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
Mastering Polytrauma: Expert insights shared by Natascha Plani and Cikizwa Mafanya
Managing patients with polytrauma presents unique challenges for physiotherapists. Trauma physiotherapists Natascha Plani and Cikizwa Mafanya share their insights on managing patients with polytrauma, focusing on pelvic and acetabular injuries. They discuss evidence-based approaches for rehabilitation during prolonged bed rest and strategies to successfully achieve functional independence prior to hospital discharge. Subscribe to Physiotherapy Trauma Talks for more expert discussions that will enhance your clinical practice. Podcast website: https://physiotherapytraumatalks.buzzsprout.com/2431934/episodes
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. Welcome back to Physiotherapy Trauma Talks. In this episode, we're going to discuss the role of the physiotherapist in the management of patients with polytrauma. I'm joined today by Natasha Plany, who is a returning guest to the podcast, and with us is Chikizwa Mafanya, who is a colleague of Natasha here at the Alberton Net Care Hospital. So welcome to both of you and thank you for your willingness to participate in this episode. Thank you, can we start off by maybe just talking about the common causes and mechanisms of injury that you see in patients admitted with polytrauma injury to your ICU.
Speaker 2:As a level one trauma facility at MedCare Alberton Hospital. We see a lot of motor vehicle accidents, we see a lot of pedestrian accidents, and then we also see a lot of injury on duties, particularly workers who fall from heights, and quite a number of crush injuries that frequently involve the pelvis.
Speaker 1:Yeah, so high energy injuries that cause these extensive fractures or dislocations In general, how old would you say your patients commonly are when they present with polytrauma injury and what is the gender demographic?
Speaker 2:And what is the gender demographic? So I haven't got exact statistics, but we have about a 70-30% split of males compared to females in these type of injuries and the majority, in keeping with the rest of the trauma population I'd say would be between 20 and 40 years of age, especially your injury on duty patients. But we are also seeing a fair share of older patients, because we're seeing motor vehicle accidents and those type of things and also older people thinking they can still do DIY and climb on ladders and fall and that population is obviously a bit more difficult to deal with because they're older, with more comorbidities, so they're more complicated.
Speaker 1:Yeah, so the demographic fits in with what's been reported throughout South Africa in general that you have younger adult males being more involved in these high-impact injuries because of the risk-taking behavior on the road and elsewhere. So that confirms what we know from the evidence that we've got. I remember when I was a more junior physiotherapist working in the trauma ICU, I used to feel fairly confident treating patients with polytrauma when they had injuries to their extremities and to the chest, but always felt a little bit more unsure when managing patients with injuries to the pelvic girdle and to the acetabulum and to the hip. So in your context, because you deal with these patients on a daily basis, could you maybe just share with our listeners how your trauma surgeons diagnose these patients and also how would they decide to manage patients conservatively versus taking them for surgery immediately?
Speaker 3:So these patients, they come through casualty and then they would go through CT scans. So mainly CT scans and if they are not severe injuries they will just do x-rays. But if the injury is severe then they move from x-rays to CT scans and mostly diagnosed by an orthopedic surgeon.
Speaker 1:And how often are your patients managed from a surgical point of view?
Speaker 3:We see quite a lot of high impacting injuries here, mostly the unstable fractures managed by a theatre, and it can be internal fixation or external fixation. And the stable ones. They would be either on traction for six weeks or they would get up and go. If it's not a severe injury, okay.
Speaker 1:So patients with injuries to the pelvic girdle, they would be managed more frequently with an external fixator. Is that correct, or do they also do internal fixation for pelvic injuries?
Speaker 3:So mostly, if it's an open bug fracture which the whole ring is disrupted, they would be managed by X-fixers. Which the whole ring is disrupted, they would be managed by X-fixers Okay. And if it's just maybe, say, the acetabulum, then they would put internal fixators Okay. Or if it's stable like a pubic ramus, they would get up and go.
Speaker 3:Yeah, and that would be determined by the level of pain that the patient is getting, that the patient is getting up and going. We give them crutches just for support and then within three weeks, then they can fully wait again.
Speaker 1:Okay, I would just like to touch a little bit more on the patient with an external fixator that's been placed around the pelvic area. What precautions would physiotherapists need to take when they treat patients like this in the ICU or in the ward setting? What common precautions are there to exercise therapy and to weight-bearing and mobilization?
Speaker 3:So when it comes to if the patient doesn't have any internal injuries, then it's better to manage as just the X-fix and turning in bed early is contraindicated. So they'll be lying on their backs and mainly what we're looking at is to keep all the muscles strong, like your isometric exercises, and slowly progress to lifting up against gravity, like brooding.
Speaker 2:I think we also need to just be aware of hip flexion and how much of that is allowed. So, Bernadette, you want to elaborate on that?
Speaker 3:So hip flexion you go easy on that and, as the pain allows, maximum will be 45 degrees. So this is the patient has been in bed maybe for three weeks and then later on towards the third week, then you can actually be 45 degrees, okay.
Speaker 1:So you mentioned the importance of doing isometric exercises to maintain the integrity of the muscles, strength and also starting to do some activity through limited range of motion.
Speaker 3:What is the normal restriction to mobilizing these patients into a seated position or getting them up out of bed. So ideally, if they have an X-fix, they will be in bed for six to eight weeks, depending on the surgeon, what he wants. So sitting them up is contraindicated. But later on, say by fourth week to, if you're aiming for six weeks, fourth week to the sixth week, then they can start sitting up 35 degrees up to 45, up until the surgeon says okay, they can sit up to 90 degrees, getting out of bed.
Speaker 2:I think it's just important to mention here that if you just think about the time we're talking about and how as physios we like to really get patients mobilizing early, it's really a bad situation for us to be in. Often these patients are ventilated, so at any rate for the first two to four weeks you wouldn't have been able to mobilize them anyway, so it helps a little bit. Weeks you wouldn't have been able to mobilize them anyway, so it helps a little bit. But it's a significant amount of time to be in bed and not move. So it's really important to get by in on these patients to do exercises. They must do their own. We provide them TheraBands in the units as soon as we can, because the amount of muscle wasting is tremendous.
Speaker 1:Yes, and just to pick up on what you mentioned about them being ventilated, these patients would often present with some form of abdominal trauma and even potentially chest injuries, which would necessitate the longer period of ventilation. Is that correct?
Speaker 2:Yes, absolutely, especially with unstable fractures. I always tell our guys, especially if there is SIJ disruption, you have to be suspicious that there is going to be a bladder injury, there could be colon injuries, going to be a bladder injury, there could be colon injuries. So that's why, when these guys come in, as a rule they all go through CT scanner so we at least have a look at what we're dealing with. You have to have a very high suspicion for those type of injuries because they're frequent. The bladder is just there. So once the ring is disrupted and your colon et cetera as well.
Speaker 1:Yeah, Just to come back to your patient who would be on traction due to acetabular injuries. What would your approach to rehabilitation be for these patients who are bed-bound? Maybe just explain how long they might be on traction in general, and again where you start with your rehabilitation as the physiotherapist?
Speaker 3:okay, these patients will be on traction for six weeks. Um, like I said earlier, you want to maintain one muscle strength and they will have a stem and pin on the knee. So the knee joint too is affected. So somehow you have to work on the knee. So the knee joint too is affected. So somehow you have to work on the knee. So you start with getting knee range of motion, which is also about 45 degrees, and then you go to the hip. But this is all progressing over the four to six weeks time. Okay, okay.
Speaker 1:You mentioned earlier, when we spoke about the patient with the external fixators on the pelvis, that one of your goals is to get them to be able to bridge. Maybe just explain to our listeners why that specifically is so important to do.
Speaker 3:Okay, bridging when we stand and we want to walk for years. So you're preparing this patient to be able to ultimately stand. So you don't want to lose that muscle strength while the patient is still lying in bed. So being up against gravity is very good for those patients. So flitting is the main thing that you can do in bed, and also just shifting and moving in bed and also to prevent pressure soles.
Speaker 2:And I think, from a practical point of view, if they're there and they can do that, they can actually help the nurses as well when it comes to things like bed bathing, changing linen, etc. So it makes it just that little bit more independent.
Speaker 1:Yes, no definitely more independent.
Speaker 1:Yes, no, definitely so.
Speaker 1:For these patients with the pelvic injuries or the acetabular injuries, we've heard that they are destined to have a longer period of bed rest before they are allowed out of bed. So you mentioned the importance of retaining as much muscle strength as possible and that you would start with isometric, so static, muscle activity and exercise, and then gradually progress to more isotonic or active range of motion exercise. I suppose it's really important to also make sure that you don't lose muscle strength in the unaffected parts of the body, and particularly when one thinks about the fact that the patient is going to get up after six weeks four to six weeks and they're going to be non-weight bearing, so they would need the muscle strength of the arms, for instance, to use a walking aid. Could you maybe just describe the strategies that you use in the ICU after the patient is awake and able to cooperate with you, and going into the ward seating of maintaining strength within the upper limbs for these patients, and what type of walking aids would you use to initially get them up and going?
Speaker 2:So in terms of upper limb strength, as I mentioned before, we like giving our patients TheraBands. So when you walk through our unit there's TheraBands attached to everything so they can work in different ranges. And we also use cycle ergometers. You get little handheld cycle things Wonderful On, take a lot, if I'm allowed to say that, and they're inexpensive and they're really easy and mobile and they're wonderful for patients because they can sit and at least move that bit and if you get them to, I suppose, like do things like bridge as well, you push down and but really trying to get them to work a little bit against resistance and then also I like the term functional exercise. So these patients must feed themselves, they must try and help turn, they must use their good leg to bridge they. There's a lot they can do. You could even put, if you wanted, a monkey chain up on a bed and they can do pull-ups from there.
Speaker 1:And the typical walking aids that you would use when you first get patients up and going.
Speaker 3:So the first time that they're getting out of bed it's going to be a little bit difficult. So we usually bring in a walking frame, okay, and then maybe take a few steps to the chair and then they sit and then slowly increase the distance, but before they go home they're usually on crutches. It's more functional than the walking frame and mostly in the ward then we start using crutches and then they can go up and down stairs and be more functional and then they go home.
Speaker 1:Okay, just to come back to the ICU environment, where we know these patients have been on Beatrice for longer than other patients. What typical things would you look out for with regards to the patient's response to being upright the first time you get them up out of bed, and would you involve the nurses to help you mobilize the patient, because we know patients in ICU are often attached to many things. So do you remove the additional attachments that are not needed at that stage to make the mobilization safer? So just in summary, what signs do you look out for to see if the patient is coping with getting up? Are the nurses involved in assisting, and what attachments would be safe to remove from the patient at that stage?
Speaker 2:It's always a good idea to remove what you possibly can, but you do need to know what drugs you can't disconnect from the patient. So in the unlikely event, for instance, that they slon basal presses, et cetera, you need to know that those are not the things, and the nurses are really handy there. We're very fortunate in our unit. They are always very happy to assist us. But we also have a system with our physios where they're all on a WhatsApp group needs help to mobilize. So if it is perhaps a bigger patient or a very weak patient and you think you're going to need additional help, then one or two of your colleagues will come and I think it makes the patients feel quite safe to have, you know, a number of people around them as well for the first time, especially if they've been quite sick and they're apprehensive.
Speaker 2:And the type of things that you have to look out for obviously is dizziness. They are all attached to monitors, so I'll always say to them that I'll know they feel bad before they do, because we can look at their heart rate. We can look at their blood pressures, Depending on their injuries. You might also just want to keep your eye on their saturations and just make sure those are the things that will tell you whether they're coping or not. And then speak to your patients. Ask them about their pain and how they're feeling. Don't wait for them to fall over. Ask them if they feel dizzy.
Speaker 1:I was just going to say from my clinical experience, the patient that is going the direction of wanting to pass out is the one that just stays straight ahead, that doesn't make eye contact with you and that doesn't respond quickly enough to questions. So then you already know there's a problem here. Yeah, thank you for that. So because these patients are severely injured, they've got sometimes very displaced fractures of the pelvic ring, issues around the SI joint. What type of complications do you commonly see in these patients?
Speaker 3:So we said earlier, it would be the bladder injuries and vascular injuries too, especially if there's a disruption on the ring. With the acetabular fractures we see quite a lot of involvement of the sciatic nerve.
Speaker 2:And just a note to also remember to just look out for DVTs. They're not common because the patients should be on clexane and they do wear stockings, but just remember they're in bed for six weeks lying with that compression and not a lot of blood flow.
Speaker 1:Yeah and I suppose one of the complications that could develop if the patient is not as adherent as they should be to the bed exercise program is pressure sores around the sacral area, the back of the heel possibly. So again raising the importance of really trying to get your patient to move as soon as possible, even if it's just in bed, through exercises and bridging to relief pressure. So you mentioned that before they go home, Chikiswa, that the patient needs to be able to be independent on crutches and that they need to be able to climb stairs. So that is already preparing them for going home. Is there anything else that goes into your discharge planning for these patients particularly?
Speaker 3:Okay, it depends. We look at also the home environment. How is the home environment? Will there be someone who will look after the patient because they're not fully functional? So in cases like that, then the patient will be sent to rehab or even a step down.
Speaker 2:Yeah, we've got to educate them about do's and don'ts and their families. Just for that period they're at home. We also I suppose, if we're talking about discharge am I understanding correctly Then we would be involved in organizing a wheelchair for them if they need going to be wheelchair-bound for a while. And then I think, really importantly, we need to make follow-up appointments for these patients and get them back in. And even if they go to rehab because they might get authorization for two or three weeks in rehab, it's a long road to recovery and the patients often don't realize it. So we try and have a system where we follow them up and we phone them three weeks after discharge and ask them how are you doing, where are you? We'd like to see you and just to try and get them back to full function. And especially if I refer you back to this young population, this is the working population, so you need them strong and back on the workforce, not disabled or dysfunctional, Definitely.
Speaker 1:Is there any particular report that you might get from a patient telephonically when you follow them up that would make you think this patient needs to come back for physiotherapy in our rooms at the hospital versus someone else that might not really need follow-up? So I suppose I'm asking about the flags that would make you say to a patient I feel you need to come in to see me so that we can reassess your situation. Is there anything that springs to mind?
Speaker 3:So this depends on the severity of the injury. If they had like an open book fracture, they'll struggle to. Even if they've been to rehab, they'll struggle to walk. So we call them back. But if they have like stable fractures that are straightforward, then we just phone and find out how you're doing and are you back at work. And sometimes when they come back to see the doctor and the doctor is not happy our doctors are very good over there for back to physio Okay, but mostly we call them so that we can assess and see where they are falling short.
Speaker 2:Yeah, I do have to say. In an ideal world, though, I think it's better if we can get the patients in front of us to see, because patients don't realize how much better they can be, and I think it's a combination of that. Patients get tired of us. By the time they've done five weeks here, three weeks in rehab, I think they just don't want to see another healthcare professional and they may think they're okay, and oftentimes we bring them back and then we can see their endurance isn't there and we can work on that and within two weeks the guys are oh, now I'm back at work full time and so much better. So if we can lay eyes on them and do some standardized testing, we would do MRC Sunscore for those listeners who are familiar with that. We would do a six-minute walk test. We can assess posture sitting. We can do a bit of return to work assessment and then refocus on the bits that still need attention.
Speaker 1:Yeah, yes, and I think the return to work assessment is so important because you've mentioned that they are young adults, they are part of the workforce and sometimes people think, oh, it will get better over time. But with proper, focused rehabilitation that over time can become much shorter than what they might realize. So thank you for sharing that. Chikiswa, you've worked in trauma care for a long time. You're an experienced physiotherapist. Do you have any last thoughts to share with our listeners, particularly those that are a little bit newer to the profession and still feel a bit intimidated by the trauma ICU setting?
Speaker 3:I understand trauma ICU is very scary, but the minute you get used to it you get comfortable. The main thing is the contraindications. You just have to understand what kind of injury is this and what can I do and how I can help the patient. But mainly contraindications and precautions. And also talking to your doctors is very important.
Speaker 1:Yeah, Natasha, any last thoughts and precautions and also talking to your doctors is very important.
Speaker 2:Yeah, natasha, any last thoughts I was just going to add to that. Tukizo was saying your contraindications and complications. But I think you need to keep learning as a physio and you need to keep developing and you need to ask for help. So it's great for us in our unit because in our practice we have a number of physios with special interests in different areas, so there's always someone to ask. And if you don't know, ask AI or Google.
Speaker 2:But go and read up and know the anatomy because you can't go wrong. But go and read up and know the anatomy because you can't go wrong If you know your anatomy and you know your contraindications, like she said, and what you're allowed and not allowed to do. And communication is really important and I don't think we must be scared to talk to our doctors, not just to ask them if we can get a patient out of bed, but actually to be able to go and say we are worried about this. Have you seen this? Because that's also our responsibility to our patient. We spend a lot of time with them and we often become aware of problems before the doctors do.
Speaker 1:Yeah, so being an advocate for your patient and speaking up when you notice something is not quite right. Natasha and Chikiswa, thank you so much for this valuable discussion. I know that the listeners out there who have not worked with these type of patients with polytrauma injury would have found this extremely useful and will be able to manage their patients in a more realistic way going forward. Thank you so much for your time. I appreciate it. Thank you.
