Evaluation of disability and handicap following injury

Age-based differences in the disability of spine injuries in pediatric and adult motor vehicle crash occupants

OBJECTIVE

The objective was to develop a disability-based metric for quantifying disability rates as a result of motor vehicle crash (MVC) spine injuries and compare functional outcomes between pediatric and adult subgroups.

METHODS

Disability rate was quantified using Functional Independence Measure (FIM) scores within the National Trauma Data Bank-Research Data System for the top 95% most frequent Abbreviated Injury Scale (AIS) 3 spine injuries (14 unique injuries). Pediatric (7-18 years), young adult (19-45 years), middle-aged adult (46-65 years), and older adult (66+ years) MVC occupants with FIM scores available and at least one of the 14 spine injuries were included. FIM scores of 1 or 2 at time of discharge were used to define disability and correspond to full functional or modified dependence in self-feeding, locomotion, and/or verbal expression. Disability rate was evaluated on a per injury basis for each AIS 3 spine injury and calculated as the proportion of cases associated with disability (i.e. FIM of 1 or 2) out of the total cases of that particular injury. Disability rates were calculated with and without the exclusion of cases with severe co-injuries (AIS 4+) to minimize bias from additional non-spinal injuries that could have contributed to disability. Associations between adjusted disability rates and existing mortality rates were investigated.

RESULTS

Locomotion impairment alone was the most frequent disability type for the top 14 AIS 3 spine injuries (7 cervical, 4 thoracic, and 3 lumbar) across all age groups and spine regions. Adjusted and unadjusted disability rates ranged from 0-69%. Adjusted disability rates increased with age: 14.8 ± 10% (mean ± SD) in pediatrics to 16.2 ± 6.6% (young adults), 29.2 ± 10.9% (middle-aged adults), and 45.0 ± 12.2% (older adults). Among all adult populations, adjusted mortality and disability rates were positively correlated (R²>0.24), with disability rates consistently greater than corresponding mortality rates.

CONCLUSIONS

Older adults had significantly greater disability rates associated with MVC spine injuries across all spinal regions. MVC disability rates for pediatrics were considerably lower. Overall, rates of mortality were significantly lower than rates of disability. The adjusted disability rates developed can supplement existing injury metrics by accounting for age- and location-specific functional implications of MVC spine injuries.

Health-related quality of life and functional outcome measures for pediatric multiple injury: A systematic review and narrative synthesis

BACKGROUND

Pediatric multiple injury is a major cause of mortality and morbidity worldwide, with varied long-term sequelae. To improve care, a better understanding of the outcome tools used following multiple injury is needed.

OBJECTIVES

This study aimed to (1) identify the outcome tools used to assess functional and health-related quality of life outcomes in pediatric multiple injury and to (2) describe the tool domains and validity.

METHODS

Eligible studies were those that included pediatric participants aged 0 to 17 years who experienced multiple injury or severe trauma based on Injury Severity Score/Abbreviated Injury Scale score and a functional outcome tool was used to assess outcomes (e.g., physical, psychological, quality of life). Excluded study designs were editorials, narrative, and systematic reviews.

RESULTS

Twenty-two papers were included encompassing 16,905 participants and 34 different outcome tools. Ten tools were validated in children of which 4 were multiple injury specific; 18 were validated in adults of which 8 were trauma specific, and 6 were previously unvalidated. The tools were a mixture of patient reported (7 of 10 validated in children and 13 of 18 validated in adults) and clinician reported (3 of 10 validated in children and 2 of 13 validated in adults). Pediatric tool domains assessed were function, mobility, activities of daily living, pain, school, cognition, emotional domains, mental health, behavior, and high-risk behaviors. Using adult-validated tools to assess children may not capture the children's true function and health-related quality of life.

CONCLUSION

There was a lack of consistency in the outcome tools used following multiple injury in children. Adult-validated measures may not accurately capture pediatric outcomes after multiple injury. To fully understand the impact of pediatric multiple injury and make comparisons between studies, development of a core outcome set is required.

LEVEL OF EVIDENCE

Quantitative observational studies, level III.

Neutrophil gelatinase-associated lipocalin as a biomarker for short-term outcomes among trauma patients: A single-center observational study

BACKGROUND

Urinary biomarkers for organ dysfunction could predict the outcomes of severe trauma patients. However, the use of neutrophil gelatinase-associated lipocalin (NGAL) as a biomarker of trauma is not well studied.

OBJECTIVES

To evaluate the association between the short-term prognosis of trauma patients and NGAL levels.

METHODS

We conducted a single center study and compared predictive performances between NGAL levels and the trauma severity.

RESULTS

A total of 104 patients were included in the study. Patients were divided into two groups based on ISS score of 16. There was no significant difference in patient characteristics based on trauma severity. However, the lactate level was significantly higher in the more severe group. There was a significant association between urinary NGAL levels and trauma severity indicators, such as intensive care unit stay (ICU) (p = 0.005) and emergency care unit (ECU) stay (p = 0.049). In addition, receiver operating curve analysis showed that as a predictor, NGAL could be used for detecting severity with moderate precision, especially for short-term outcomes (specificity 70.6 for ICU and 69.0 for ECU stay).

CONCLUSION

In this study, we revealed that the level of NGAL could predict the degree of invasiveness in trauma patients with moderate precision and estimate the duration of treatment during the acute phase. It is necessary to examine the validity of the findings of this study using a prospective, cohort, and multi-center collaborative study design.

Effects of Virtual Reality on Cardiac Rehabilitation Programs for Ischemic Heart Disease: A Randomized Pilot Clinical Trial

(1) Background: The aim of the present study was to determine the effects of a virtual reality (VR) program, as a complementary tool to a conventional cardiac rehabilitation (CR) program in phase II of patients with ischemic heart disease compared to a conventional treatment group. (2) Methods: A single blinded randomized clinical trial was conducted. The patients were randomized to a control group (CG) or an experimental group (EG). The EG carried out a training based on VR of aerobic exercise using the XBOX ONE console and Kinect sensor. Ergometry, metabolic equivalents (METS), Functional Independence Measure, 6-min walk test (6MWT), the Short Form Health Survey-36 Questionnaire (SF-36), the Beck Depression Inventory-II, and the degree of satisfaction and adherence to treatment were used as outcome measures. (3) Results: Our results showed no statistically significant differences between the two groups. Statistical analysis within group for the EG showed statistically significant changes in the variables HR final ergometry, ergometry minutes, % ergometry, METS, final HR 6MWT, 6MWT distance, 6MWT number of laps, and for the SF-36 and Beck Depression Inventory-II. (4) Conclusion: A VR-based video game program, as an adjunct tool to a CR program, showed improvements in ergometry, METS, resistance to fatigue and health-related quality of life with excellent adherence and satisfaction perceived by patients with ischemic heart disease in phase II.

Competitive advantage gained from the use of helicopter emergency medical services (HEMS) for trauma patients: Evaluation of 1724 patients

OBJECTIVES

The aim of the study was to analyze helicopter emergency medical service (HEMS) in comparison to EMS, in respect to patient's mortality and morbidity.

DESIGN

From a cohort of traumatized patients (n = 1724) prospectively enrolled in the German trauma registry (DGU-R) at Frankfurt University Hospital from 2009 to 2013, 1646 could be analyzed for in-hospital mortality and short-term outcome (GOS) at discharge and compared between HEMS and EMS.

MEASUREMENTS AND MAIN RESULTS

129 patients (7.8%) died in the hospital. Unadjusted mortality was significantly lower in the HEMS group compared to EMS (p = 0.001). In a multiple logistic regression analysis after adjustment of variables including reanimation and age as the strongest predictors, in-hospital mortality was significantly reduced in HEMS (p = 0.014, OR = 0.21). Further predictors in the multiple logistic regression analysis were GCS > = 8 (p = 0.001), RRsys (p < 0.001), ISS at Head/Neck > = 3 (p = 0.003), and total ISS > = 9 (p < 0.001). Total rescue time and on scene time were associated with mortality (p < 0.001) but not included in the multiple logistic regression model. Without adjustment, short-term outcome (GOS) was significantly improved (p = 0.014). In a linear model, after adjusting for multiple variables including age, ISS Head/Neck > = 3, ISS Extremities > = 3, GCS > = 8, and RRsys as the strongest predictors (p < 0.001), the association remained significant (p = 0.043). Further predictors in the multiple linear regression analysis were total ISS > = 9 (p = 0.002), ISS abdomen (p = 0.001), and ISS Chest (p = 0.011).

CONCLUSIONS

A significant improvement for in-hospital survival for HEMS could be demonstrated. Especially in Germany, with a high number of secondary call outs (about 44%) after EMS has already reached the traumatized patient, HEMS must be the first choice for severely injured trauma patients. Dispatch criteria for immediate alarm of HEMS are recommended under practical considerations.

A feasibility study to assess pre-admission status and six month outcomes of major trauma patients admitted to an intensive care unit, using the WHO DAS 2.0

PURPOSE

To report the feasibility of assessing pre-admission functional status of ICU trauma patients, with repeat assessment at six months post ICU discharge using a standardised measure.

MATERIALS AND METHODS

A prospective longitudinal observational cohort design recruited consecutive adult major trauma admissions to a UK general ICU, between 1st November 2016 and 1st November 2017. The 12-item World Health Organisation Disability Schedule 2.0 was completed to assess pre-admission functional status as soon as possible after ICU admission. This was repeated at six months post ICU discharge, through ICU follow-up clinic, by post, or by telephone.

RESULTS

The ICU physiotherapy team were trained in the use of the measure in 2.5 h. Initial assessments were completed for 57 participants. Mean time from admission to assessment was 38 h, with assessments completed in an average of three minutes. The median six month score was 28.5, increasing from baseline by a median of 15.5 points. Of the responses received 20 (65%) were via post, 4 (13%) by telephone, and 7 (23%) via follow-up clinic.

CONCLUSIONS

Standardised assessment of pre-admission function was feasible. Future research should investigate the clinical relevance of scores and the validity of the measure in trauma patients.

Factors associated with non-return to work in the severely injured victims 3 years after a road accident: A prospective study

Road accidents may impact victims' physical and/or mental health and socio-occupational life, particularly the capacity to return to work. The purpose of our study is to assess modifiable medical and socio-occupational factors of non-return to work in the severely injured 3 years after a road accident. Among1,168 road accidents casualties in the Rhône administrative Département of France followed for five years, 141 of the 222 severely injured (Maximal Abbreviated Injury Scale ≥ 3) aged more than 16 years who were in work at the time of the accident, reported whether they had returned to work in the 3 years following the accident. The subgroups of those who had (n=113) and had not returned to work (n=28) were compared for socio-occupational (gender, age, educational level, marital status, socio-occupational group) accident-related medical factors (type of road user, type of journey, responsibility in the accident, initial care) and post-accident medical factors (pain intensity, post-traumatic stress disorder, physical sequelae, quality of life) by using standardized tools. Severity of initial head, face and lower-limb injury, intense persistent pain, post-traumatic stress disorder, poor self-assessed quality of life and health status at 3 years were associated with non-return to work on univariate analysis. On multivariate analysis, severity of initial head and lower-limb injury, intense persistent pain at 3 years and post-traumatic stress disorder were significantly associated with non-return to work 3 years following severe road-accident injury. Post-traumatic stress disorder and chronic pain were essential modifiable medical determinants of non-return to work in the severely injured after a road accident: early adapted management could promote return to work in the severely injured. Improve early adapted treatment of pain and PTSD in the rehabilitation team should help the severely injured return to work following a road accident.

Recovery of functional capacity in severe trauma victims at one year after injury: association with trauma-related and hospital stay aspects

[Purpose] The aim of this study was to investigate the functional capacity of trauma survivors one year after hospital discharge and to identify associations with trauma- and hospital stay-related aspects in a developing country. [Subjects and Methods] This study included severe trauma patients (Injury Severity Score ≥16; ≥18 years old) who were admitted to an intensive care unit in Sao Paulo, Brazil. Hospital stay data were collected from the patients’ records. Functional capacity was assessed using the Glasgow Outcome Scale and Lawton Instrumental Activities of Daily Living Scale one year after hospital discharge. Patients were asked if they had returned to work/school. [Results] Forty-nine patients completed follow-up. According to the Glasgow Outcome Scale data, most patients had moderate or mild/no dysfunction. The Lawton Instrumental Activities of Daily Living Scale showed that 60–70% of the subjects performed most activities independently. Multiple linear regression of the Glasgow score, Acute Physiology and Chronic Health Disease Classification System II score, length of mechanical ventilation, and hospital length of stay revealed an association between the Lawton Instrumental Activities of Daily Living Scale and hospital length of stay. Overall, 32.6% of the subjects had returned to work/school. [Conclusion] Most severe trauma patients experienced functional recovery, although only one-third had returned to work/school one year after hospital discharge. Hospital length of stay was identified as a significant predictor of functional recovery.

Measurement of Disability and Its Predictors Among Trauma Patients: A Follow-up Study

Background:

Globally more than a billion people, 15% of the population, lives with disability and most of disabilities are caused by injuries.

Objectives:

The aim of this study was to describe the prevalence of disability and its predictors at 1 and 3 months post-injury in Kashan City during 2014 - 2015.

Patients and Methods:

In this longitudinal follow-up study, 400 injured patients 15 - 65 years referred to Shahid Beheshti hospital in Kashan and hospitalized more than 24 hours were assessed for disability status with the WHODAS II 12-item instrument at 1 and 3-months post-injury. Patients based on their disability scores were divided into 5 groups: none, mild, moderate, severe and very severe. Work status was assessed at the 3-month follow-up with one question “Are you back at work following your injury”. Also, demographic characteristics and information about injury were gathered by a checklist. Data were analyzed using chi-square, Mann-Whitney U, Kruskal Wallis, Pearson correlation coefficient and logistic regression by SPSS software. The significance level was set at P < 0.05.

Results:

The mean disability scores at 1 and 3 months post-injury was 30.3 (9.2) and 18.8 (8.3), respectively and there was a statistical significant difference between disability status at 1 and 3 months after trauma (P < 0.0001). The rates of return to work in 262 employed patients at 1 and 3 months after injury were 29% and 55.4%, respectively. The disability score showed a statistically significant correlation with Injury Severity Score (ISS) (P < 0.0001), work return (P = 0.033), intensive care unit transfer (P < 0.0001), trauma type (P = 0.001) and age (P = 0.004). Also, age, ISS, duration of hospital stay and injury to extremities were predictors of disability.

Conclusions:

More than half of the patients were disabled after 3 months of trauma. Elderly patients, patient with severe trauma, and long hospitalization and patients with extremity injuries were high risk for disability.

More becomes less: management strategy has definitely changed over the past decade of splenic injury--a nationwide population-based study

Background. Blunt spleen injury is generally taken as major trauma which is potentially lethal. However, the management strategy has progressively changed to noninvasive treatment over the decade. This study aimed to (1) find out the incidence and trend of strategy change; (2) investigate the effect of change on the mortality rate over the study period; and (3) evaluate the risk factors of mortality. Materials and Methods. We utilized nationwide population-based data to explore the incidence of BSI during a 12-year study period. The demographic characteristics, including gender, age, surgical intervention, blood transfusion, availability of CT scans, and numbers of coexisting injuries, were collected for analysis. Mortality, hospital length of stay, and cost were as outcome variables. Results. 578 splenic injuries were recorded with an estimated incidence of 48 per million per year. The average 12-year overall mortality rate during hospital stay was 5.28% (29/549). There is a trend of decreasing operative management in patients (X², P = 0.004). The risk factors for mortality in BSI from a multivariate logistic regression analysis were amount of transfusion (OR 1.033, P < 0.001, CI 1.017–1.049), with or without CT obtained (OR 0.347, P = 0.026, CI 0.158–0.889), and numbers of coexisting injuries (OR 1.346, P = 0.043, CI 1.010–1.842). Conclusion. Although uncommon of BSI, management strategy is obviously changed to nonoperative treatment without increasing mortality and blood transfusion under the increase of CT utilization. Patients with more coexisting injuries and more blood transfusion had higher mortality.

Do the severity and the body region of injury correlate with long-term outcome in the severe traumatic patient?

BACKGROUND AND OBJECTIVES

To investigate if the Injury Severity Score (ISS) and the Abbreviated Injury Score (AIS) are correlated with the long-term quality of life in severe trauma patients.

METHODS

Patients injured from 2005 to 2007 with an ISS≥15 were surveyed 16-24 months after injury. The Health Assessment Questionnaire (HAQ-DI) was used for measuring the functional status and the Short Form-12 (SF-12) was used for measuring the health status divided into its two components, the PCS (Physical Component Summary) and the MCS (Mental Component Summary). The results of the questionnaires were compared with the ISS and AIS components. Results of the SF-12 were compared with the values expected from the general population.

RESULTS

Seventy-four patients filled the questionnaires (response rate 28%). The mean scores were: PCS 42.6±13.3; MCS 49.4±1.4; HAQ-DI 0.5±0.7. Correlation was observed with the HAQ-DI and the PCS (Spearman's Rho: -0.83; p<0.05) and no correlation between the HAQ-DI and the MCS neither between the MCS and PCS (Spearman's Rho=-0.21; and 0.01 respectively). The cutaneous-external and extremities-pelvic AIS punctuation were correlated with The PCS (Spearman's Rho: -0.39 and -0.34, p<0.05) and with the HAQ-DI (Spearman's Rho: 0.31 and 0.23; p<0.05). The physical condition compared with the regular population was worse except for the groups aged between 65-74 and 55-64.

CONCLUSIONS

Patients with extremities and pelvic fractures are more likely to suffer long-term disability. The severity of the external injuries influenced the long-term disability.

Determinants of limitations in unpaid work after major trauma: a prospective cohort study with 15 months follow-up

OBJECTIVE

To identify determinants of limitations in unpaid work (household work, shopping, caring for children and odd jobs around the house) in patients who had suffered major trauma (ISS≥16) and who were in full-time employment (≥80%) at the time of injury.

DESIGN

Prospective cohort study.

SETTING

University Medical Centre Utrecht, a level 1 trauma centre in the Netherlands.

METHOD

All severely injured (ISS≥16) adult (age≥16) trauma survivors admitted from January 1999 to December 2000 who were full-time employed at time of the injury were invited for follow-up (n=214). Outcome was assessed with the 'Health and Labour Questionnaire' (HLQ) at a mean of 15 months (SD=1.5) after injury. The HLQ was completed by 211 patients.

RESULTS

Response rate was 93%. Logistic regression analyses identified the percentage of permanent impairment (% PI), level of participation (RtW), co-morbidity, lower extremity injury (LEI) and female gender as determinants of limitations in unpaid work. Patients with a post-injury status of part-time or no return to work experienced more limitations in unpaid work than those who returned to full-time employment.

CONCLUSIONS

Resuming paid work after major trauma is not associated with reductions in unpaid activities. To assess the long-term outcome of rehabilitation programmes, we recommend a measure that combines patient's satisfaction in their post-injury jobs with a satisfactory level of activities in their private lives.

A systematic review of studies measuring health-related quality of life of general injury populations

Background

It is important to obtain greater insight into health-related quality of life (HRQL) of injury patients in order to document people's pathways to recovery and to quantify the impact of injury on population health over time. We performed a systematic review of studies measuring HRQL in general injury populations with a generic health state measure to summarize existing knowledge.

Methods

Injury studies (1995-2009) were identified with main inclusion criteria being the use of a generic health status measure and not being restricted to one specific type of injury. Articles were collated by study design, HRQL instrument used, timing of assessment(s), predictive variables and ability to detect change over time.

Results

Forty one studies met inclusion criteria, using 24 different generic HRQL and functional status measures (most used were SF-36, FIM, GOS, EQ-5D). The majority of the studies used a longitudinal design, but with different lengths and timings of follow-up (mostly 6, 12, and 24 months). Different generic health measures were able to discriminate between the health status of subgroups and picked up changes in health status between discharge and 12 month follow-up. Most studies reported high prevalences of health problems within the first year after injury. The twelve studies that reported HRQL utility scores showed considerable but incomplete recovery in the first year after discharge.

Conclusion

This systematic review demonstrates large variation in use of HRQL instruments, study populations, and assessment time points used in studies measuring HRQL of general injury populations. This variability impedes comparison of HRQL summary scores between studies and prevented formal meta-analyses aiming to quantify and improve precision of the impact of injury on population health over time.

Functional outcome after road-crash injury: description of the ESPARR victims cohort and 6-month follow-up results

OBJECTIVE

It is essential to know about the long-term consequences of road crashes involving corporal injury in order to adopt relevant public health measures.

METHODS

The ESPARR cohort comprises 1168 road-crash victims, aged 16 or over, managed in hospitals in the Rhône administrative départment (France). It is based on the Registry of Road Traffic Casualties, which has been collecting exhaustive data since 1995. Two groups are monitored: mild to moderate (M-AIS 1 or 2) and severe (M-AIS > or =3). Patients were interviewed at the point of primary care, between 1 October 2004 and 31 July 2006. 6 months later, their state of health and presence of pain were compared. Multivariate analysis (logistic regression) was performed to identify factors related to residual pain.

RESULTS

Adults of the cohort were compared to the road crash population as a whole recorded over the same period in the same area. At 6 months post-accident, only 31.9% of victims deemed their health status to have entirely returned to normal; 63.8% of mild to moderate and 89.2% of severe cases reported residual pain, but neither pain frequency nor intensity correlated with M-AIS. Residual pain was related to lower limb injuries (OR=1.6; 95% CI=1.1-2.4). After adjustment, pain was essentially related to age, seriousness of the lesions and a stay in a rehabilitation unit.

CONCLUSION

The ESPARR cohort provides a unique opportunity in France to describe the trajectory of a road crash victim, in terms both of care and rehabilitation and of resumption of work and personal activity.

Cost-effectiveness of an integrated 'fast track' rehabilitation service for multi-trauma patients involving dedicated early rehabilitation intervention programs: design of a prospective, multi-centre, non-randomised clinical trial

Background

In conventional multi-trauma care service (CTCS), patients are admitted to hospital via the accident & emergency room. After surgery they are transferred to the IC-unit followed by the general surgery ward. Ensuing treatment takes place in a hospital's outpatient clinic, a rehabilitation centre, a nursing home or the community. Typically, each of the CTCS partners may have its own more or less autonomous treatment perspective. Clinical evidence, however, suggests that an integrated multi-trauma rehabilitation approach ('Supported Fast-track multi-Trauma Rehabilitation Service': SFTRS), featuring: 1) earlier transfer to a specialised trauma rehabilitation unit; 2) earlier start of 'non-weight-bearing' training and multidisciplinary treatment; 3) well-documented treatment protocols; 4) early individual goal-setting; 5) co-ordination of treatment between trauma surgeon and physiatrist, and 6) shorter lengths-of-stay, may be more (cost-)effective.

This paper describes the design of a prospective cohort study evaluating the (cost-) effectiveness of SFTRS relative to CTCS.

Methods/design

The study population includes multi-trauma patients, admitted to one of the participating hospitals, with an Injury Severity Scale score > = 16, complex multiple injuries in several extremities or complex pelvic and/or acetabulum fractures. In a prospective cohort study CTCS and SFTRS will be contrasted. The inclusion period is 19 months. The duration of follow-up is 12 months, with measurements taken at baseline, and at 3,6,9 and 12 months post-injury.

Primary outcome measures are 'quality of life' (SF-36) and 'functional health status' (Functional Independence Measure). Secondary outcome measures are the Hospital Anxiety & Depression Scale, the Mini-Mental State Examination as an indicator of cognitive functioning, and the Canadian Occupational Performance Measure measuring the extent to which individual ADL treatment goals are met. Costs will be assessed using the PROductivity and DISease Questionnaire and a cost questionnaire.

Discussion

The study will yield results on the efficiency of an adapted care service for multi-trauma patients (SFTRS) featuring earlier (and condensed) involvement of specialised rehabilitation treatment. Results will show whether improved SFTRS logistics, combined with shorter stays in hospital and rehabilitation clinic and specialised early rehabilitation training modules are more (cost-) effective, relative to CTCS.

Trial registration

Current Controlled Trials register (ISRCTN68246661) and Netherlands Trial Register (NTR139).

The 'M2 DASH'-Manchester-modified Disabilities of Arm Shoulder and Hand score

The Disability of the Arm, Shoulder, and Hand (DASH) questionnaire was originally designed as a measure of disability in patients with disorders of the upper limb, but the DASH score is also affected by disability because of lower limb disorders. The aim of this study was to investigate the construct validity of the DASH questionnaire and to create a revised DASH questionnaire, the Manchester-modified or M2 DASH, with fewer questions that is more specific to the upper limb. Patients were asked to fill in the DASH questionnaire in a fracture clinic after ethical approval. This included 79 patients with upper limb injuries, 61 patients with lower limb injuries, and 52 control subjects. The mean DASH scores for the three groups varied significantly, and the lower limb group had a mean score of 16. The M2 DASH questionnaire was developed using questions more specific to the upper limb and included questions 1-4, 6, 13-17, 21-23, and 26-30 from the original questionnaire. The mean M2 DASH score for the lower limb group was 9 and, unlike the original DASH score, was not statistically different from the control group. The M2 DASH scores were then calculated for the upper limb group and a correlation study showed highly significant correlation between the original DASH scores and the M(2) DASH scores. Our study shows that the original DASH questionnaire is not specific for the upper limb. The M2 DASH questionnaire has the advantage of being more specific for the upper limb than the DASH questionnaire, and it correlates well with the original DASH questionnaire when looking at isolated upper limb injuries.

Life beyond severe traumatic injury: an integrative review of the literature

It is only recently that recognition of the serious and debilitating sequelae of trauma has prompted exploration of outcomes beyond survival, such as disability, health status and quality of life. This paper aims to review the literature describing outcomes following severe traumatic injury to provide clinicians with a greater understanding of the recovery trajectory following severe trauma and highlight the issues faced by those recovering from such injury. Electronic databases, published reference lists and the Internet were searched to identify relevant literature. The heterogeneous nature of published literature in this area prohibited a systematic approach to inclusion of papers in this review. Trauma survivors report significant sequelae that influence functional status, psychological wellbeing, quality of life and return to productivity following severe injury. Key themes that emerge from the review include: current trauma systems which provide inadequate support along the recovery trajectory; rehabilitation referral which is affected by geographical location and provider preferences; a long-term loss of productivity in both society and the workplace; a high incidence of psychological sequelae; a link between poor recovery and increased drug and alcohol consumption; and valued social support which can augment recovery. Future research to evaluate interventions which target the recovery needs of the severely injured patients is recommended. Particular emphasis is required to develop systematic, sustainable and cost-effective follow-up to augment the successes of existing acute trauma services in providing high quality acute resuscitation and definitive trauma management.

Functional outcome at 2.5, 5, 9, and 24 months after injury in the Netherlands

BACKGROUND

The collection of empirical data on the frequency, severity, and duration of functioning is a prerequisite to identify patient groups with long term or permanent disability.

METHODS

We fielded postal questionnaires in a stratified sample of 8,564 injury patients aged 15 years and older, who had visited an emergency department in the Netherlands. Measurements were at 2.5, 5, 9, and 24 months after the injury and included a generic health status classification (EQ-5D), socio-demographic, and medical information. We analyzed determinants of long-term functional outcome by multivariate regression analysis.

RESULTS

Five months after the injury health status of nonhospitalized injury patients was comparable to the general population's health (EQ-5D summary measure 0.87). Health status of patients admitted for 3 days or less improved until 9 months (0.82). For those admitted more than 3 days health status improved until 24 months (0.48 toward 0.67), but remained below population norms. Hospitalization, age and sex (females), type of injury (spinal cord injury, hip fracture, and lower extremity injury), and comorbidity were significant predictors of poor functioning in the long term.

CONCLUSIONS

Recovery patterns vary widely between nonhospitalized, shortly, and long hospitalized injury patients. Nonhospitalized injury patients recover within 5 months from an injury whereas a considerable group of hospitalized injury patients suffer from persistent health problems. Our study indicates the importance of health monitoring with an adapted longitudinal design for injury patients. The time intervals used should match the various stages of the recovery process, which depends on the severity of the injury studied.

Guidelines for the Conduction of Follow-up Studies Measuring Injury-Related Disability

BACKGROUND

Scientific knowledge on functional outcome after injury is limited. During the past decade, a variety of measures have been used at various moments in different study populations. Guidelines are needed to increase comparability between studies.

METHODS

A working group of the European Consumer Safety Association conducted a literature review of empirical studies into injury-related disability (1995-2005). We included injury from all levels of severity and selected studies using generic health status measures with both short-term and long-term follow up. The results were used as input for a consensus procedure toward the development of guidelines for defining the study populations, selecting the health status measures, selecting the timings of the assessments, and data collection procedures.

RESULTS

The group reached consensus on a common core of health status measures and assessment moments. The group advises to use a combination of EuroQol-5D and Health Utilities Mark III in all studies on injury-related disability. This combination covers all relevant health domains, is applicable in all kinds of injury populations and in widely different age ranges, provides a link with utility scores, and has several practical advantages (e.g., brevity, availability in different languages). For specific types of injury, the common core may be supplemented by injury-specific measures. The group advises a common core of assessments at 1, 2, 4, and 12 months after injury.

CONCLUSIONS

Our guidelines should be tested and may lead to improved and more consistent epidemiologic data on the incidence, severity, and duration of injury-related disability.

The importance of quality of survival as an outcome measure for an integrated trauma system

Risk-adjusted survival rates have been the principle mode of comparison between trauma systems. In mature trauma systems, it is possible that there will be further improvements in survival but these are likely to be small. In the future, the largest gains will come from quality of life and improved function of the survivors. The issues related to measuring quality of survival for trauma systems are reviewed, including feasibility, ethical considerations, risk adjustment of outcomes of survivors, and challenges for selection of instruments and administration. In addition, the preliminary experiences of measuring outcomes in survivors through the Victorian State Trauma Registry are discussed. Although function and quality of life have been identified as important factors to measure in trauma populations, a standardised protocol has not been established. The experience in Victoria suggests that monitoring of population-based outcomes in survivors is feasible and may create the basis for benchmarking the level of morbidity in survivors.

Routine Follow Up of Major Trauma Patients From Trauma Registries: What are the Outcomes?

BACKGROUND

Routine measurement of outcomes other than mortality in trauma is needed to monitor trauma care, benchmark trauma hospitals and systems, and to guide resource provision. Trauma registries are ideally placed to capture morbidity outcomes such as functional loss, disability, and handicap. This study aimed to provide a broad description of the 6-month outcomes of major trauma patients captured by a population-based trauma registry, establish the follow-up rate of registry patients, and determine any biases associated with loss to follow up.

METHODS

The Victorian State Trauma Registry (VSTR) is a population-based registry in Victoria, Australia. Major trauma patients captured by the VSTR with a date of injury from October 1, 2003 to September 30, 2004 were followed up at 6 months postinjury by telephone to collect information about their living status, functional levels, and return to work.

RESULTS

Of the 1,102 eligible patients, 67% were successfully followed up at 6 months postinjury. Eighteen patients had died since discharge. Patients lost to follow up were less severely injured (p = 0.004) and younger (p = 0.010) at baseline than those followed up. The vast majority of major trauma patients are independent with respect to locomotion (78%), feeding (93%), and expression (93%) by 6 months postinjury. Of those working before injury, 60% had returned to work.

CONCLUSIONS

The findings show that follow up of registry patients is feasible, results in few biases in the follow-up population, and reports similar findings to individual studies of trauma populations.

Retorno à atividade produtiva de motociclistas vítimas de acidentes de trânsito

OBJETIVOS: caracterizar os motociclistas internados no hospital e residentes no município de Maringá, segundo as atividades desenvolvidas no momento do acidente, ocupação anterior ao trauma e o retorno à produtividade entre nove meses e um ano após esse evento, além de identificar os fatores associados para alteração da produtividade dessas vítimas. MÉTODOS: a amostra foi constituída por 61 motociclistas vítimas de acidentes de trânsito nos meses de fevereiro e março de 1999. Os dados foram obtidos do prontuário hospitalar e de entrevistas domiciliares. RESULTADOS: no momento do acidente 45,9% das vítimas realizavam atividades relacionadas ao trabalho remunerado, enquanto 29,5% desenvolviam atividades de lazer, e as demais, outras atividades. Quanto à atividade produtiva das vítimas antes do acidente, o predomínio foi daquelas que realizavam atividade remunerada (81,9%). No período entre nove e doze meses pós-trauma, 20,4% das vítimas relataram atividade produtiva alterada. CONCLUSÃO: houve associação estatisticamente significativa entre a situação de produtividade após o acidente e as variáveis: Injury Severity Score, New Injury Severity Score e percepção do estado de saúde pela vítima.

Does the disabilities of the arm, shoulder and hand (DASH) scoring system only measure disability due to injuries to the upper limb?

Although the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was designed, and has been validated, as a measure of disability in patients with disorders of the upper limb, the influence of those of the lower limb on disability as measured by the DASH score has not been assessed. The aim of this study was to investigate whether it exclusively measures disability associated with injuries to the upper limb. The Short Musculoskeletal Functional Assessment, a general musculoskeletal assessment instrument, was also completed by participants. Disability was compared in 206 participants, 84 with an injury to the upper limb, 73 with injury to the lower limb and 49 controls. We found that the DASH score also measured disability in patients with injuries to the lower limb. Care must therefore be taken when attributing disability measured by the DASH score to injuries of the upper limb when problems are also present in the lower limb. Its inability to discriminate clearly between disability due to problems at these separate sites must be taken into account when using this instrument in clinical practice or research.

Prevalence and Determinants of Disabilities and Return to Work after Major Trauma

OBJECTIVE

The purpose of this study was to assess the prevalence and determinants of disabilities and return to work after severe injury in a Dutch, Level I trauma center.

METHODS

We prospectively included 295 patients with an Injury Severity Score > or = 16 treated between January 1996 and January 1999. All survivors received a mailed questionnaire in 2000, at least 1 year after their initial hospital admission. Health status was measured by the EuroQol-5D instrument, and the Glasgow Outcome Scale. Additional questions were asked about cognitive functioning and return-to-work rates. Regression analyses was conducted to explore the associations between these functional outcome measures and patient characteristics.

RESULTS

Of the 295 patients included, 99 (34%) died in hospital or during follow-up. From the 196 survivors, a response was obtained from 166 (85%). Of the survivors, 33% had to change their work or daily activity as a result of their injuries. Of the 127 patients of working age (18-65 years), 33 (26%) were unable to work and depended on social security. Problems with mobility, self-care, daily activities, pain/discomfort, anxiety/depression, and cognitive ability were found in 34%, 15%, 51%, 58%, 37%, and 57%, respectively. The EuroQol-5D summary score (0.76) was far below that of the general population norms. The number of body areas affected, injury severity (Injury Severity Score > or = 25), and gender (female) were significant independent predictors of worse long-term functional outcome.

CONCLUSION

Severe trauma has a substantial impact on long-term functioning. Empiric quantitative data, as presented in this study, enable us to estimate the burden of injury and to evaluate the quality of trauma care programs.

Lost working days, productivity, and restraint use among occupants of motor vehicles that crashed in the United States

BACKGROUND

In 2001, 6.3 million passengers were involved in motor vehicle crashes. This study aimed to determine the number of work days lost as a result of motor vehicle crashes and factors that influenced people's return to work.

METHODS

This was a retrospective, population based cohort study of occupants in motor vehicles involved in crashes from the 1993-2001 Crashworthiness Data System produced by the National Highway Traffic Safety Administration. The sample population of people aged 18-65 years included two groups: occupants who survived and were working before the crash and occupants who were injured fatally and were estimated to have been working before the crash. Multivariate linear regression was used to analyze the impact of restraint use and injury type on return to work.

RESULTS

Overall, 30.1% of occupants of vehicles that crashed missed one or more days of work. A crash resulted in a mean 28.0 (95% confidence interval 15.8 to 40.1) days lost from work, including losses associated with fatalities. The 2.1 million working occupants of vehicles that crashed in 2001 lost a total of 60 million days of work, resulting in annual productivity losses of over $7.5 billion (2964 to 12 075). Unrestrained vehicle occupants accounted for $5.6 billion in lost productivity.

CONCLUSIONS

Motor vehicle crashes result in large and potentially preventable productive losses that are mostly attributable to fatal injuries.

Health-Related Quality of Life and Disability in Survivors of Multiple Trauma One Year After Intensive Care Unit Discharge

OBJECTIVE

To evaluate health-related quality of life and disability in multiple-trauma patients requiring intensive care unit management.

DESIGN

A total of 87 survivors of multiple trauma, with a median age of 31 yrs and a median Injury Severity Score of 22, were enrolled in the present study. The Nottingham Health Profile, Glasgow Outcome Scale, and Rosser Disability Scale were used to assess the functional consequences of trauma 1 yr after intensive care unit discharge.

RESULTS

A total of 64 of 87 patients had a problem in at least one of the six domains related to subjective health status. The most prevalent complaint was related to somatic subdimensions, but emotional functioning was also affected. Nottingham Health Profile part 2 showed that 63 of the survivors experienced problems in at least one of the daily activities. Of particular importance, inability to work was reported by 47% of the patients. Fifty-nine percent experienced moderate-to-severe disability as evaluated by Glasgow Outcome Scale and Rosser Disability Scale. High aggregate injury severity score along with severe head trauma were independent predictors of poor health-related quality of life and disability.

CONCLUSIONS

The majority of survivors of major trauma exhibit considerable levels of disability and impairment in health-related quality of life. Global injury severity score and degree of brain trauma determine functional limitations. This information may help in organizing long-term rehabilitation of multiple-trauma patients.

Influence of trauma system implementation on process of care delivered to seriously injured patients in rural trauma centers

BACKGROUND

Statewide trauma systems are implemented by health care policy makers whose intent is to improve the process of care delivered to seriously injured patients. In Oregon, Advanced Trauma Life Support (ATLS) training was mandated for all physicians employed in the emergency department of trauma centers. The purpose of this study was to test the hypothesis that mandatory ATLS training favorably influenced processes of care.

METHODS

Seriously injured patients treated at 9 rural Level 3 and Level 4 hospitals were studied before (PRE) and after (POST) implementation of Oregon's trauma system. The processes of care evaluated on the basis of chart review were 20 diagnostic and therapeutic interventions advocated in the ATLS course. A cumulative process score (CPS) between 0 and 1 was assigned on the basis of the processes of care delivered. A CPS of 1 indicated optimal process of care.

RESULTS

Mean CPS for 506 PRE period patients (0.44 +/- 0.27) was significantly lower than the mean CPS for 512 POST period patients (0.57 +/- 0.27) with an unpaired t test (P <.001). For the subgroup with injury severity score of 16 to 34, the mean CPS of survivors (0.67 +/- 0.19) was significantly higher than the mean CPS of decedents (0.57 +/- 0.25).

CONCLUSIONS

Process of care for seriously injured patients improved after categorization of rural trauma centers in Oregon. Evidence shows improved process of care may have benefitted patients with serious but survivable injuries. Measurement of process of care is an alternative to mortality analysis as an indication of the quality of care.

Cervical spine trauma in the injured child: a tragic injury with potential for salvageable functional outcome,

BACKGROUND/PURPOSE

Cervical spine injuries are uncommon in children, and, therefore, presumptive immobilization and diagnosis remain controversial. The purpose of this study was to review the author's experience with cervical spine injuries in children to determine the incidence, injury mechanism, pattern of injury, and subsequent functional outcome.

METHODS

Fifty-two children over a 6-year period (1994 to 1999) with a cervical spine injury secondary to blunt trauma were identified (1.3% incidence). The functional independent measure (FIM) was assessed at the time of discharge in each of 3 categories: communication, feeding, and locomotion.

RESULTS

Mean age of the study children was 10.7 +/- 0.7 years. Eight children (15%) were less than 5 years old, and 4 (8%) were less than 2 years old. The mechanism of injury included motor vehicle crash (52%), falls (15%), bicycle accidents (11%), sports-related injuries (10%), pedestrian accidents (8%), and motorcycle crashes (4%). Seven patients died yielding an overall mortality rate of 13%. Injuries were distributed along the cervical spinal cord as follows: 5 atlanto-occipital dislocations, 28 C1 to C3 injuries, 17 C4 to C7 injuries, and 2 ligamentous injuries. FIM scores were recorded for 18 patients. Seventeen communicated independently, 14 fed themselves independently, and 12 had independent locomotive function.

CONCLUSIONS

Cervical spine injuries occur in children across a spectrum of ages. Although atlanto-occipital dislocation is a highly lethal event, children with C1 to C7 injuries have a high likelihood of reasonable independent functioning.