Gunshot Injuries Assessment and Treatment Considerations: Difference between revisions
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=== N'''ociceptive Pain Drivers''' Therapeutic Management === | === N'''ociceptive Pain Drivers''' Therapeutic Management === | ||
# Education:<ref name=":1" /> | # Patient Education:<ref name=":1" /> | ||
#* Explain how physiotherapy or how your intervention works | #* Explain how physiotherapy or how your intervention works | ||
#* Explain what is expected from the patient | #* Explain what is expected from the patient | ||
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# [[Manual Therapy|Manual therapy:]]<ref name=":1" /> | # [[Manual Therapy|Manual therapy:]]<ref name=":1" /> | ||
#* Joint traction and glides to address joint stiffness. | #* Joint traction and glides to address joint stiffness. | ||
#* [[Scar Management|Scar mobilisation]] if it is useful and necessary. | #* [[Scar Management|Scar mobilisation]] if it is useful and necessary | ||
#Exercises<ref>Kinney M, Seider J, Beaty AF, Coughlin K, Dyal M, Clewley D. The impact of therapeutic alliance in physical therapy for chronic musculoskeletal pain: A systematic review of the literature. Physiother Theory Pract. 2020 Aug;36(8):886-898.</ref> | |||
== #4: N'''ervous System Dysfunction Drivers''' == | == #4: N'''ervous System Dysfunction Drivers''' == | ||
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* Peripheral nerve injuries | * Peripheral nerve injuries | ||
* Neuropathic pain as a result of gunshot injury or surgeries related to gunshot injuries | * Neuropathic pain as a result of gunshot injury or surgeries related to gunshot injuries | ||
* Central sensitisation. | * Central sensitisation <ref>Volcheck MM, Graham SM, Fleming KC, Mohabbat AB, Luedtke CA. Central sensitization, chronic pain, and other symptoms: Better understanding, better management. Cleve Clin J Med. 2023 Apr 3;90(4):245-254. </ref> | ||
=== N'''ervous System Dysfunction Drivers Assessment''' === | === N'''ervous System Dysfunction Drivers Assessment''' === | ||
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=== N'''ervous System Dysfunction Drivers Therapeutic Management''' === | === N'''ervous System Dysfunction Drivers Therapeutic Management''' === | ||
* Patient Education about pain neuroscience | |||
* Modalities: TENS | |||
* Manual therapy, scar mobilisation, soft tissue interventions from a nervous compromise due to internal scarring. ''Warning'': maintain caution due to possibility of retained fragments. Some of the fragments can be risky to mobilise and it is necessary to '''receive an approval from the surgical team'''. | |||
* Mirror therapy | |||
For the more severe cases, for example, with the central sensitisation, you can apply some type of specific treatments. That can be a mirror therapy, even if there's no amputation. You can use graded motor imagery, which can be helpful in the neuropathic pain or central sensitisation. Sometimes you still need to refer your patients, especially with the real neuropathic pain. You can refer them to medical treatment, some of them may require some opioid treatments, and even some of them will require some further surgical exploration to relieve excessive pressure on their nerves due to internal scarring or other types of problems inside. | |||
== #3: C'''omorbidity Factors''' == | == #3: C'''omorbidity Factors''' == | ||
'''Modifiable factors:'''<ref name=":1" /> | '''Modifiable factors:'''<ref name=":1" /> | ||
* Sleep disturbance: patient suffering from post-traumatic stress disorder, depression or anxiety are at high risk of developing sleep disturbance | * Sleep disturbance: patient suffering from post-traumatic stress disorder, depression or anxiety are at high risk of developing sleep disturbance <ref>Burgess HJ, Burns JW, Buvanendran A, Gupta R, Chont M, Kennedy M, Bruehl S. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6551250/pdf/nihms-1523407.pdf Associations Between Sleep Disturbance and Chronic Pain Intensity and Function: A Test of Direct and Indirect Pathways.] Clin J Pain. 2019 Jul;35(7):569-576.</ref> | ||
* Diabetes: can lead to nervous system dysfunctions like diabetic neuropathy | * Musculoskeletal problems | ||
'''Less modifiable factors:'''<ref name=":1" /> | |||
* Diabetes: can lead to nervous system dysfunctions like diabetic neuropathy <ref>Rosenberger DC, Blechschmidt V, Timmerman H, Wolff A, Treede RD. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7148276/pdf/702_2020_Article_2145.pdf Challenges of neuropathic pain: focus on diabetic neuropathy.] J Neural Transm (Vienna). 2020 Apr;127(4):589-624. </ref> | |||
* Visceral damage in the thoracic or abdominal gunshot injuries | * Visceral damage in the thoracic or abdominal gunshot injuries | ||
=== Comorbidity Factors Assessment === | === Comorbidity Factors Assessment === | ||
* Outcome measures | * Outcome measures:<ref name=":1" /> | ||
** Pittsburgh Sleep Quality Index (PSQI) for a sleep disturbance | ** Pittsburgh Sleep Quality Index (PSQI) for a sleep disturbance | ||
** Harvard Trauma Questionnaire for PTSD | ** Harvard Trauma Questionnaire for PTSD | ||
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=== Comorbidity Factors Management === | === Comorbidity Factors Management === | ||
* Patient Education | |||
* Relaxation for sleep disturbance | |||
* Lifestyle modifications in case diabetes, smoking or substance abuse | |||
* Aerobic exercise for musculoskeletal problems | |||
* Referrals to adequate services: internal disease specialist, psychiatrist, or a psychologist. | |||
Revision as of 12:37, 22 April 2024
This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! (22/04/2024)
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Top Contributors - Ewa Jaraczewska and Jess Bell
Introduction[edit | edit source]
General Rules in the Management of Gunshot Injuries[edit | edit source]
- Build a therapeutic alliance and trust relationship with your patient
- Explain your roles and your abilities
- Be realistic and set your patient's expectations
- Agree on some mutual goals and responsibilities with your patient
- Collect information related to patient's history throughout assessment and interventions
- Use trauma-informed approach
- Avoid re-traumatisation of your patient
- Be sensitive to unrevealed story of captivity or torture
Pain and Disability Drivers Model[edit | edit source]
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." [1]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:[2]
- Nociceptive pain drivers
- Nervous system dysfunction drivers
- Comorbidity factors
- Cognitive-emotional drivers
- 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. [2] Based on the assessment results, the provider can weigh the relative contribution of each domain in the patient’s profile.[3]
Pain and Disability Drivers Model and Gunshot Injuries[edit | edit source]
In gunshot injuries, the PDDM allows to create a "comprehensive picture of the patient's clinical presentation". [4] Gunshot injuries can be complex and challenging, and people surviving gunshot injury live with long-term disabilities: [5]
- Pain or neurologic deficits associated with gunshot injury are severe and can become long lasting [6]
- Anxiety, depression or other signs of stress affect 50% of patients with gunshot injury while in hospital[7]
- Disfigurement following gunshot injury can cause further complications and mental health issues [8]
- Gunshot injuries affect sleeping, eating, working, and other previously taken-for-granted activities [9]
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:[4]
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:[4]
- 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[edit | edit source]
- Choose an assessment frame to standardise your approach
- Use outcome measures when appropriate
- Focus on providing self-capacity to your patient and refer them to required services
- Select treatment tools based on the combat field's reality and the PDDM examination findings
- Prioritise the domains with the most impact on individual's recovery and try to provide them with some tools and some relief.
General Goals[edit | edit source]
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[edit | edit source]
Modifiable factors:[4]
- 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:[4]
- 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[edit | edit source]
- Patient Education:[4]
- 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
- Modalities:[4]
- Transcutaneous Electrical Nerve Stimulation (TENS) for pain control.[10]
- 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." [11]
- Heating agents as a supportive tool to address joint stiffness and soft tissue stiffness.
- Manual therapy:[4]
- Joint traction and glides to address joint stiffness.
- Scar mobilisation if it is useful and necessary
- Exercises[12]
#4: Nervous System Dysfunction Drivers[edit | edit source]
Gunshot injuries are likely to have a neural component due to that cavitation effect, which can easily disturb the surrounding nerves.[4]
Modifiable factors:[4]
- 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:[4]
- Peripheral nerve injuries
- Neuropathic pain as a result of gunshot injury or surgeries related to gunshot injuries
- Central sensitisation [13]
Nervous System Dysfunction Drivers Assessment[edit | edit source]
The neurological assessment should include the following components:[4]
- 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
Nervous System Dysfunction Drivers Therapeutic Management[edit | edit source]
- Patient Education about pain neuroscience
- Modalities: TENS
- Manual therapy, scar mobilisation, soft tissue interventions from a nervous compromise due to internal scarring. Warning: maintain caution due to possibility of retained fragments. Some of the fragments can be risky to mobilise and it is necessary to receive an approval from the surgical team.
- Mirror therapy
For the more severe cases, for example, with the central sensitisation, you can apply some type of specific treatments. That can be a mirror therapy, even if there's no amputation. You can use graded motor imagery, which can be helpful in the neuropathic pain or central sensitisation. Sometimes you still need to refer your patients, especially with the real neuropathic pain. You can refer them to medical treatment, some of them may require some opioid treatments, and even some of them will require some further surgical exploration to relieve excessive pressure on their nerves due to internal scarring or other types of problems inside.
#3: Comorbidity Factors[edit | edit source]
Modifiable factors:[4]
- Sleep disturbance: patient suffering from post-traumatic stress disorder, depression or anxiety are at high risk of developing sleep disturbance [14]
- Musculoskeletal problems
Less modifiable factors:[4]
- Diabetes: can lead to nervous system dysfunctions like diabetic neuropathy [15]
- Visceral damage in the thoracic or abdominal gunshot injuries
Comorbidity Factors Assessment[edit | edit source]
- Outcome measures:[4]
- Pittsburgh Sleep Quality Index (PSQI) for a sleep disturbance
- Harvard Trauma Questionnaire for PTSD
- Hospital Anxiety and Depression Scale
Comorbidity Factors Management[edit | edit source]
- Patient Education
- Relaxation for sleep disturbance
- Lifestyle modifications in case diabetes, smoking or substance abuse
- Aerobic exercise for musculoskeletal problems
- Referrals to adequate services: internal disease specialist, psychiatrist, or a psychologist.
Resources[edit | edit source]
- bulleted list
- x
or
- numbered list
- x
References[edit | edit source]
- ↑ Longtin C, Décary S, Cook CE, Martel MO, Lafrenaye S, Carlesso LC, Naye F, Tousignant-Laflamme Y. Optimizing management of low back pain through the pain and disability drivers management model: A feasibility trial. PLoS One. 2021 Jan 20;16(1):e0245689.
- ↑ 2.0 2.1 Naye F, Décary S, Tousignant-Laflamme Y. Development and content validity of a rating scale for the pain and disability drivers management model. Arch Physiother 2022; 12(14).
- ↑ Tousignant-Laflamme Y, Cook CE, Mathieu A, Naye F, Wellens F, Wideman T, Martel MO, Lam OT. Operationalization of the new Pain and Disability Drivers Management model: A modified Delphi survey of multidisciplinary pain management experts. J Eval Clin Pract. 2020 Feb;26(1):316-325.
- ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 Altunbezel Z. Gunshot Injuries Assessment and Treatment Considerations. Plus course 2024
- ↑ Raza S, Thiruchelvam D, Redelmeier DA. Death and long-term disability after gun injury: a cohort analysis. CMAJ Open. 2020 Jul 14;8(3):E469-E478.
- ↑ Ajmal S, Enam SA, Shamim MS. Neurogenic claudication and radiculopathy as delayed presentations of retained spinal bullet. Spine J. 2009 Oct;9(10):e5-8.
- ↑ Wiseman T, Foster K, Curtis K. Mental health following traumatic physical injury: an integrative literature review. Injury. 2013 Nov;44(11):1383-90.
- ↑ Smith RN, Seamon MJ, Kumar V, Robinson A, Shults J, Reilly PM, Richmond TS. Lasting impression of violence: Retained bullets and depressive symptoms. Injury. 2018 Jan;49(1):135-140.
- ↑ Lee J. Wounded: life after the shooting. The ANNALS of the American Academy of Political and Social Science. 2012 Jul;642(1):244-57.
- ↑ Vance CG, Dailey DL, Rakel BA, Sluka KA. Using TENS for pain control: the state of the evidence. Pain Manag. 2014 May;4(3):197-209.
- ↑ Wang ZR, Ni GX. Is it time to put traditional cold therapy in rehabilitation of soft-tissue injuries out to pasture? World J Clin Cases. 2021 Jun 16;9(17):4116-4122.
- ↑ Kinney M, Seider J, Beaty AF, Coughlin K, Dyal M, Clewley D. The impact of therapeutic alliance in physical therapy for chronic musculoskeletal pain: A systematic review of the literature. Physiother Theory Pract. 2020 Aug;36(8):886-898.
- ↑ Volcheck MM, Graham SM, Fleming KC, Mohabbat AB, Luedtke CA. Central sensitization, chronic pain, and other symptoms: Better understanding, better management. Cleve Clin J Med. 2023 Apr 3;90(4):245-254.
- ↑ Burgess HJ, Burns JW, Buvanendran A, Gupta R, Chont M, Kennedy M, Bruehl S. Associations Between Sleep Disturbance and Chronic Pain Intensity and Function: A Test of Direct and Indirect Pathways. Clin J Pain. 2019 Jul;35(7):569-576.
- ↑ Rosenberger DC, Blechschmidt V, Timmerman H, Wolff A, Treede RD. Challenges of neuropathic pain: focus on diabetic neuropathy. J Neural Transm (Vienna). 2020 Apr;127(4):589-624.
