Gunshot Injuries Assessment and Treatment Considerations

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General Rules in the Management of Gunshot Injuries

1. Build a therapeutic alliance and trust relationship with your patient
2. Explain your roles and your abilities
3. Be realistic and set your patient's expectations
4. Agree on some mutual goals and responsibilities with your patient
5. Collect information related to patient's history throughout assessment and interventions
6. Use trauma-informed approach
7. Avoid re-traumatisation of your patient
8. Be sensitive to unrevealed story of captivity or torture

Pain and Disability Drivers Model

Pain and Disability Drivers Model (PDDM) provides an assessment frame to standardise healthcare provider's approach for the management of gunshot injuries. It "identifies the domains driving pain and disability to guide clinical decisions." PDDM besets the multidimensional elements from the International Classification of Functioning, Disability and Health framework. This model includes the following five biopsychosocial domains that drive pain and disability:

1. Nociceptive pain drivers
2. Nervous system dysfunction drivers
3. Comorbidity factors
4. Cognitive-emotional drivers
5. Contextual drivers (social and environmental)

Each domain is further divided into two categories: (1)modifiable drivers of pain and disability, and (2)more complex and/or less modifiable elements. Based on the assessment results, the provider can weigh the relative contribution of each domain in the patient’s profile.

Pain and Disability Drivers Model and Gunshot Injuries

In gunshot injuries, the PDDM allows to create a "comprehensive picture of the patient's clinical presentation". Gunshot injuries can be complex and challenging, and people surviving gunshot injury live with long-term disabilities:

• Pain or neurologic deficits associated with gunshot injury are severe and can become long lasting
• Anxiety, depression or other signs of stress affect 50% of patients with gunshot injury while in hospital
• Disfigurement following gunshot injury can cause further complications and mental health issues
• Gunshot injuries affect sleeping, eating, working, and other previously taken-for-granted activities

The PDDM in gunshot injury should be followed from contextual drivers to nociceptive pain drivers. It is a reversed model of PDDM as compared to PDDM used in patients with musculoskeletal conditions and addresses contextual drivers first:

5.Nociceptive pain drivers

4.Nervous system dysfunction drivers

3.Comorbidity factors

2.Cognitive-emotional drivers

1.Contextual drivers (social and environmental)

The PDDM in gunshot injuries is based on the following factors:

• Addressing a negative or passive coping style first is necessary because the patient will not follow healthcare providers advice on active lifestyle modifications related to their comorbidities
• Addressing central sensitisation issues is required for a successful peripheral interventions

Assessment and Interventions Rules in the Gunshot Injuries

1. Choose an assessment frame to standardise your approach
2. Use outcome measures when appropriate
3. Focus on providing self-capacity to your patient and refer them to required services
4. Select treatment tools based on the combat field's reality and the PDDM examination findings
5. Prioritise the domains with the most impact on individual's recovery and try to provide them with some tools and some relief.

General Goals

The primary goal of all interventions in gunshot injuries is to ensure patients' compliance and sustainability of rehabilitation activities. The treatment is usually lengthy and there may not be enough allocated time to address every problem the patient presents with.--Zafer Altunbezel

#5: Nociceptive Pain Drivers

Modifiable factors:

• Functional mobility deficits due to some joint limitations after the immobilisation.
• Impaired myofascial flexibility.
• Functional stability deficits due to muscle imbalances or impaired movement patterns.

Less modifiable factors:

• Structural mobility deficits in the form of fixed deformity after the complex fractures.
• Excessive scarring around the gunshot area due to neural or vascular compromise.
• Structural stability deficits due to damaged joint, a torn ligament or tendon or muscle wasting.
• General deconditioning as a result of a prolonged immobilisation.

Nociceptive Pain Drivers Therapeutic Management

1. Education:
   • Explain how physiotherapy or how your intervention works
   • Explain what is expected from the patient
   • Explain the goal and principles of patient's active participation in the treatment
   • Explain the need to exercise to regain strength and function
2. Modalities:
   • Transcutaneous Electrical Nerve Stimulation (TENS) for pain control.
   • Cold for inflammation at the initial phases. Note: "when considering a cryotherapy protocol for treating soft-tissue injuries, variables such as its forms, local or whole-body, physical agents, cooling temperature, and time duration must be well-designed and controlled."
   • Heating agents as a supportive tool to address joint stiffness and soft tissue stiffness.
3. Manual therapy:
   • Joint traction and glides to address joint stiffness.
   • Scar mobilisation if it is useful and necessary.

#4: Nervous System Dysfunction Drivers

Gunshot injuries are likely to have a neural component due to that cavitation effect, which can easily disturb the surrounding nerves.

Modifiable factors:

• Radiculopathy or radicular symptoms due to some nerve root compromise.
• Abnormal impulse generating sites(AIGS): demyelinated axonal zones along the nerve tract, especially around the gunshot injury zone as a result of excessive scarring, excessive pressure or excessive tension. It is characterised by a spontaneous upwards and downwards pain radiation and can lead to development of central sensitisation. AIGS can be identified with application of neurodynamic tests.

Less modifiable factors:

• Peripheral nerve injuries
• Neuropathic pain as a result of gunshot injury or surgeries related to gunshot injuries
• Central sensitisation.

Nervous System Dysfunction Drivers Assessment

The neurological assessment should include the following components:

• Fundamental sensory and motor examination
• Neurodynamic tests
• Neuropalpation
• Outcome measures:
  • DN4 (Douleur Neuropathique en 4 Questions)
  • LANNS (Leeds Assessment of Neuropathic Symptoms and Signs)
  • Central Sensitisation Inventory

#3: Comorbidity Factors

Modifiable factors:

• Sleep disturbance: patient suffering from post-traumatic stress disorder, depression or anxiety are at high risk of developing sleep disturbance.
• Diabetes: can lead to nervous system dysfunctions like diabetic neuropathy.
• Visceral damage in the thoracic or abdominal gunshot injuries
• Musculoskeletal problems

Comorbidity Factors Assessment

• Outcome measures
  • Pittsburgh Sleep Quality Index (PSQI) for a sleep disturbance
  • Harvard Trauma Questionnaire for PTSD
  • Hospital Anxiety and Depression Scale

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