Physiotherapy Trauma Talks
In Physiotherapy Trauma Talks we discuss the key roles that physiotherapists and other healthcare practitioners play in the management and rehabilitation of patients with traumatic injury. Experts in trauma care offer their insights about in-hospital patient care and post-discharge follow up service delivery. New research in the field of trauma care and rehabilitation is shared to provide answers to your questions.
Physiotherapy Trauma Talks
Measuring Success: Outcome Tools in Trauma Care with Associate-Professor Ronel Roos
Outcome measures aren't just numbers on a page—they're powerful communication tools that transform physiotherapy practice in trauma care. Associate-Professor Roos explains how outcome measures create a universal language between patients, clinicians, and healthcare funders. Ronel shares how these tools guide critical decision-making throughout the rehabilitation journey—from acute care to discharge planning. For busy trauma physiotherapists, she offers a treasure trove of quick-to-implement assessment options requiring minimal equipment but delivering maximum impact. Whether you're a new graduate navigating your first trauma placement or a seasoned clinician looking to enhance your practice, this episode provides practical insights you can implement immediately. Consider sharing your thoughts about this discussion with me using the link provided, I would love to hear from you!
Podcast website: https://physiotherapytraumatalks.buzzsprout.com
Book: 'Cardiopulmonary Physiotherapy in Trauma: An Evidence-based Approach’ published by World Scientific: https://doi.org/10.1142/13509
Hi there, fellow physiotherapists. I am Helene van Asvegen, your host for Physiotherapy Trauma Talks, where we discuss everything related to trauma care. So if you are passionate to learn more about physiotherapy in the field of trauma to ensure that you provide the best possible care for your patients, then this is the right podcast series for you. Today, I am joined by Ronelle Ruiz, who is an Associate Professor in Physiotherapy at the University of the Witwatersrand in Johannesburg, and she is joining me for this discussion about the use of outcome measures in clinical practice. Renelle, welcome to this discussion.
Speaker 2:Thank you, Helene, and thank you very much for the introduction. I'm looking forward to our discussions.
Speaker 1:Would you mind starting and just sharing some of your experience with our listeners, particularly in relation to your clinical work in the trauma field, but also your experience as an educator and a researcher and I've been a full-time academic for the last 15 years where I've been affiliated with the University of the Witwatersrand in Johannesburg-Hauten.
Speaker 2:Part of my teaching the last 15 years has been that I teach cardiorespiratory and I also teach intensive care physiotherapy to the undergraduate students and I've also been involved with some of the postgraduate teaching. Part of our teaching load also includes clinical supervision of students at clinical placements. So even though I'm a full-time academic, I am at the clinical placements two days a week and that clinical supervision is conducted in the public sector hospitals in Gateng, but we're also quite blessed to have private sector hospitals where our students work. And then, prior to joining the university, if I think of more my trauma experience, I started as a clinician working in the public sector on the West Rand where I was responsible for the burn units at Leratong Hospital for physiotherapy services. When I was working there Also worked in the surgical wards where we often saw patients being admitted due to interpersonal violence and assaults, and then we also had patients admitted due to motor vehicle accidents and then subsequently referred for physiotherapy.
Speaker 2:My experience following the public sector, I also worked in the mining industry for a period. So the mining industry it was a gold mine on the West Rand and they had their own hospital. So we saw the patients and often it was trauma due to accidents on duty and usually it was related to mining accidents, so accidents that happened underground, such as explosions or rock falls, and then the patients were admitted to hospital, to the ICU or orthopedic ward. They were managed by the orthopedic surgeon or the general surgeon and then we saw them on the wards or ICU. The workers lived on residences at the mine. So following discharge from the hospital the patients were brought to outpatient physiotherapy and occupational therapy. So then we did outpatient care with the individuals and when we were finished with the outpatient care we had a fully equipped gymnasium. So then we transferred them onto the gymnasium where they did full body conditioning and we had physiotherapy assistants and technicians that then took over the care of the patients. Over the care of the patients, they then did gym training and following discharge from the gymnasium we then referred them on to occupational therapy where they did work assessment and they did work hardening in a different building and before the patients went underground again, they did an exercise tolerance test in a room that was heated, because underground it can be 39 or 40 degrees Celsius. Yeah, so the mining industry was really very good exposure because it was from acute care all the way through.
Speaker 2:Then I went and worked in the private sector as well, in private hospitals in Gauteng and with the private sector hospitals. It was the trauma ICU that I also worked in and the private practices that provided the care at the hospitals had outpatient clinic or practice as well. So we normally our daily routine was that we would work in the hospital in the morning and then we would see the other patients in the afternoon in the practice. So it was often patients that had traumatic injuries that were subsequently discharged from the hospital, that then were followed up as outpatients at the practice. So that was, you know, that's basically my clinical experience More the research related to trauma, research related to trauma.
Speaker 2:I think my MEC could be slotted into.
Speaker 2:I did my MEC in traumatology and my topic of my dissertation was related to exercise testing after patients were receiving prolonged mechanical ventilation, where we implemented an exercise test and measured objective outcomes, vital signs, but then also including subjective outcomes with the modified Borg scale, where we looked at effort and we looked at the relationship with regards to the patient's reported effort and what we physically saw in the patients.
Speaker 2:And then other research projects that I've been involved in was two MEC students. So the one MEC student did a systematic review where she looked at the effects of non-pharmacological the effects of non-pharmacological physiotherapy interventions on pain and physical function in patients with rib fractures and I think her study just highlighted that there was a big need for research to be done and that often in the literature the physios are not reporting outcomes with recognized functional outcome tools. And then a follow-up study on that was also an MEC project where the student looked at the effect of physiotherapy modalities on intercostal drainage and other secondary outcomes such as length of hospital stay and then also infection rates in patients that had chest trauma but was managed with the intercostal drain.
Speaker 1:Thank you for sharing that, and I'm sure that our listeners will agree with me in saying that you have got extensive background in the field of traumatology and therefore it's wonderful and a privilege to have you in this discussion about the importance of outcome measures in patient care. So, as we continue, do you want to just explain from your point of view why you feel that the use of outcome measures in trauma care is so important?
Speaker 2:I think when we use outcome measures, it's a way that we can actually evaluate what we do. It is also beneficial in relation to communication, so it optimizes communication between the patient and the health care worker, the physio. It also facilitates the communication between the health care team members, team members, and then it also is very valuable in relation to optimizing communication between health services and funders. It is also so if you work in traumatology or you work in cardiorespiratory. Many of the outcome measures overlap that we use in the acute care sector, so it's almost a language. So if you talk about this outcome, your colleague will know exactly what you mean, and if you interact with the multidisciplinary team and they become familiar with the outcome measures that you use, it improves the understanding of the need for physiotherapy as well, because if we use outcome measures, we evaluate what we do and we're providing evidence for what we are doing. So therefore it is part of evidence-based practice.
Speaker 1:Yes, I totally agree with what you've shared, and I think two important points that you've highlighted is that outcome measures become communication tools between the healthcare provider and the patient, but also between the members of the multidisciplinary team involved in trauma care, and secondly, that it helps to provide the evidence that we need to support what we do on a daily basis. So thank you for sharing that. Any other thoughts?
Speaker 2:It is also very important outcome measures, because when you are a physiotherapist and you use an outcome measure, it also helps with your decision making regarding clinical care. So if you have specific tools that you are using and you know what these tools or outcome measures assess, you get to know the outcome measure as well. Then it also guides your treatment that you are doing and it also guides changes in the treatment plan and some of the outcome measures that we use also gives us an idea of you know when a patient is ready for discharge. It's. Some of the studies highlight that the outcome measures link with where the patient needs to go to. They might need to go to a rehabilitation facility or it's safe to actually discharge the patient home. So I think it's very important. It helps with decision-making for the clinician, but also decision making in relation to the continuation of care. Yes, indeed.
Speaker 1:We sometimes hear people referring to outcome measures as being subjective or objective in nature. Would you mind sharing your thoughts about this?
Speaker 2:concept.
Speaker 2:Subjective outcome measures is where you use a measure and the patient provides feedback.
Speaker 2:So the patient needs to reflect on something and then provide you feedback. Some of the tools are also an easy one would be a visual analog scale where you ask the patient the pain levels, for instance, but some of the tools so subjective outcome measures that you can use at the bedside, but it can also be patiented outcome measures where it's more longer term, where you evaluate could be that you are evaluating the patient's experience and also the satisfaction regarding management and so forth, where objective outcome measures is more something that we assess, that the clinician looks at signs and symptoms that the patient reports and then analyze that information and use it to monitor the patient's change over time. So objective outcome measures can be performance-based measures, such as a functional assessment tool. It can also be clinician reported measures, so say, for instance, using a stethoscope to auscultate a patient's chest wall to provide you information on patient's ventilation. Yeah, so objective outcome measure is what we assess and the subjective outcome measure is more where your patient provides feedback.
Speaker 1:Yes, indeed, as you are very aware, I'm sure the trauma setting within an intensive care unit or high care unit can be quite a busy environment to work in and sometimes physiotherapists have quite a high patient caseload to get through on a daily basis. Based on your experience, are there any quick-to-use outcome measures that you think will help a physiotherapist specifically with their patient assessment?
Speaker 2:So for me it's very important. With the outcome measures, context and settings differ and the resources we have also differ. So to me, it's important that you use an outcome measure where you are reliant on yourself, you use what you have, and where you use the equipment that you have available in your context. Yes, so if you use an outcome measure where you need specialised equipment, if you're working in a context where there's resource limitations, you're never going to use that outcome measure and you would always say I'm not using it because I don't have the resources. So for me, it's very important that there's tools that we can use, that's not expensive and that most of us have available. So for me, when working with a patient in trauma ICU, I'd like to know if the patient is awake and alert and whether they can interact with me. So we have access to the ICU chart. We can do the Glasgow Coma Scale rating.
Speaker 2:But a short and easy assessment tool to use to evaluate the patient's cooperation is the standard five questions, and it's basically five questions that you ask your patient. It's a lot easier to remember and quick to evaluate. So so that to me to evaluate, so that to me to evaluate orientation and cooperation of the patient is important and it also gives me an idea of how much active involvement the patient will exhibit when treating, whether it's going to be an active treatment or it's going to be a bit more passive, if the patient is sedated, for instance. Yes, but I think with trauma there's always pain involved and physical discomfort. So I think it's really important so, when the patients are awake and that they're interactive, that you can observe the patient for any discomfort as you move them. But I think patient-reported feedback using a pain scale such as the Wong-Baker pain scale is quite important. So educational level differs between countries and settings and when a patient is maybe a little bit confused, they might be able to understand the Wombach pain scale a bit better than the numeric pain scale.
Speaker 2:Yeah indeed, then also when we start, many of our patients might require oxygen therapy, might require oxygen therapy invasively or non-invasively, you know, with a face mask. But if they have dysfunctional oxygenation ability when we start doing rehabilitation, the chances are very good that the patients might complain of dyspnea. So I think for patient-reported feedback, I think a tool such as the modified Borg dyspnea scale is also important.
Speaker 1:Yes, I totally agree, and often in patients with chest trauma we see that blood in the interpleural space, due to a hemonymo thorax, doesn't always completely drain through the intercostal drainage system and it congeals in the interpleural space, which means that a part of the lung is being restricted with regards to expansion. So I agree with you that it's really important to assess a patient's level of dyspnea as soon as we start getting them active and out of bed, so that we can see how that potentially impacts on their ability to breathe.
Speaker 2:Then I think as well. So if we think that we're managing a patient that might be on the ventilator, you will review the ventilation settings and modes. But I think, as part of respiratory physiotherapy, an objective calculation that you can do is dynamic compliance, and the majority of the ventilators the new ventilators now displays the dynamic compliance for you. So as you're managing your patient, you can check compliance in real time as you are working with the patient. So I think that's important. And then, if arterial blood gas analysis are done regularly, you might also be able to monitor the patient's PF ratio and see how that changes over time with the different interventions. That's done and then auscultation and evaluating what you are hearing if you're hearing any added sounds, and then also listening to the breath sounds, if you are hearing good ventilation throughout the lung. I think that is a valuable tool that we have available.
Speaker 2:And then, depending on your setting, chest x-rays might be done regularly as well, and it's an objective assessment. So reviewing the x-ray and seeing how your patient's lung is expanding and so forth, and then looking at chest wall movement and also feeling the chest wall by doing thoracic expansion evaluation, and that can be done manually, just by placing your hands on the chest wall and observing displacement that you're seeing. But you can also use a tape measure if the patient is able to sit on each of the bed and they are at that point of their rehab, and then patients with trauma will most likely have fractures limb fractures, yes, and they might. So it could be managed with internal fixation and we will start working on improving range at joints, yes, so I think it's also important to measure range objectively when there's limitations, so using a goniometer if possible, and then, as active movement returns, a tool the MRC SUMSCORE is very valuable as well to evaluate muscle strength in the patient.
Speaker 2:Yeah, and then mobility assessment, so as the patient starts being able to roll and sit up and then transfer B2C and then activities away from the B site. So I value the functional status score of ICU. So the FSS ICU and then the ICU mobility scale is also easy. It's a tool, easy to implement and it's a quick assessment that can be done. If you are working with patients with burn injuries in the burns ICU, then the functional assessment for burn score, the FAB, is also very valuable.
Speaker 1:Thank you for those suggestions and for most of what you suggested. One doesn't need additional tools apart from a stethoscope and a goniometer, and the rest of the outcome measures are freely available online, so those are very useful as the patient's condition improves and they are transferred to a ward setting. Do you think that there are any additional outcome measures that one can consider, including?
Speaker 2:in your management of the patient. So I think you know the aim would be, as soon as the patient is on the ward, is to get them more active and to get them more mobile. Then they will be dependent on doing more activity and I think it's then important to see how they respond to the added activity. So then, starting to look more at exercise capacity assessment so if a patient is able to walk, do a walking test such as the two-minute walk test or the six two minute walk test or the six minute walk test. If a patient is unable to manage that yet and is only able to walk short distances, then maybe the timed up and go test can be used. And with both these suggestions, and with both these suggestions, the patients can use a mobility aid and many of our trauma patients will have lower extremity fractures. That's been managed and we would walk them with a frame or crutches or gutter crutches. So the timed up and go and the six-minute walk test or two-minute walk test, we can do with the mobility aid as well.
Speaker 1:Yes, and I think, even before one comes to a test for assessing mobility away from the bedside, there's also a nice test that you can do at the bedside, just looking at the patient's ability to stand up from a seated position, so to do the one-minute sit-to-stand test. And I think most patients should be able to do that, particularly when we are looking at transferring them out of bed to sit in a chair, even if they do use a walking aid. So that's also another quick-to-administer test.
Speaker 2:I agree with you fully. It's a one-minute to stand test and it's also a test that can be done quite quickly. I think the patient population. So if we're thinking trauma, I think it would be more of value in someone that might have had chest wall trauma, where they don't have limitations in the lower extremities, meaning no fractures, but also individuals that had laparotomies. I would discourage using the one-minute sit-stand test because we know standing up when you have had a laparotomy is really uncomfortable and we tend to do that slowly and controlled to limit the discomfort that we feel. But with the one-minute sit-to-stand test we actually want the patient to be able to stand up as frequently as they can. So the test might be limited due to discomfort and not necessarily ability and exercise capacity.
Speaker 2:But one-minute sit-to-stand test is a very good tool. Another one so you can also use it in ICU. But you will need equipment. And if we think on respiratory muscle training, we want to assess and evaluate respiratory muscle training. We want to assess and evaluate respiratory muscle strength. So if you have a tool like a PowerBreathe KH1 device where you can measure maximal inspiratory pressure to give you a guide on muscle strength, if you don't have such a tool. You can always use a peak flow meter to also measure peak flow over time when you are working on improving mobility, improving respiratory muscle strength, if you have that available.
Speaker 1:Yes, and I think assessment of respiratory muscle strength would be very suited for patients who have had a longer period of intubation and mechanical ventilation and episodes of sepsis, which we know impacts the respiratory muscles just as much as the peripheral muscles due to the systemic inflammatory response to sepsis. So I think those are two interesting and important outcome measures to keep in mind as we rehabilitate these patients that survive sepsis as a result of their traumatic injury.
Speaker 2:So we spoke about measures where we are evaluating mobility and function, and then we also spoke about measures where we are evaluating mobility and function, and then we also spoke about exercise tolerance and tolerance for activity and peripheral muscle strength and I think that needs to continue on the ward as well and then respiratory muscle strength. I think if we work in ICU, the patient is connected to monitors and they might be connected to a ventilator as well, so we are able to assess vital signs automatically. It doesn't take an effort to evaluate a patient's vital sign when, if you are on the ward, the patient is normally not connected to equipment, but it's still very important to evaluate the patient's vital signs.
Speaker 1:Yes.
Speaker 2:To see how they respond to management over time. See how they respond to management over time. And many patients with trauma also are managed with surgical procedures and with the added interventions the chances of infection can escalate. And there's a very nice simple tool that you can monitor for any signs of sepsis, the QuickSofa score, where you evaluate respiratory rates, glasgow Coma Scale values and then systolic blood pressure. And I think if you routinely monitor vital signs and you are, as you are, interacting and assessing Glasgow coma scale values, you have that detail to calculate the quick sofa score.
Speaker 1:Do you know if there's an online calculator that one can use?
Speaker 2:Yes, Eliane, there is, you can download it onto. It's an app that you can download onto your cell phone, that you can use, and if you just access it through Wi-Fi on your cell phone if you're at the hospital, it's easy to assess and it gives you the score. So if you are concerned that these signs of infection and you've got this value, it's a nice tool to be able to communicate with the medical team as well on the findings of your patient.
Speaker 1:Yeah, yes, thank you very much for that handy tip and I think it will also impress the doctors when they come around on the ward round and you say that you've assessed the quick SOFA score and this is your finding.
Speaker 2:Thank you, yeah, and then also. So I think it's also important. So we've spoken about the MRC-SOMS school for peripheral muscle strength, but it's also very valuable to assist grip strength in the patient. So handheld dynamometry if you have such a device that you can objectively assess and then also evaluate according to normative values for the patient that you are working with. So on the ward we start promoting more activity than what we did in the ICU and our patients are able to provide more extensive feedback.
Speaker 2:So it could be very valuable as well to get an idea of what the patient's physical activity was prior to the trauma and prior to hospital admission. So a very easy tool is the physical activity vital sign, where you ask the patient two questions about how many days a week they were active and then also the time of the activity you calculate to see if they are normally active for 150 minutes a week. And there's one additional question that you can ask about strength training to get an idea whether the individual actually participated in strengthening exercises, to give you an idea of what the baseline value was before hospital admission if they sustained trauma, that's valuable. And then, in a patient that might, you know, have sustained trauma but they've got a cardiac condition as well. So looking at the New York Heart Association classification of breathlessness so that you evaluate the breathlessness in relation to the activity that they are doing, and then a patient who might have had a chronic respiratory condition such as COPD and then sustained trauma, using the modified MRC dyspnea scale, it could also be very beneficial.
Speaker 1:Yeah, that's very important. Renelle, thank you for sharing all of this information. I'm sure that you've given our listeners some food for thought. We all recognize that some days might be busier than others in a trauma setting and therefore, even if people just try to implement one or two of the mentioned outcome measures, it might help to create a bigger impact on their patient intervention and communication with the patient and discharge planning than it had before, without considering any outcome measures for treatment. As we wrap up this discussion, are there any last thoughts that you'd like to share with our audience?
Speaker 2:I think you know, for physio services, we want to demonstrate the effect that we have on patients' outcome and we in our daily practice we assess subjective or objective outcome measures and we document it in the clinical notes.
Speaker 2:But I think it's also very beneficial if you, just like you said, if you have a specific tool, so a functional tool that is recognized, you're using it. So obviously you recognize the benefit of using that assessment tool. But if you are able to demonstrate to the larger team the effect of implementing that assessment as part of the care, I think it's important to include the data that you're collecting to maybe a larger registry so that you belong to a team that consists of multiple healthcare practitioners. And if you include a specific functional status scoring tool that's part of assessing outcome over ICU, the ward, I think it could be quite valuable for communication at higher levels. So I think it's important. We are clinicians, but some clinicians are also managers and involved in bigger decisions. So I think we also need to consider one outcome tool data that can be included in a data registry so that we can look at the outcome of trauma care on a bigger scale and not just medical outcomes but also have a rehabilitation outcome in such a registry.
Speaker 1:Renelle, thank you so much for sharing your thoughts with us today and for your time. I really appreciate it. Thank you very much, Eliane.
