Prospective observational study to examine health-related quality of life and develop models to predict long-term patient-reported outcomes 6 months after hospital discharge with blunt thoracic injuries

EarLy Exercise in blunt Chest wall Trauma: A multi-centre, parallel randomised controlled trial (ELECT2 Trial)

INTRODUCTION

The aim of this trial was to investigate the impact of early thoracic and shoulder girdle exercises on chronic pain and Health-Related Quality of Life in patients with blunt chest wall trauma, when compared to normal care.

METHODS

A multi-centre, parallel, randomised controlled trial, in which adult patients presenting to hospital with blunt chest wall trauma were allocated to either control or intervention group. The intervention was an exercise programme consisting of four simple thoracic and shoulder girdle exercises, completed for one week. Outcomes measures included prevalence and severity of chronic pain using the Brief Pain Inventory, health-related quality of life using EQ-5D-5 L, and cost effectiveness, measured at initial presentation and three months post-injury.

RESULTS

360 participants were recruited. Participants' mean age was 63.6 years (standard deviation (SD): 17.9 years) and 213 (59.8 %) were men. After loss-to-follow-up, the survey response rate at three months was 73.0 % (251/344 participants). The primary analysis, for chronic pain prevalence at three months post-injury, found no statistically significant differences between intervention and control groups, with lower rates in the control (intervention: 35/126 (27.8 %), control: 20/117 (17.1 %); adjusted odds ratio 1.862; 95 % CI: 0.892 to 3.893, p = 0.098). There were no statistically significant differences between intervention and control groups for pain severity at three months post-injury, (intervention mean (SD): 2.15 (2.49), control: 1.81 (2.10); adjusted difference 0.196, 95 % CI:0.340 to 0.731; p = 0.473); or Health-Related Quality of Life (intervention mean (SD): 0.715 (0.291), control: 0.704 (0.265); adjusted difference: 0.030; 95 % CI:0.033 to 0.094; p = 0.350). The health economic analysis found the intervention was associated with higher costs compared to normal care.

CONCLUSION

The results of this trial did not support a 'one-size fits all' simple, early exercise programme for patients with blunt chest wall trauma. Future research should consider the impact of a personalised exercise programme, commenced by the patient at least one week post-injury.

Blunt mechanism chest wall injury: initial patient assessment and acute care priorities

Blunt mechanism chest wall injury (CWI) is commonly seen in the emergency department (ED), since it is present in around 15% of trauma patients. The thoracic cage protects the heart, lungs and trachea, thereby supporting respiration and circulation, so injury to the thorax can induce potentially life-threatening complications. Systematic care pathways have been shown to improve outcomes for patients presenting with blunt mechanism CWI, but care is not consistent across the UK. Emergency nurses have a crucial role in assessing and treating patients who present to the ED with blunt mechanism CWI. This article discusses the initial assessment and acute care priorities for this patient group. It also presents a prognostic model for predicting the probability of in-hospital complications following blunt mechanism CWI.

Scoping review of the literature to ascertain how the STUMBL Score clinical prediction model is used to manage patients with blunt chest wall trauma in emergency care

INTRODUCTION

The STUMBL Score clinical prediction model was originally developed and externally validated to support clinical decision-making of patients with blunt chest wall trauma in the Emergency Department. The aim of this scoping review was to understand the extent and type of evidence in relation to the STUMBL Score clinical prediction model as a component of the management of patients with blunt chest wall trauma managed in the Emergency Care setting.

METHODS

A systematic search was conducted across databases, including Medline, Embase and the Cochrane Central Register of Controlled Trials from Jan 2014 to Feb 2023. In addition, a search of the grey literature was undertaken along with citation searching of relevant studies. Published and non-published sources of all research designs were included. Data extracted included specific details about the participants, concept, context, study methods and key findings relevant to the review question. Data extraction followed the JBI guidance and results presented in tabular format accompanied with a narrative summary.

RESULTS

A total of 44 sources originating from eight countries were identified, 28 were published and 16 grey literature. Sources were grouped into four separate categories: 1) external validation studies, 2) guidance documents, 3) practice reviews and educational resources 3) research studies and quality improvement projects, 4) grey literature unpublished resources. This body of evidence describes the clinical utility of the STUMBL Score and has identify how the score is being implemented and used differently in different settings including analgesic selection and participant eligibility for including in chest wall injury research studies.

DISCUSSION

This review demonstrates how the STUMBL Score has evolved from solely predicting risk of respiratory complications to a measure which supports clinical decision making for the use of complex analgesic modes and as a guide for eligibility in chest wall injury trauma research studies. Despite external validation of the STUMBL Score, there is a need for further calibration and evaluation, particularly relating to these repurposed functions of the score. Overall, the clinical benefit of the score remains clear and its wide usage demonstrates the impact it has on clinical care, patient experience and clinician decision making.

Early exercise in blunt chest wall trauma: protocol for a mixed-methods, multicentre, parallel randomised controlled trial (ELECT2 trial)

INTRODUCTION

Chronic pain and disability are now well-recognised long-term complications of blunt chest wall trauma. Limited research exists regarding therapeutic interventions that can be used to address these complications. A recent feasibility study was completed testing the methods of a definitive trial. This protocol describes the proposed definitive trial, the aim of which is to investigate the impact of an early exercise programme on chronic pain and disability in patients with blunt chest wall trauma.

METHODS/ANALYSIS

This mixed-methods, multicentre, parallel randomised controlled trial will run in four hospitals in Wales and one in England over 12-month recruitment period. Patients will be randomised to either the control group (routine physiotherapy input) or the intervention group (routine physiotherapy input plus a simple exercise programme completed individually by the patient). Baseline measurements including completion of two surveys (Brief Pain Inventory and EuroQol 5-dimensions, 5-Levels) will be obtained on initial assessment. These measures and a client services receipt inventory will be repeated at 3-month postinjury. Analysis of outcomes will focus on rate and severity of chronic pain and disability, cost-effectiveness and acceptability of the programme by patients and clinicians. Qualitative feedback regarding acceptability will be obtained through patient and clinician focus groups.

ETHICS/DISSEMINATION

London Riverside Research Ethics Committee (Reference number: 21/LO/0782) and the Health Research Authority granted approval for the trial in December 2021. Patient recruitment will commence in February 2022. Planned dissemination is through publication in a peer-reviewed Emergency Medicine Journal, presentation at appropriate conferences and to stakeholders at professional meetings.

TRIAL REGISTRATION NUMBER

ISRCTN65829737; Pre-results.