TRAUMA REHABILITATION

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CHAPTER 106 TRAUMA REHABILITATION

Wayne Dubov, Michael M. Badellino, Michael D. Pasquale

In 2002, unintentional injury was the most common cause of death between the ages of 1 and 44 years. There were 161,000 total injured deaths (56 per 100,000 population) that year. It was the fifth leading cause of death for all ages, after heart disease, malignant neoplasms, cerebrovascular events, and chronic respiratory disease. For males, it is the third leading cause of death, and seventh overall for females.1 Motor vehicle collision (MVC) was the most common cause of death related to trauma.

There were many more nonfatal than fatal injuries. In 2004, there were 29,654,475 (∼10,000/100,000) in the United States—involving all races, ages, and both sexes. Falls were most common (2756/100,000), followed by transportation-related injuries (1545/100,000). Violent nonfatal injuries occurred at a rate of 755/100,000.1

Trauma rehabilitation is the restoration of injured patients. Rehabilitation of patients who sustain traumatic injuries is unique compared to other types of rehabilitation. There is a large range of types and degree of diagnoses associated with trauma. Patients will therefore have many different medical, surgical, and rehabilitation needs.

Musculoskeletal injuries (such as fractures to limbs, pelvis, and spine) limit function and are the most common hospitalized injuries. Traumatic brain injuries, spinal cord injuries, peripheral nerve injuries, burns, and amputations are also common. Although patients with chest and abdominal injuries are frequently admitted, these conditions do not often lead to long-term disability.

The focus of this chapter is the assessment and rehabilitation of patients in a Level 1 trauma care setting. The role of a physiatrist (specialist in physical medicine and rehabilitation) is discussed, as well as the role of the trauma rehabilitation team.

TRAUMA REHABILITATION TEAM

The trauma rehabilitation team at our particular acute Level 1 trauma center consists of a physiatrist and departments of physical therapy (PT), occupational therapy (OT), and case management. The request for consultation by other team members is determined by the patient’s needs and includes speech pathology and substance abuse counseling. A trauma rehabilitation consultation is initiated by the trauma service (the admitting service), and this provides an automatic consult to physiatry, PT, OT, and case management.

The physiatrist is the physician leader of the trauma rehabilitation team. This physician establishes rehabilitation needs and provides diagnostic evaluation after reviewing all available test results, assessing the patient’s injuries, and determining any contraindications for early mobility. Emphasis is placed on detection and evaluation of neurological injuries. The physiatrist’s examination is multisystem, with focus on orthopedic and neurological injuries such as traumatic brain injury (TBI), spinal cord injury (SCI), and peripheral nerve injury. The presence of a physiatrist allows a physician consultant to perform a tertiary survey, looking for any previously unrecognized injuries.

Team physical therapists perform an examination and assess the injuries. They then work with a patient in the acute care setting to improve functional mobility. They may also play a role in wound care. Occupational therapists assess the patient to determine how to facilitate basic activities of daily living and to maximize functional restoration of the upper extremities. They also fabricate splints and provide family teaching. Speech pathologists assess swallowing and make recommendations related to appropriate food consistency. They also assess for any cognitive and language deficits, particularly in patients sustaining TBI.

The case manager usually has a background in social service or nursing. Case managers play an integral role by assisting patients and their families with social and discharge planning issues. These managers are responsible for securing durable medical equipment, such as wheelchairs and modified commodes, for patients who are being discharged to home. See Figure 1 regarding rehabilitation screening of trauma patients.

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Figure 1 Rehabilitation screening of trauma patients (all ages). fx, Fracture; MMSE, mini mental state examination; MTBI, mild traumatic brain injury; OT, occupational therapy; PMH, past medical history; PT, physical therapy; rehab, rehabilitation; SCI, spinal cord injury; TBI, traumatic brain injury.

ASSESSMENT OF PATIENTS WITH SPINAL CORD INJURY

Epidemiology of Traumatic Spinal Cord Injury in the United States

The incidence of SCI is estimated to be approximately 40 new cases per million population per year, or roughly 11,000. The estimated prevalence in the United States is 250 million persons.2 SCI primarily affects young adults. The average age at the time of injury is 37.6 years. The percentage of persons older than 60 years at injury has increased from 4.7% in 1980 to 10.9% since 2000. Of the SCI reported to the national database, 79% has occurred among males. Since 2000, MVC have accounted for 47.5% of SCI cases reported. Falls are the next most common cause of SCI, followed by acts of violence and recreational activities. Since 2000, the most frequent neurological category is incomplete tetraplegia (34.5%), followed by complete paraplegia (23.1%), complete tetraplegia (18.4%), and incomplete paraplegia (17.5%).3

Neurological Classification

Determining the neurological level and completeness of injury is the most accurate way of prognosticating recovery and functional outcome. Using the International Standards of Neurological and Functional Classification of Spinal Cord Injury, the examiner determines the motor and sensory level on the right and left and ascertains whether the injury is complete or incomplete.4

Using standard dermatomes and myotomes defined by the American Spinal Injury Association (ASIA), motor level is defined as the most caudal segment to have a muscle grade of 3. Five muscle groups are tested in the upper extremities, and five muscle groups are tested in the lower extremities. Each muscle group is supplied by two root levels, and each muscle group is graded from 0 to 5. Therefore, if the muscle grade is at least 3 of 5 the proximal root is believed to be intact. The sensory level is defined as the most caudal dermatome to have normal sensation to pin prick and light touch. Specific testing points are defined by ASIA4 (Figure 2).

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Figure 2 American Spinal Injury Association Impairment Scale.

(Adapted from American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, rev. 2006. Chicago, American Spinal Injury Association, 2006.)

In addition to defining the neurological level, the completeness of injury must be determined. See the ASIA impairment scale in Figure 2. A complete injury results in no motor or sensory function preserved in the sacral segments (ASIA A). There are four incomplete levels of ASIA: B, C, D, and E. Incomplete is defined as sparing of sensory and/or motor function below the neurological level that includes the sacral (S4-S5) segments.

There are a number of incomplete SCI syndromes, including central cord syndrome, Brown-Sequard syndrome, anterior cord syndrome, dorsal column syndrome, cauda equina syndrome, and conus medullaris syndrome. Central cord syndrome occurs in the cervical cord and produces greater weakness in the upper extremities than lower extremities. Brown-Sequard syndrome is a lesion that produces ipsilateral motor and proprioceptive loss and contralateral loss of pain and temperature perception. Anterior cord syndrome causes variable loss of motor function, pain, and temperature perception while sparing proprioception. This is usually seen with injury to the anterior spinal artery in the thoracic level. Dorsal column syndrome is rare and would produce abnormal proprioception but preserved motor function and pain and temperature sensation. In cauda equina syndrome, the lumbosacral roots are injured because the spinal cord ends at approximately the L1-L2 level. This causes lower motor neuron symptoms, such as areflexic bladder, bowel, and lower limbs. Conus medullaris syndrome involves injury to the end of the spinal cord. At this level, the lumbar and sacral roots are affected.

Acute Medical Management

All patients with acute traumatic SCI receive methylprednisolone. This is based on the National Acute Spinal Cord Injury Studies (NASCIS), the last being NASCIS 3. This study concluded that patients treated within 3 hours of injury should receive 24 hours of steroids, and those treated in 3–8 hours of injury should receive 48 hours of steroids.5

The degree of respiratory dysfunction after SCI is related to the neurological level and the completeness of injury. The level of pulmonary dysfunction increases concomitantly with the level of injury.

C1-C3 neurological levels will require ventilatory support. The phrenic nerve (supplied by C3-C5 nerve roots) will be intact in patients with a C5 neurological level and below. As the level descends from mid-cervical to lower cervical, and then to thoracic, there will be greater innervation to abdominal and intercostal muscles—thereby making the work of breathing easier. The primary objective in early pulmonary management in SCI is to minimize secondary complications, including preventing hypoxemia, preventing and treating atelectasis, reducing risk of aspiration, and providing aggressive pulmonary management to compensate for impaired clearing of secretions.6

During spinal shock (temporary loss of all or most spinal reflexic activity below the level of injury), sympathetic activity is reduced or absent. This leads to bradycardia and hypotension. After resuscitation, elastic stockings, abdominal binders, adequate hydration, and gradual upright positioning are used to reduce the effects of orthostatic hypotension.

Bladder management is usually accomplished with an indwelling catheter, as the bladder is often initially areflexic. The goals of team bladder management are to allow the bladder to empty, prevent urinary retention, minimize urinary tract infections, and determine which methods facilitate independent bladder management. Methods may include use of an indwelling Foley catheter or placement of a suprapubic tube. Intermittent catheterization is appropriate for patients with use of their upper extremities.

Male patients who have reflex voiding and detrusor hyperreflexia may require a sphincterotomy procedure or pharmacological agents to reduce outflow resistance and allow use of an external catheter. Some patients with incomplete spinal cord injuries will be incontinent. Urodynamic studies are useful at some point to help classify the neurogenic bladder, in order to select adequate bladder management methods.

A bowel program should be established. Initially, a paralytic ileus is common. Patients may be placed on a stool softener and a daily or every-other-day suppository, with digital stimulation. This routine should be established about the same time each day. The goal is to prevent or minimize incontinence between bowel programs.

Deep venous thromboembolism (DVT) prevention is extremely important, as DVT and pulmonary embolism are major causes of morbidity and mortality in the SCI population. Sequential compression devices should be used, with or without elastic stockings, to improve lower extremity venous return. Such methods are contraindicated in patients with severe arterial insufficiency. Pharmacologic prophylaxis should be initiated within the first 72 hours, when not contraindicated. Low-molecular-weight heparin is the current recommendation. Anticoagulation should be continued for 8 weeks in patients with uncomplicated complete motor impairments, and for 12 weeks in complete motor injuries with other risk factors (lower limb fractures, history of thrombosis, cancer, heart failure, obesity, and age over 70). Vena cava filter placement is indicated in SCI patients with a contraindication for pharmacologic prophylaxis.7

ASSESSMENT OF PATIENTS WITH TRAUMATIC BRAIN INJURY

Epidemiology of Traumatic Brain Injury in the United States

There are 1.4 million people who sustain TBI in the United States annually. Approximately 50,000 will die, 235,000 are hospitalized, and 1.1 million are treated and released from the emergency department.8 Between 80,000 and 90,000 people experience long-term disability associated with TBI.9 According to the TBI Model System database, MVCs account for 48.3%—with the next most common cause of TBI being falls, followed by violence. The most common cause of death from MVCs is TBI. Approximately 5.3 million Americans (or about 2% of the population) currently live with disabilities caused by TBI.10

Pathophysiology of Traumatic Brain Injury

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