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
Trunk Trauma Part 2: Blunt Chest Injury and Physiotherapy with Prof Ceri Battle
What happens when a traumatic fall leads to multiple broken ribs? How do physiotherapists determine which patients need immediate attention and which can safely go home? These questions drive Professor Ceri Battle's groundbreaking work in blunt chest trauma management. The first 72 hours post-injury represent the danger zone, where targeted physiotherapy interventions can prevent life-threatening complications. Whether you're a physiotherapy student, experienced clinician, or healthcare professional working with trauma patients, this episode offers practical insights into assessment tools, management techniques, and the evolving science of chest trauma recovery. 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. So welcome back to another episode of Physiotherapy Trauma Talks. Today, our discussion is going to focus on the management of patients with blunt chest trauma and specifically, the role that physiotherapists play in this regard.
Speaker 1:I'm honoured to have as my guest today Kerry Battle. Kerry is an honorary professor at Swansea Bay University and a consultant physiotherapist at Morriston Hospital in Swansea in Wales in the United Kingdom, and also a very experienced researcher in the field of physiotherapy management of patients with blunt chest trauma. Kerry, thank you so much for joining the discussion this afternoon. It's lovely to have you as a guest on the show. Thank you for having me. So, kerry, would you mind starting off by telling our listeners about what made you interested in working in the field of trauma physiotherapy and specifically blunt chest trauma?
Speaker 2:Yes, well, I actually started out as a critical care physiotherapist, so I'm a respiratory physio and I've worked for about 25 years in critical care. And I can remember a specific patient who came on to our critical care unit. He was a paramedic who had recently retired and he'd fallen on ice and he'd landed on his chest wall and he'd come to our emergency department complaining of pain. Our emergency department team had assessed him and they'd sent him home with some painkillers and an advice leaflet. Department team had assessed him and they'd sent him home with some painkillers and an advice leaflet. And then about three days later he came back to our emergency department with quite severe breathing difficulties and he ended up on our critical care unit, which is where I first met him.
Speaker 2:And it sort of dawned on me that we don't always manage these patients well. They quite often present to our emergency departments and they're doing really well, we don't think there are any problems, but then a few days later they come back with problems. And it was at that point my interest really was piqued in how do we risk stratify these patients in the first instance? And that really was the beginning of how I got interested in managing chest trauma.
Speaker 1:Yeah, that's a very interesting background to where your profession developed into the field. Could you maybe just share with us? We know that in the UK there's a much higher incidence of blunt chest trauma versus penetrating chest trauma, whereas in developing countries like South Africa we have the exact opposite. So I was just wondering, with the patient population that you see with blunt chest trauma, what is the average age, the gender, demographics and the causes of injury most often?
Speaker 2:So our demographics changed over the last 10 years or so. So when I first worked with this patient group it tended to be the sort of younger male patient who'd been involved in a road traffic accident. But over the last 10 years and there's been research to show this in the UK the demographic has really changed. So now we're seeing much more of the older adults or patients who are 60 and above and they've had a fall from a standing height. So I think that sort of matches the demographic really of the population in the UK, which is sort of older than it used to be and there are less males. Now, sort of averaged out a little bit, we see a fairly equal split between males and females compared to 10 years ago.
Speaker 1:Okay, that's quite interesting. I just wanted to clarify when you say people that fall from a standing height, that would be from a height of less than two meters.
Speaker 2:Yes, that's right. So we would say a fall from standing height or less than two meters, as you say. Yes, Okay.
Speaker 1:And I assume, because the population is older, that there are often osteoporotic rib fractures Is that correct.
Speaker 2:Yeah, we're getting a lot of fragility fractures lately. So, as you say, osteoporotic fractures, the same as the people who fall and fracture their hip. That's much more commonly recognized, isn't it? The hip fractures. But for us we see probably an equal amount, if not more, fractures to the chest wall than the hip in the UK now.
Speaker 1:And I suppose other causes might be sport related or people riding horses that are not used to it and then fall off the horses and injure their chest wall.
Speaker 2:Yeah, we do get. We will see patients who've had a fall from greater than two metres. For us it tends to be, believe it or not. The most sort of common mechanism I see is an elderly gentleman who's fallen off a ladder and I quite often say to these people why are you up a ladder when you're in your 70s and 80s? But yeah, we'll see sort of sporting injuries, people who've fallen from a greater height than two meters, and road traffic accidents and road traffic collisions, whether that's as a pedestrian or vehicle versus vehicle or vehicle versus bicycle. Occasionally. Sort of sporting injuries and assaults is the other one, obviously, but we get far more blunt chest trauma than we do penetrating trauma, like you would.
Speaker 1:Yeah, so when these patients present themselves at the casualty or emergency department of the hospital, how involved are your physiotherapists at that stage in their care.
Speaker 2:Well, this is something that's changed recently. Initially it would only be on an on-call basis. So if a clinician, a doctor, in the ED had assessed the patient and felt that they would benefit from chest physio or physiotherapy of any sort, we would be called really on an on-call basis and my team, the surgical and critical care team, would cover that during the day on a bleep service or the on-call person overnight. But more recently, I would say in the last two years or so, we've got physios who are based down in the emergency department all day, so they would pick up the chest trauma patients. So they would pick up the chest trauma patients.
Speaker 1:We've also got things like the older person service, so those older adults who come in with a fall, they would be picked up by physios who are specifically working in the emergency department, but within the older adult department, within that, yeah that's really interesting, and I remember one of the papers that you published in 2012 or 2013 showed the criteria of patients in the emergency department that are more likely to develop complications, and they were those that had more than three rib fractures and that were older. But there were other criteria as well. Could you maybe just remind me of that?
Speaker 2:Yes, of course. So, as you say, it was a patient age of 65 years or more. It was whether the patient had three or more rib fractures. And then there were three other variables. So the others were whether the patient had a history of chronic lung disease, whether they were using anticoagulant therapy before their injury, and the third one was the oxygen saturations on initial assessment on presentation to the emergency department. So the lower the oxygen saturations, obviously the greater risk.
Speaker 1:Yeah, that's right. So it's amazing that you've got a 24-hour physiotherapy service in your emergency department and that you managed to identify these criteria of patients that would need more physiotherapy input, I would assume, in the emergency department to prevent complications from developing. I remember reading about the Stumble score and I know that you were very instrumental in creating this clinical prediction tool. Would you just mind sharing a little bit about that?
Speaker 2:Yeah, of course. So this came out of that case. I told you when you asked me the question about how I got into chest trauma management chest trauma management. So after that patient came in, a group of us as clinicians decided we needed to do something where we would create some sort of a clinical prediction model or risk stratification tool which would help us determine which patients were going to go on and develop complications within the next few days. And that really was where the StumbleScore work began. So we created something as a small pilot study and the tool we created seemed to improve outcomes, but we hadn't done it very scientifically. So somebody at that time said one of you needs to consider doing this as a PhD, and that was sort of where the PhD work started. And then, with the PhD work, I sort of went back to the beginning and created the StumbleScore in a much more scientifically robust manner, and that was where it all started, really back in 2009, I think.
Speaker 1:Now yeah, that's great. And is this a tool that people use in your hospital on a daily basis?
Speaker 2:Yeah, so the tool is used. Well, in fairness, the tool is now used in numerous countries across the world. So it's very much used in the UK and in the majority of hospitals, and then it's also used in. I know it's used in hospitals within Europe, in New Zealand, australia, america, ukraine more recently. So it's used really extensively now across the world, apart from South Africa.
Speaker 1:I seem to remember you saying yeah, hopefully it will come into being at some point in South Africa, but yeah, that's fantastic. So it just shows how your research that you did for your PhD actually translated into clinical practice across the world, which is fantastic. So, just to clarify, the StumbleScore is the most appropriate place to use that the emergency department, or can it also be used on the trauma wards or the trauma ICU setting?
Speaker 2:No, it was validated for use in the emergency department only. I know people have started using it outside of the sort of settings with which it's been validated and we do advise against that because obviously we don't know if that actually works or not. So yeah, we advise stick to the emergency department. It's also been used for other things than what we validated it for. So initially it was validated simply to guide discharge disposition from the emergency department, so could the patient go home or did they need ward or critical care. But now it's used to direct whether the patient gets regional analgesia, whether they get physiotherapy referral, all sorts of other uses, which makes me a little bit nervous because it hasn't yet been validated for those uses. Robustly, I would say, management.
Speaker 1:So, apart from triaging patients in the emergency department to see who is at higher risk and who might need more immediate physiotherapy, let's talk a little bit about the physiotherapy management of patients in the emergency department. We'd assume that all patients receive pain management, but what would the physiotherapist typically do in the emergency department for these patients?
Speaker 2:I think the key thing with these and this comes from some of the work we've all been doing recently, our sort of international physiotherapy team, obviously with your part I think one of the key things is we've recognised is self-management. So we really need to educate the patient on how to self-management. So we we really need to educate the patient on how to self-manage, whether they're going home or to a ward or to critical care. They need to take some ownership for their management of their injury and I think that for me, over the last few years, has become much more of a priority than anything else we do.
Speaker 1:Okay, yeah, no, that's great, and I think putting the patient in charge in a sense, or helping them to take responsibility for their own wellness despite the injury and educating them along the way is really important. So for those patients that are admitted to the hospital I know that everybody always says they don't have enough staff that are available to cover the trauma wards or the ICU that need more care over others or do you do a general assessment of everybody and then sort of stratify your interventions accordingly?
Speaker 2:Yeah, so we would. We've got a pathway we've introduced in the last few years and the pathway starts off with that initial assessment. We assess the patient as early as possible, ideally within the 24, the 24 hours, and then we would risk stratify using the StumbleScore. So if the patient scored more than 16 or not, we would then target those patients, and obviously that's using a little bit of clinical common sense as well. So even if they score highly, but they're very independent and they have a very good understanding of their injury and self-management, we may not sort of use the Stumble score quite strictly, but, as I said, so the ones that score highly we would prioritise, and that would only really be for the first 72 hours of the patient's stay. I mean, they may well be discharged home before then, but that's that high-risk period, is that first 72 hours?
Speaker 1:But that's that high risk period. Is that first 72 hours? Okay, and just to let the listeners know that if you search for stumble score online, you immediately find the online calculators. So it's really user friendly tool to use and easy to get the scores when you just enter some basic patient demographics and results in there. So very user-friendly. But I wanted to ask you, with the great emphasis on educating the patients to self-manage, how do you test whether the patient understands what you want them to do?
Speaker 2:I think for me personally, I would make sure I would give the information in my initial assessment. I would, obviously, when I say self-management and education, you're still teaching the basics. So you're teaching the need for deep breathing exercises, so that volume expansion that we need these patients. And then the secretion removal, so the cough, the huff, the forced expiratory technique. So I would teach the patient those things. I would also teach them about monitoring their pain, their dynamic pain score. I think that's particularly important. And then when I reassess them later the same day, because I'd like to see them twice in that first day I would be able to gain an understanding of how much they've retained and how much they've taken on board that advice. And I think that's key because obviously there's other complications we need to consider with these patients. It's not just the pulmonary complications. We know acute delirium now is much more recognised as an early complication in these patients. So that would inhibit how much self-management the patient could do, obviously. So it's that second assessment, I think, which would allow you to evaluate their understanding.
Speaker 1:Yeah, and the recall of the information that you shared earlier. Yeah, so you mentioned the lung volume expansion. That gets priority in physio management. Its priority in physio management secretion clearance. I know that sometimes people are hesitant to introduce range of motion activities. Is that something that you do with your patients soon after admission?
Speaker 2:It is, and it's something that I've always thought is very important. But more recently I finished a big multicre trial that looked at introducing early exercise programme for these patients within the first seven days after their injury and we looked at the impact on chronic pain and disability at three months after the injury and what we found it was. It was quite surprising to me because I thought all those patients that we'd got moving very early and we'd given them range of motion exercises they would have a lower incidence of chronic pain and disability and in actual fact we found the opposite. So the conclusion of our it was called the elect trial. The conclusion was that we actually felt that starting it very early perhaps wasn't the most important component of that rehab program and perhaps it should be started once that very acute phase of pain had passed. But obviously we need another trial to look at that to see whether that was an accurate conclusion to make.
Speaker 1:Yeah, that's very interesting because you would expect that range of motion and reduced stiffness would impact the incidence of chronic pain. But maybe because your trauma population is older and they experience pain more acutely and differently to a younger trauma population. Possibly that's why you found the results that you had. You found the results that you had, so it would be interesting to see, when you repeat that on a younger population, whether you get the same results or not?
Speaker 2:Yeah, and I think we did adjust for age, but it's still very difficult to say, isn't it? And the results were not statistically significant. I know there was a paper published last week that said that the higher levels of pain experienced, the risk factors for that does tend to be older population and whether they've received opioid medication or not. So I think perhaps you know it was it was. We should have considered things like that within the trial as well.
Speaker 1:OK, yeah, now that's a fair point. No, that's a fair point, kerry. You made mention of a care pathway that you developed, or based on an expert consensus document that had key recommendations for the management of patients with blunt chest trauma, and it talks about patients who had surgical fixation of the ribcage and how they should be managed post-operatively. Do most of your patients undergo surgical fixation or not?
Speaker 2:Until recently we would fix around, I would say, about 10% of our patients who had three or more fractures and that tends to be about the UK average as well. So about 10% of those patients with three or more. Our trauma surgeon who used to do the surgery has just moved up to another hospital. So now we're not fixing anywhere near that number and I think it's starting potentially to go out of vogue surgical fixation in the UK. However, in the States and America it's increasing exponentially. So I think patients when they're assessed it's more. Why wouldn't we fix this patient? So there's a real difference I think now between the states and other countries.
Speaker 1:Yes, yeah, and certainly in South Africa, the minority of patients would undergo surgical fixation and it would only be those with multiple fractures who you're really struggling to wean off mechanical ventilation and to have had several failed extubations. So, yeah, it's also a procedure that's not done much in South Africa. So if you had to reflect on your patient population with blunt chest trauma, what typical complications do they develop and in what percentage of your patient population would you think those complications are likely to develop?
Speaker 2:I think the most common complications are obviously the pulmonary complications. So we'd see the lower respiratory tract infections, pneumonias we do, and we would probably see that in. The numbers have dropped recently. When I did my stumble study 10 years or so ago more than that now I think our numbers were about 40%, but I think that's almost halved recently in more recent research. So we would expect to see pulmonary complications in around 20% of the patients. And then your other complications would be things like acute delirium, which I mentioned earlier, especially in my population because it's older, and also severe pain as well. So if a patient is, if their pain is poorly controlled, I would class that as being a complication of a blunt injury and I would say that that is not uncommon either. So we'd probably see that, probably in about 10% of our patients.
Speaker 1:Yeah, interestingly we recently published some work from South Africa and Sweden where we combined patients with blunt and penetrating chest trauma from six participating centers and one of the things that we found predicted a longer hospital length of stay was patients who were older, with blunt chest trauma and who still had moderate to severe pain on day three after admission. So that sort of ties in nicely with what you said you also see in your population in Wales.
Speaker 1:So acute pain is a real problem that needs to be addressed as soon as possible and I think physiotherapists are well placed to be advocates for pain management for patients in those very early days after admission.
Speaker 2:Yeah, I agree with that, and I think there's often a misunderstanding by physiotherapists that we can actually have a role in improving a patient's pain. So we think about the need for pharma to treat pain or the regional blocks or epidurals or whatever the clinicians use. There's also a role for physiotherapists in this and we've talked about this before. I know, you know we can and you've published on this is that we can do a adjunctive sort of pain treatments with our heat, our ice, our acupuncture TENS you know this supported cough teaching a patient to move in a manner that eases their pain so they're not constantly pulling on the fractured bone end. So we've got a real role in pain management as physios, as well as being an advocate for the sort of pharmacological or the invasive pain techniques.
Speaker 1:Yes, no, that's definitely very true. Pain techniques yes, no, that's definitely very true. So we've spoken about the respiratory system management, especially looking at lung volume expansion, clearing secretions to prevent atelectasis or secondary chest infections. We've spoken about range of motion exercises and maybe just to mention particularly of the trunk flexion, extension, side flexion, rotation activities as soon as the severe pain is under control.
Speaker 1:And then, in your key recommendations paper that was published in 2023, you also mentioned the importance of early mobilization, despite the fact that your other study didn't show that it influenced chronic pain and quality of life. But there is so much research generated over the last 10 years that shows the benefits of early mobilization in many patient populations, and I would think that the same benefits could be seen in patients with chest trauma. And you mentioned that your patients typically would go home on day three if there's no complications and if their pain is under control. So at what stage after admission would you be proactive in getting your patients out of bed into a chair, possibly marching on the spot, and getting them to walk away from the bedside?
Speaker 2:I'd start as soon as possible. To be honest, and I think, going back to my trial, the elect trial, I think that might have been the issue, because I think our control group, we said, were for normal routine physio and I think the normal routine physio now we get everybody up and walking straight away. So I think that may well have been why there were no difference between the group who were doing the upper limb and the trunk exercises, compared to the control group that were just getting up and walking. So I'm with you, I agree, very early mobility is absolutely key to these patients and I would get a patient up and in the chair as soon as I could at a very least. And we will get our ventilated patients as well up into the chair, even when they're ventilated, as soon as possible awake and sat out. You know marching on the spot. I think that is key for these patients. You know marching on the spot. I think that is key for these patients.
Speaker 1:Yes, I agree 100 percent. So by the time that your patients are ready to go home, how do you prepare them for discharge?
Speaker 2:What information do you share with them?
Speaker 2:I think the key thing for these patients is making sure they understand the red flags, as we'd call them.
Speaker 2:So what do they need to look out for if they start to deteriorate and where do they go if that happens? So that would be one of the first things I'd want the patient to know, and then it's obviously providing advice about how they get back to normal. So how do they return to function, back to baseline function, if they want to go back to work or to sport or to drive, caring responsibilities, there's all those things is making sure that you give the patient that information so when they go home, they're safe and they have a full understanding of what they need. And one of the key things that came out of our consensus guidelines was the need for good written resources, because we know patients will forget from one moment to the next the information you give them, especially when you're bombarding them with advice, and they don't always think of something while they're with you that they may need once they've gone home. So good written resources is definitely key for this patient group as well.
Speaker 1:Yes, you mentioned that you cover within the red flags. Would you mind to just explain what that means?
Speaker 2:Of course. So if a patient, when they're with us, they're coping well and they're managing to take deep breaths and cough, we would be quite happy that they were suitable for discharge. But if, when they went home, they found that they started to become more productive or they were becoming more breathless or their pain had become more severe and unmanageable, those sorts of things for me would be what I would tell the patient to be aware of as a red flag and, in some situations, what I would always tell the patient other clinicians would say oh, go back to your general practitioner, your GP, if you've got problems. I would always say to the patient if you get any of those, you come straight back to the emergency department, because we know how difficult it is to get a GP appointment. Or you know they may wait two or three days and by that time you know these complications could have got to the point where you know they can lead to death. And that's exactly what happened with my paramedic.
Speaker 1:Oh, my goodness, that's terrible. Oh, my goodness that's terrible. That sort of leads me to the last point that I wanted problems from a medical point of view. But do you have a specific follow follow-up service in the physiotherapy outpatients department?
Speaker 2:Yeah, we more recently introduced a new service, which I'm still evaluating, and what we're doing with that is we're phoning the patients at home at six weeks to see how they're getting on, because by six weeks we would be expecting the patients, their pain, to be very much controlled and starting to return to function. We know just through our bony healing that six to eight weeks the patient should be starting to return to normal. But research has shown us that there's at least a third of patients who will go on to develop chronic pain. So by that six week point we should be starting to get a feel for which of these patients are not returning to normal and which of the third, or fit into that third, who are going to go on and experience pain. So what I would do is phone the patient, have a chat, ask how they're getting on and then the majority of these patients, they're fine, they're quite happy. They may have one or two questions and then that's it, they're discharged.
Speaker 2:But if there's, if they're in that sort of smaller group who are having problems, then I would bring them back.
Speaker 2:Either bring them back into the, to the um, to the physio department, and one of my outpatient colleagues might see them or if they're having breathing difficulties, I might refer them to a colleague who who specializes in breathing pattern disorders and that sort of thing. So it's knowing what services you've got available, because we're all resource limited and it's sort of trying to fit people into where I've I've managed to get a few of the patients into the critical care follow-up clinic where they'll be managed um there. So it's, it's that sort of thing. A A key thing just to say is medication advice. We know we're getting a problem with opioid misuse. A lot of these patients go home on opioids and they're not told how to wean from them. So it'll be one of the questions I'll ask is what medication are you still using? And I'll be checking that they're not still using their opioids, because we really do need to address this sort of opioid crisis that we're seeing now more internationally.
Speaker 1:Yes, indeed, how to retain their passion for trauma. Or words of encouragement for younger physiotherapists who have just entered the field of trauma care.
Speaker 2:Yeah, I think you hit the nail on the head there and it's about maintaining that passion in what we do, isn't it? And for me, doing any sort of clinical, academic role like we do, where you're sort of trying to improve patient care, it can be sort of hard work and you do feel like work takes over your life sometimes. But I always go back to that initial patient where we could have done things better and for me, I felt we'd failed him. I always go back to that patient and remind myself of why we're doing this and how much a difference we can make to patients lives just by changing some small things in our practice. Sometimes. It's about always making sure we're doing the best we can for our patient and I always think is this how I would want one of my family members treated? And if I'm not answering yes, that is then what do we need to change? How can we make it better?
Speaker 1:Yeah, those are very wise words, kerry, thank you so much for your willingness to participate in this episode today. I appreciate your time and thank you so much for sharing your thoughts with the listeners.
Speaker 2:Thank you for inviting me. I've really enjoyed chatting to you.
Speaker 1:And thank you also to our listeners for your continued interest in trauma care. And just to let you know that the number of downloads of episodes for this podcast are increasing on a daily basis. So thank you for continuing to listen, and please continue to spread the news about the podcast with your colleagues. And then, lastly, remember to use the send me a text link in the show notes to share your thoughts about today's episode. See you next time.
