Clinical presentation, acute care management and discharge information of patients with thoracic trauma in South Africa and Sweden: a prospective multicenter observational study

PURPOSE

Thoracic trauma causes pain and hospitalisation. Middle- and high-income countries have different trauma contexts and populations. To report patients' clinical presentation (pain and shortness of breath) and its influence on hospital length of stay (LOS), acute care management, and discharge destinations in South Africa (SA) and Sweden.

METHODS

Prospective observational multicenter study by means of clinical record review. Two centers in SA and four centers in Sweden participated. One thousand nine hundred and eighteen adults with thoracic trauma were screened over the 20 months period. Study objectives guided information retrieved from clinical records. Statistical analysis was done with significance at p-value < 0.05.

RESULTS

Three-hundred-sixty-four participants were recruited with most being male (n = 170/179 (95%) SA; n = 125/185 (68%) Sweden). Type and mechanism of injury differed (SA penetrating (82%) versus Sweden blunt (95%); SA assaults (90%) versus Sweden falls (44%)). Unilateral haemopneumothorax was common (SA 68%, Sweden 35%) and managed with intercostal drainage. Rib cage injuries were common in the Swedish cohort with rib fixation surgery for 17%. Physiotherapy treatment frequency was mostly daily. Blunt injury resulted in higher pain levels during deep breathing (day 1: p = 0.014; day 2: p < 0.001; day 3: p < 0.001) and shortness of breath during activity (day 1: p = 0.036; day 2: p = 0.003; day 3: p < 0.001). LOS was shorter for SA cohort (5 (± 4) versus 7 (± 5) days; p = 0.024). Age influenced LOS in the blunt injury group. Discharge destination was mostly home (99% SA, 56% Sweden).

CONCLUSION

Priority care is indicated for those who are older and have blunt thoracic injury to prevent pulmonary complications and prolonged hospitalisation.

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.

Financing of physical rehabilitation services in Iran: a stakeholder and social network analysis

Background

Inadequate financing is one of the major barriers in securing equitable access to high-quality physical rehabilitation services, without imposing financial hardship. Despite this, no sufficient attention has been paid to physical rehabilitation services and no specific financial resources have been allocated to such services in many countries including Iran. Owing to the fact that effective decision- and policy-making requires identifying possible stakeholders and actors and their characteristics, in the current study a stakeholder analysis and also a social network analysis (SNA) was conducted to identify the potential stakeholders and also their characteristics involved in physical rehabilitation financing (PRF)-related policies in Iran.

Methods

The present study was performed in two phases. Firstly, semi-structured interviews and relevant document review were conducted to identify the stakeholders. Then, the position, power, interest, and influence of each stakeholder were determined using a web-based questionnaire. Secondly, SNA approach was utilized to map and visualize the interactions among stakeholders.

Results

The findings showed that there are different stakeholders in PRF-related decision- and policy-making processes in Iran. In addition, the position, power, interest, and influence level of the identified stakeholders were varied. Moreover, although some stakeholders, like the Ministry of Health and the parliament have the highest level of power and position, they lack sufficient interest to participate in PRF-policies. Furthermore, SNA demonstrated that social network density was low, which indicates the lack of proper collaboration and interaction among the stakeholders.

Conclusion

As many powerful and influential stakeholders had low interest levels to warrant participate in the FPR-related decision- and policy-making processes in Iran, employing careful and effective strategies, that is ongoing negotiations, receiving advocacy, and making senior managers and policy-makers aware can be helpful.

Physiotherapy management of patients with trunk trauma: A state-of-the-art review

BACKGROUND

Trauma injury remains a significant health risk for all on a global level. Patients with trunk trauma suffer blood loss, inflammation and hypoxia and are at risk of developing respiratory and musculoskeletal complications during their recovery. Physiotherapists are an integral part of the interprofessional team that manages patients who sustain trunk trauma.

OBJECTIVES

To describe the physiotherapy management of adult patients with trunk trauma, their quality of life, post-discharge rehabilitation service provision, and outcome measures used in the physiotherapy management.

METHOD

A non-systematic narrative review of published literature was performed.

RESULTS

Mobilisation, functional exercises, deep breathing exercises and active coughing are used to optimise patients' respiratory and musculoskeletal functioning. Some physiotherapists educate patients on the use of pain management strategies to reduce discomfort from rib fractures, surgical sites and intercostal drainage bottle tubing. Survivors of trunk trauma experience limitations in physical function up to two years. Little is known about post-discharge rehabilitation service provision to these patients after discharge. Few physiotherapists use outcome measures as part of their daily clinical practice.

CONCLUSION

Physiotherapy management of patients with blunt or penetrating trunk trauma during hospitalisation and after discharge is a field of clinical practice that is rich for high-quality research related to service provision, cost analysis and interventions used.

CLINICAL IMPLICATIONS

Physiotherapy clinicians and researchers can use the findings of this review as a guide to their management of adult patients recovering from trunk trauma.