 patients (mean age: 59.34 ± 15.97; 34 females and 42 males) with fractures in the lower thoracic and lumbar spine. They were selected from patients of our hospital who received an anterolateral VBR surgery on the corresponding lower spine region over a nine-year period. Only patients were examined with X-rays and complete follow-up records. Exclusion criteria were changes due to degeneration and pathological fractures. Patients were divided into two groups, the thoracotomy group (Th10-L1) and the lumbotomy group (L2-5), respectively. Minimum one year after surgery, patients were asked about their well-being using a precasted questionnaire.

RESULTS

No significant differences with respect to the subjective impression of the patients concerning their back pain, spinal functional impairment, their general functional status and their quality of life impairment. Unfortunately, however, only a rather modest but significant increase of the post-surgical life quality was reported.

CONCLUSIONS

Patients who underwent VBR in the lower thoracic or lumbar spine show modest long-term well-being. The results suggest that injuries to the lower thoracic or lumbar spine requiring vertebral body replacement should be classified as severe injuries since they adversely affect the patients' long-term well-being.

TRIAL REGISTRATION

Study of clinical outcome of patients after vertebral body replacement of the ventral thoracal and lumbal spine, DRKS00031452. Registered 10th March 2023 - Prospectively registered. Trial registration number DRKS00031452.

Outcomes of severely injured pregnant trauma patients: a multicenter analysis

Nearly 10% of pregnant women suffer traumatic injury. Clinical outcomes for pregnant trauma patients (PTPs) with severe injuries have not been well studied. We sought to describe outcomes for PTPs presenting with severe injuries, hypothesizing that PTPs with severe injuries will have higher rates of complications and mortality compared to less injured PTPs. A post-hoc analysis of a multi-institutional retrospective study at 12 Level-I/II trauma centers was performed. Patients were stratified into severely injured (injury severity score [ISS] > 15) and not severely injured (ISS < 15) and compared with bivariate analyses. From 950 patients, 32 (3.4%) had severe injuries. Compared to non-severely injured PTPs, severely injured PTPs were of similar maternal age but had younger gestational age (21 vs 26 weeks, p = 0.009). Penetrating trauma was more common in the severely injured cohort (15.6% vs 1.4%, p < 0.001). The severely injured cohort more often underwent an operation (68.8% vs 3.8%, p < 0.001), including a hysterectomy (6.3% vs 0.3%, p < 0.001). The severely injured group had higher rates of complications (34.4% vs 0.9%, p < 0.001), mortality (15.6% vs 0.1%, p < 0.001), a higher rate of fetal delivery (37.5% vs. 6.0%, p < 0.001) and resuscitative hysterotomy (9.4% vs. 0%, p < 0.001). Only approximately 3% of PTPs were severely injured. However, severely injured PTPs had a nearly 40% rate of fetal delivery as well as increased complications and mortality. This included a resuscitative hysterotomy rate of nearly 10%. Significant vigilance must remain when caring for this population.

Parameters influencing health-related quality of life after severe trauma: a systematic review (part II)

INTRODUCTION

It is increasingly recognized that health-related quality of life (HRQoL) is a relevant outcome to study in populations comprising severely injured patients. Although some studies have readily demonstrated a compromised HRQoL in those patients, evidence regarding factors that predict HRQoL is scarce. This hinders attempts to prepare patient-specific plans that may aid in revalidation and improved life satisfaction. In this review, we present identified predictors of HRQoL in patients that have suffered severe trauma.

METHODS

The search strategy included a database search until the 1st of January 2022 in the Cochrane Library, EMBASE, PubMed, and Web of Science, and reference checking. Studies were eligible for inclusion when (HR)QoL was studied in patients with major, multiple, or severe injury and/or polytrauma, as defined by authors by means of an Injury Severity Score (ISS) cut-off value. The results will be discussed in a narrative manner.

RESULTS

A total of 1583 articles were reviewed. Of those, 90 were included and used for analysis. In total, 23 possible predictors were identified. The following parameters predicted reduced HRQoL in severely injured patients and came forward in at least more than three studies: higher age, female gender, lower extremity injuries, higher rate of injury severity, lower achieved educational level, presence of (pre-existing) comorbidities and mental illness, longer duration of hospital stay, and high level of disability.

CONCLUSION

Age, gender, injured body region, and severity of injury were found to be good predictors of health-related quality of life in severely injured patients. A patient-centered approach, based on individual, demographic, and disease-specific predictors, is highly recommended.

[Quality of Life and Return to Work Following Rehabilitation - Results of the icfPROreha Study]

BACKGROUND

Not only the severity of an injury, but also bio-psycho-social factors affect health-related quality of life and participation in social life after severe musculoskeletal injuries.

METHODS

Multicentre prospective longitudinal study with follow-up up to 78 weeks after discharge from inpatient trauma rehabilitation. Data were collected using a comprehensive assessment tool. Quality of life was assessed using the EQ-5D-5L, return to work by patients' self-reports and routine data of health insurances. Analyses of the association between quality of life and return to work, change over time in quality of life compared to the general German population and multivariate analyses to predict quality of life were conducted.

RESULT

Of 612 study participants (444 men (72.5%); M=48.5 years; SD 12.0), 502 (82.0%) returned to work 78 weeks after discharge from inpatient rehabilitation. Quality of life improved during rehabilitation treatment from 50.18 to 64.50 (mean of visual analogue scale of EQ-5D-5L) and slightly to 69.38 78 weeks after discharge from inpatient trauma rehabilitation. EQ-5D index was below the values of the general population. In total, 18 factors were selected to predict quality of life 78 weeks after discharge from inpatient trauma rehabilitation. Among others, pain at rest and suspected anxiety disorder at admission had a very strong effect on quality of life. Contextual factors such as therapies after acute care and self-efficacy also had an effect on quality of life 78 weeks after discharge from inpatient rehabilitation.

CONCLUSION

Bio-psycho-social factors affect long-term quality of life of patients with musculoskeletal injuries. Already at the time of discharge from acute treatment and even more at the beginning of inpatient rehabilitation, decisions can be made in order to achieve the best possible quality of life for those affected.

Health-related quality of life after severe trauma and available PROMS: an updated review (part I)

Introduction

Throughout the years, a decreasing trend in mortality rate has been demonstrated in patients suffering severe trauma. This increases the relevance of documentation of other outcomes for this population, including patient-reported outcome measures (PROMs), such as health-related quality of life (HRQoL). The aim of this review was to summarize the results of the studies that have been conducted regarding HRQoL in severely injured patients (as defined by the articles’ authors). Also, we present the instruments that are used most frequently to assess HRQoL in patients suffering severe trauma.

Methods

A literature search was conducted in the Cochrane Library, EMBASE, PubMed, and Web of Science for articles published from inception until the 1st of January 2022. Reference lists of included articles were reviewed as well. Studies were considered eligible when a population of patients with major, multiple or severe injury and/or polytrauma was included, well-defined by means of an ISS-threshold, and the outcome of interest was described in terms of (HR)QoL. A narrative design was chosen for this review.

Results

The search strategy identified 1583 articles, which were reduced to 113 after application of the eligibility criteria. In total, nineteen instruments were used to assess HRQoL. The SF-36 was used most frequently, followed by the EQ-5D and SF-12. HRQoL in patients with severe trauma was often compared to normative population norms or pre-injury status, and was found to be reduced in both cases, regardless of the tool used to assess this outcome. Some studies demonstrated higher scoring of the patients over time, suggesting improved HRQoL after considerable time after severe trauma.

Conclusion

HRQoL in severely injured patients is overall reduced, regardless of the instrument used to assess it. The instruments that were used most frequently to assess HRQoL were the SF-36 and EQ-5D. Future research is needed to shed light on the consequences of the reduced HRQoL in this population. We recommend routine assessment and documentation of HRQoL in severely injured patients.

Assessment of patient-reported outcomes after polytrauma - instruments and methods: a systematic review

OBJECTIVES

We (1) collected instruments that assess health-related quality of life (HRQoL), activities of daily living (ADL) and social participation during follow-up after polytrauma, (2) described their use and (3) investigated other relevant patient-reported outcomes (PROs) assessed in the studies.

DESIGN

Systematic Review using the Preferred Reporting Items for Systematic Review and Meta-Analysis guideline.

DATA SOURCES

MEDLINE, Embase, CINAHL, PsycINFO, CENTRAL, as well as the trials registers ClinicalTrials.gov and WHO ICTRP were searched from January 2005 to April 2018.

ELIGIBILITY CRITERIA

All original empirical research published in English or German including PROs of patients aged 18-75 years with an Injury Severity Score≥16 and/or an Abbreviated Injury Scale≥3. Studies with defined injuries or diseases (e.g. low-energy injuries) and some text types (e.g. grey literature and books) were excluded. Systematic reviews and meta-analyses were excluded, but references screened for appropriate studies.

DATA EXTRACTION AND SYNTHESIS

Data extraction, narrative content analysis and a critical appraisal (e.g. UK National Institute for Health and Care Excellence) were performed by two reviewers independently.

RESULTS

The search yielded 3496 hits; 54 publications were included. Predominantly, HRQoL was assessed, with Short Form-36 Health Survey applied most frequently. ADL and (social) participation were rarely assessed. The methods most used were postal surveys and single assessments of PROs, with a follow-up period of one to one and a half years. Other relevant PRO areas reported were function, mental disorders and pain.

CONCLUSIONS

There is a large variation in the assessment of PROs after polytrauma, impairing comparability of outcomes. First efforts to standardise the collection of PROs have been initiated, but require further harmonisation between central players. Additional knowledge on rarely reported PRO areas (e.g. (social) participation, social networks) may lead to their consideration in health services provision.

PROSPERO REGISTRATION NUMBER

CRD42017060825.

[Rehabilitation after multiple traumata]

BACKGROUND

The reintegration into the social and professional environment and the achievement of the best possible quality of life after multiple injuries can often only be achieved after a lengthy rehabilitation process and belongs in the hands of experienced doctors, therapists, and rehabilitation managers.

REHABILITATION PHASES

Rehabilitation after serious accidents must be differentiated from "normal" orthopedic rehabilitation after elective surgery. The challenges of trauma rehabilitation require coordinated rehabilitation phases. This is the only way to avoid the so-called "rehab hole" between discharge from the acute clinic and the start of post-acute rehabilitation. A 6-phase model is described. After acute treatment (phase A) and any necessary early rehabilitation (phase B), phase C of post-acute rehabilitation places special demands on the rehabilitation facility. Phase D of the follow-up rehabilitation is established. The further rehabilitation (phase E) provides measures specifically tailored to the consequences of the accident, such as pain rehabilitation or activity-oriented procedures. Long-term follow-up care for previously severely injured patients is necessary (phase F).

PROSPECTS

An integration of trauma rehabilitation centers into the existing trauma network remains the goal to improve the outcome after polytrauma.

Polytrauma outcome: implementation of health-related quality of life assessment into the German Trauma Registry

INTRODUCTION

As a result of improvement in polytrauma management within the last years, more patients survive a significant trauma. Trauma registers, such as the TraumaRegister DGU^®, played a role in identifying risk factors of poor outcomes which led to an improvement of survival rates. In recent years the health-related quality of life (HRQoL) after trauma got into the focus of trauma studies.

MATERIALS AND METHODS

Under the sponsorship of the German Society of Trauma Surgery (DGU) the members of the Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) convened intending to identify an assessment tool for implementation into the TraumaRegister DGU^®.

RESULTS

After the conduct of a systematic literature review, the working group decided to choose the 12-item Short-Form Health Survey (SF-12) and five more questions, capturing the satisfaction of treatment, work capacity and trauma-related medical treatment.

CONCLUSION

The data collection of HRQoL and the additional variables started in 2017 in participating clinics as a part of the regular data collection of the TraumaRegister DGU^®.

Comparison of manual and computer assigned injury severity scores

BACKGROUND

The study objective was to compare the ISS manually assigned by hospital personnel and those generated by the ICDPIC software for value agreement and predictive power of length of stay (LOS) and mortality.

METHODS

We used data from the 2010-2016 trauma registry of a paediatric trauma centre (PTC) and 2014 National Trauma Data Bank (NTDB) hospitals that reported manually coded ISS. Agreement analysis was performed between manually and computer assigned ISS with severity groupings of 1-8, 9-15, 16-25 and 25-75. The prediction of LOS was compared using coefficients of determination (R²) from linear regression models. Mortality predictive power was compared using receiver operating characteristic (ROC) curves from logistic regression models.

RESULTS

The proportion of agreement between manually and computer assigned ISS in PTC data was 0.84 and for NTDB was 0.75. Analysing predictive power for LOS in the PTC sample, the R²=0.19 for manually assigned scores, and the R²=0.15 for computer assigned scores (p=0.0009). The areas under the ROC curve indicated a mortality predictive power of 0.95 for manually assigned scores and 0.86 for computer assigned scores in the PTC data (p=0.0011).

CONCLUSIONS

Manually and computer assigned ISS had strong comparative agreement for minor injuries but did not correlate well for critical injuries (ISS=25-75). The LOS and mortality predictive power were significantly higher for manually assigned ISS when compared with computer assigned ISS in both PTC and NTDB data sets. Thus, hospitals should be cautious about transitioning to computer assigned ISS, specifically for patients who are critically injured.

Quality of life after multiple trauma: results from a patient cohort treated in a certified trauma network

PURPOSE

Besides mortality, the patient-reported outcome (PRO) in survivors of multiple trauma is of increasing interest. So far, no data on patient-reported outcome measures (PROMs) after multiple trauma from an entire trauma network are available. Within this study, the course of the PRO over time and differences between level I and level II trauma centers within an entire trauma network was evaluated.

METHODS

Multiple injured patients, treated in a rural trauma network over 2 years, were prospectively included in this study. After 6, 12 and 24 months the results of the European Quality of Life (EuroQoL) EQ-5D outcome instrument were evaluated. To adjust for differences in trauma severity between level I and level II centers, the Revised Injury Severity Classification II (RISC II) and the Functional Capacity Index (FCI) were used to adjust the life-quality results of patients.

RESULTS

501 patients were included, 118 patients with an ISS < 16 points, 383 patients reached 16 points or more. Despite a steady increase of EQ-5D index over time (6 months: 0.71 ± 0.31; 12 months: 0.74 ± 0.28; 24 months: 0.76 ± 0.27; p < 0.001), the values of a reference population could not be reached even 2 years after trauma (EQ-5D reference population: 0.9). After adjustment for trauma severity, no significant differences in PROMs between level I and level II centers could be detected (p = 0.188).

CONCLUSION

The consistently low EQ-5D index relative the reference population and the lack of a difference between level I and II centers suggest that improved strategies for polytrauma aftercare are called for.

The association between patient education level and economic status on outcomes following surgical management of (fracture) non-union

BACKGROUND

Socioeconomic disparities are an inherent and currently unavoidable aspect of medicine. Knowledge of these disparities is an essential component towards medical decision making, particularly among an increasingly diverse population. While healthcare disparities have been elucidated in a wide variety of orthopaedic conditions and management options, they have not been established among patients who present for treatment of an ununited fracture. The purpose of this study is to answer the following questions: 1) Following surgical management of (fracture) non-unions, are there differences in outcomes between differing ethnic groups? 2) Following surgical management of (fracture) non-unions, are there differences in outcomes between patients with differing education levels? 3) Following surgical management of (fracture) non-unions, are there differences in outcome between patients with differing incomes?

METHODS

Between September 2004 and December 2017, operatively treated patients who presented with a long bone fracture non-union were prospectively followed. These patients presented with a variety of fracture non-unions that underwent surgical intervention. Sociodemographic factors were recorded at presentation. Long-term outcomes were evaluated using the Short Musculoskeletal Function Assessment (SMFA), pain scores, post-operative complications and physical exam at latest follow up. The SMFA is a 46-item questionnaire, assessing patient functional and emotional response to musculoskeletal ailments.

RESULTS

Three-hundred-twenty-nine patients met inclusion criteria. Patients with a lower education had worse long-term functional outcomes (P < 0.001) and increased pain scores (P = 0.002) at latest follow-up. Patients who made less than $50,000 annually had worse long-term functional outcomes (P = 0.002) and reported higher pain scores (P = 0.003) following surgical management of (fracture) non-unions. Multiple linear regression demonstrated education level to be an independent predictor of long-term functional outcomes following surgical management of (fracture) non-unions (B= -0.154, 95% Confidence Interval [CI]=-10.96 to -1.26, P = 0.014). No differences existed in outcomes or pain scores between those of different ethnic groups. No differences existed regarding post-operative complications and time to union between patients of different ethnic groups, educational levels and income status.

CONCLUSION

Patients with lower education levels and individuals who make less than $50,000 annually have worse functional outcomes following surgical management of (fracture) non-unions. Orthopaedic trauma surgeons should therefore be aware of these disparities, and consider early interventions aimed at optimizing patient recovery in these subsets.

Long-term changes of patient-reported quality of life after major trauma: The importance of the time elapsed after injury

BACKGROUND

Numerous studies have identified various risk factors for a poor health-related quality of life (HRQOL) after severe trauma. The relative importance of the time elapsed after injury, however, is unknown and results of clinical studies have been conflicting.

METHODS

A cross-sectional study was performed in two trauma centres using data from the German TraumaRegister DGU^®, which contained prospectively collected information on the type and severity of the injury, on critical care, and on outcome. To evaluate HRQOL in patients surviving more than 500days after the injury, we used a self-rating instrument, the EQ-5D which contains a visual analogue scale (EQ-VAS), and which allows the calculation of a global outcome indicator, the EQ-D5 index value. Complex statistical models were used to evaluate independent associations between the time elapsed after injury and a poor HRQOL.

RESULTS

Of 380 contacted patients, follow-up assessments could be obtained in 168 patients (44.2%) 3.6±1.6 (SD) years after the injury. There was a linear association between the time elapsed after the injury and the% of contacted patients not participating in the study (p=0.013). In participating subjects, average EQ-5D index value was 0.599±0.299, and average EQ-VAS rating 67.8±22.0. A very poor quality of life (EQ-5D index value<0.6, EQ-VAS rating≤50) could be found in 43.5% and 28.0% of the patients, respectively. After adjusting for multiple confounders, the number of days elapsed after injury showed a complex non-linear and independent association with a poor HRQOL (low EQ-5D index value: p=0.027; low EQ-VAS rating: p=0.008). Frequencies of a poor HRQOL reached their minimum about four to five years after the injury and increased thereafter.

CONCLUSIONS

There is an independent, U-shaped association between the frequency of extreme values of HRQOL and the time elapsed after injury. Time patterns of HRQOL may be sensitive to increasing rates of attrition since patients with a good outcome are less likely to respond to questionnaires. Time from injury should be incorporated into all future cross sectional studies trying to identify predictors of HRQOL.

[Trisegmental fusion by vertebral body replacement : Outcome following traumatic multisegmental fractures of the thoracic and lumbar spine]

BACKGROUND

Around 5% of all trauma patients suffer from spinal trauma. Spinal fractures are mainly located in the thoracic and lumbar spine. For multisegmental vertebral fractures categorized as instable, combined dorsal instrumentation and ventral stabilization is recommended. Numerous vertebral body replacement systems are available for ventral stabilization.

OBJECTIVES

The aim of the current study was to analyze radiological results following the implantation of a hydraulic expandable vertebral body replacement and the evaluation of patients' outcome three years after implantation.

MATERIALS AND METHODS

All patients who suffered traumatic multisegmental fractures of the thoracic or lumbar spine in the period from September 2009 to September 2012 were included in this study. Patients with additional injuries or abnormal sensitivity or motor function were excluded from the current study. All patients underwent dorsal percutaneous instrumentation. Afterwards, implantation of the vertebral body replacement was performed via the mini-open approach at our level I trauma center. In the computed tomography and X‑ray imaging, the sagittal kyphotic angle was measured. Furthermore, the clinical outcome (patients' satisfaction, VAS spine score) was analyzed using a questionnaire.

RESULTS

During the above mentioned period, seven patients (four female; three male) underwent dorsal instrumentation and ventral trisegmental fusion and were identified fitting the inclusion/exclusion criteria and thus could be included in the study. Most fractures were located in the thoracic-lumbar junction and were categorized A4 according to the AO Spine classification system. The analysis of the radiological data showed a pre-operative average traumatic segmental angle of 18.1 ± 14.9°, which could be decreased by reposition procedure to 6.4 ± 1.7°. The complete follow-up, including the data three years after implantation of the vertebral body implant, was available for three patients. The traumatic segmental angle remained stable in the follow-up three years later. In one case, a subsidence of the implant of 1.5 mm was observed, having no influence on the patients' satisfaction. All three patients indicated to be very satisfied with their outcome. The VAS spine score rating was in the range between 62.4 and 70.2.

CONCLUSIONS

The current study shows that in the case of multisegmental fractures complete reposition by ligamentotaxis and by the percutaneous instrumentation system is possible. In addition to the percutaneous dorsal instrumentation, the implantation of a hydraulically expandable vertebral body replacement may allow a stable fusion after complex traumatic fractures of the thoracic and lumbar spine. Patients are very satisfied with their outcome after this procedure.

Effects of an Integrated 'Fast Track' Rehabilitation Service for Multi-Trauma Patients: A Non-Randomized Clinical Trial in the Netherlands

Objectives

The effects on health related outcomes of a newly-developed rehabilitation program, called ‘supported Fast Track multi-trauma rehabilitation service’ (Fast Track), were evaluated in comparison with conventional trauma rehabilitation service (Care as Usual).

Methods

Prospective, multi-center, non-randomized controlled study. Between 2009 and 2012, 132 adult multi-trauma patients were included: 65 Fast Track and 67 Care as Usual patients with an Injury Severity Score ≥16, complex multiple injuries in several extremities or complex pelvic and/or acetabulum fractures. The Fast Track program involved: integrated coordination between trauma surgeon and rehabilitation physician, shorter stay in hospital with faster transfer to a specialized trauma rehabilitation unit, earlier start of multidisciplinary treatment and ‘non-weight bearing’ mobilization. Primary outcomes were functional status (FIM) and quality of life (SF-36) measured through questionnaires at baseline, 3, 6, 9 and 12 months post-trauma. Outcomes were analyzed using a linear mixed-effects regression model.

Results

The FIM scores significantly increased between 0 and 3 months (p<0.001) for both groups showing that they had improved overall, and continued to improve between 3 and 6 months for Fast Track (p = 0.04) and between 3 and 9 months for Care as Usual (p = 0.03). SF-36 scores significantly improved in both groups between 3 and 6 months (Fast Track, p<0.001; Care as Usual, p = 0.01). At 12 months, SF-36 scores were still below (self-reported) baseline measurements of patient health prior to the accident. However, the FIM and SF-36 scores differed little between the groups at any of the measured time points.

Conclusion

Both Fast Track and Care as Usual rehabilitation programs were effective in that multi-trauma patients improved their functional status and quality of life. A faster (maximum) recovery in functional status was observed for Fast Track at 6 months compared to 9 months for Care as Usual. At twelve months follow-up no differential effects between treatment conditions were found.

Trial Registration

ISRCTN68246661

[Rehabilitation after polytrauma : Definitions and treatment approaches]

After initial resuscitation and surgical reconstruction of structural damages, the functional rehabilitation is one of the critical columns of polytraumatized patient management. This programme starts as early as the initial therapy in the trauma bay and proceeds until socio-professional reintegration of the patient into his pre-traumatic environment.Thus, three phases of a rehabilitation were identified: the early rehabilitation, the post-acute rehabilitation and the continuative rehabilitation.Since the mortality after major trauma is continuously decreasing, the life quality of trauma victims came more and more into the focus of the actual scientific discussion. To improve this life quality, several rehabilitation programmes were developed and varius instruments were developed to quantify outcome results, such as the GOS or the SF-36, respectively.The aim of this review is to describe these various programmes and instruments, to improve the individual rehabilitation process for polytraumatized patients.

[Rehabilitation in the German statutory accident insurance. Guide to the new outpatient and inpatient structures]

BACKGROUND

The German statutory accident insurance (DGUV) has the statutory mandate to eliminate or to prevent an aggravation of the consequences of accidents by all appropriate means and is based on the principle of rehabilitation before pension. For this, special methods have been developed in recent decades, such as employer's mutual insurance inpatient further treatment (BGSW, Berufsgenossenschaftliche Stationäre Weiterbehandlung) and extended outpatient physiotherapy (EAP, Erweiterte Ambulante Physiotherapie). In 2012 the workplace-related musculoskeletal rehabilitation (ABMR, Arbeitsplatz-bezogene muskuloskelettale Rehabilitation) was added to these complex treatments.

SPECIAL REHABILITATION MEASURES

For complex injuries and delayed healing these methods approach their limits. The accident clinics of the Association of Clinics in Statutory Accident Insurance (KUV, Klinikverbund der gesetzlichen Unfallversicherung) provide a number of specialized rehabilitation measures in order to ensure an optimal seamless rehabilitation of the severely injured. In addition to complex inpatient rehabilitation (KSR, Komplexe Stationäre Rehabilitation) integrated special rehabilitation procedures, such as neurorehabilitation for severely traumatic brain injured patients and rehabilitation after spinal cord injury and other special rehabilitation methods, such as occupation-oriented rehabilitation (TOR, Tätigkeitsorientierte Rehabilitation) and pain rehabilitation, ensure that the German Society for Trauma Surgery (DGU) phase model of trauma rehabilitation is implemented. This provides an early start in the context of acute treatment as so-called early rehabilitation. After a specialized post-acute rehabilitation, additional therapeutic options are often required.

CONCLUSION

An appropriate treatment of severely injured patients is important, for example through rehabilitation managers, which must not end with discharge from the rehabilitation hospital. The aim of all efforts is the reintegration into the working and social environment in addition to the best possible quality of life.

[Quality of life after multiple trauma]

BACKGROUND

Multiple trauma is an independent injury pattern which, because of its complexity, is responsible for 25 % of the costs for the treatment of all injured patients. Because of the often long-lasting physical impairment and the high incidence of residual permanent handicaps, it is apparent that multiple trauma can lead to a reduction in patient quality of life.

OBJECTIVES

The aim of this study was to give an overview of the known data concerning the change in quality of life for multiple trauma patients. Furthermore, predictors for the reduction of quality of life after multiple trauma will be identified.

MATERIALS AND METHODS

A MedLine search was performed to identify studies dealing with the outcome after multiple trauma.

RESULTS

In addition to functional outcome parameters, the term quality of life has become more important in recent years when it comes to evaluating the outcome following injury. While the mortality after multiple trauma could be significantly reduced over the years, there is no comparable effect on the quality of life. Predictors for a worse quality of life after multiple trauma are female gender, high age, low social status, concomitant head injuries and injury to the lower extremities.

CONCLUSION

The fact that mortality after multiple trauma has decreased but not impairment of the quality of life makes it clear that in addition to the acute medical treatment, a follow-up treatment including not only physiotherapy but also psychotherapy is crucial for multiple trauma patients.