Gunshot Injuries Assessment and Treatment Considerations

Original Editor - Zafer Altunbezel

Top Contributors - Ewa Jaraczewska and Jess Bell  

Introduction[edit | edit source]

Gunshot injuries in civilian and military populations have serious long-term health and socioeconomic consequences worldwide.[1]Primary injuries following ballistic trauma include soft-tissue damage and loss, haemorrhage, bone fracture, nerve and vascular injuries and pain.[1]The effects of these injuries are disability, extended hospitalisations, and overall poor quality of life. Identification and management of firearm-related impairments require a team approach and individual skills to prioritise interventions and prevent further damage. This page provides an in-depth review of the Pain and Disability Drivers Model applied in assessing and treating gunshot injuries.

General Rules in the Management of Gunshot Injuries[edit | edit source]

  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 the patient's history throughout assessment and interventions
  6. Use a trauma-informed approach
  7. Avoid re-traumatisation of your patient
  8. Be sensitive to unrevealed stories of captivity or torture

Pain and Disability Drivers Model[edit | edit source]

The Pain and Disability Drivers Model (PDDM) provides an assessment frame to standardise healthcare providers' approach to managing gunshot injuries. It "identifies the domains driving pain and disability to guide clinical decisions." [2]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:[3]

  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 divided into two categories: (1)modifiable drivers of pain and disability and (2)more complex and/or less modifiable elements. [3] Based on the assessment results, the provider can weigh the relative contribution of each domain in the patient’s profile.[4]

Please watch this optional video describing the PDDM :

[5]

Pain and Disability Drivers Model and Gunshot Injuries[edit | edit source]

In gunshot injuries, the PDDM allows the creation of a "comprehensive picture of the patient's clinical presentation". [6] Gunshot injuries can be complex and challenging, and people surviving gunshot injury live with long-term disabilities: [7]

  • Pain or neurologic deficits associated with gunshot injury are severe and can become long-lasting [8]
  • Anxiety, depression or other signs of stress affect 50% of patients with gunshot injury while in hospital[9]
  • Disfigurement following gunshot injury can cause further complications and mental health issues [10]
  • Gunshot injuries affect sleeping, eating, working, and other previously taken-for-granted activities [11]

The management of the gunshot injury using PDDM should address contextual drivers first. It is a reversed model of PDDM as compared to PDDM used in patients with musculoskeletal conditions:[6]

#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:[6]

  • 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 successful peripheral interventions

Basic Rules for the Assessment and Interventions in the Gunshot Injuries[edit | edit source]

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

General Goals[edit | edit source]

The primary goal of all interventions in gunshot injuries is to ensure patient 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:[6]

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

Less modifiable factors:[6]

  • 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 are due to damaged joints, torn ligaments, tendons, or muscle wasting.
  • General deconditioning as a result of a prolonged immobilisation.

Nociceptive Pain Drivers Therapeutic Management[edit | edit source]

  1. Patient Education:[6]
    • Explain how physiotherapy or how your intervention works
    • Explain what is expected from the patient
    • Explain the goal and principles of the patient's active participation in the treatment
    • Explain the need to exercise to regain strength and function
  2. Modalities:[6]
    • Transcutaneous Electrical Nerve Stimulation (TENS) for pain control.[12]
    • 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." [13]
    • Heating agents as a supportive tool to address joint stiffness and soft tissue stiffness.
  3. Manual therapy:[6]
    • Joint traction and glides to address joint stiffness.
    • Scar mobilisation if it is useful and necessary
  4. Exercises[14]

#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.[6]

Modifiable factors:[6]

  • 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 spontaneous upward and downward pain radiation and can lead to the development of central sensitisation. AIGS can be identified by applying neurodynamic tests.

Less modifiable factors:[6]

  • Peripheral nerve injuries
  • Neuropathic pain as a result of gunshot injury or surgeries related to gunshot injuries
  • Central sensitisation [15]

Nervous System Dysfunction Drivers Assessment[edit | edit source]

The neurological assessment should include the following components:[6]

Please watch this optional video discussing the principles of neuro palpation:

[16]

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. [17] Warning: maintain caution due to the possibility of retained fragments. Some fragments can be risky to mobilise, and it is necessary to receive approval from the surgical team.
  • Mirror therapy, graded motor imagery in the neuropathic pain or central sensitisation[15]
  • Referral to speciality services for medical or surgical management

#3: Comorbidity Factors[edit | edit source]

Modifiable factors:[6]

  • Sleep disturbance: a patient suffering from post-traumatic stress disorder, depression or anxiety are at high risk of developing sleep disturbance [18][19]
  • Musculoskeletal problems

Less modifiable factors:[6]

  • Diabetes: can lead to nervous system dysfunctions like diabetic neuropathy [20]
  • Visceral damage in the thoracic or abdominal gunshot injuries

Comorbidity Factors Assessment[edit | edit source]

Comorbidity Factors Management[edit | edit source]

  • Patient Education
  • Relaxation for sleep disturbance
  • Lifestyle modifications in case of diabetes, smoking or substance abuse
  • Aerobic exercise for musculoskeletal problems
  • Referrals to adequate services: internal disease specialist, psychiatrist, or psychologist.

#2: Cognitive and Behavioural Drivers[edit | edit source]

  • Unhelpful beliefs and thoughts that can be related to the pain, injury, or treatment received
  • Pain catastrophizing that might cause an excessive fear towards movement and pain[21]
  • Passive coping style

Cognitive and Behavioural Drivers Assessment[edit | edit source]

Cognitive and Behavioural Drivers Management[edit | edit source]

#1: Contextual Drivers (Social or Environmental Factors)[edit | edit source]

  • Factors related to being a military personnel or combatant, such as excessive fear of sending back to the frontline.
  • Unrealistic expectations related to returning to the battlefield
  • Concerns related to access to basic needs after or during the treatment (shelter, food, basic needs)
  • Poor family or social support
  • Losses experienced among the patient's families or loved ones

Contextual Drivers Management[edit | edit source]

  • Referral to adequate services

Resources[edit | edit source]

References[edit | edit source]

  1. ↑ 1.0 1.1 Moriscot A, Miyabara EH, Langeani B, Belli A, Egginton S, Bowen TS. Firearms-related skeletal muscle trauma: pathophysiology and novel approaches for regeneration. NPJ Regen Med. 2021 Mar 26;6(1):17.
  2. ↑ 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.
  3. ↑ 3.0 3.1 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).
  4. ↑ 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.
  5. ↑ MedBridge. The Pain and Disability Drivers Model - Eric Hegedus | MedBridge. Available from: https://www.youtube.com/watch?v=5IfFpJANFGw [last accessed 22/4/2024]
  6. ↑ 6.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.09 6.10 6.11 6.12 6.13 6.14 Altunbezel Z. Gunshot Injuries Assessment and Treatment Considerations. Plus course 2024
  7. ↑ 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.
  8. ↑ Ajmal S, Enam SA, Shamim MS. Neurogenic claudication and radiculopathy as delayed presentations of the retained spinal bullet. Spine J. 2009 Oct;9(10):e5-8.
  9. ↑ Wiseman T, Foster K, Curtis K. Mental health following traumatic physical injury: an integrative literature review. Injury. 2013 Nov;44(11):1383-90.
  10. ↑ 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.
  11. ↑ Lee J. Wounded: life after the shooting. The ANNALS of the American Academy of Political and Social Science. 2012 Jul;642(1):244-57.
  12. ↑ 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.
  13. ↑ 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.
  14. ↑ 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.
  15. ↑ 15.0 15.1 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.
  16. ↑ MedBridge. Neuro Palpation Video: Jack Stagge | MedBridge. Available from: https://www.youtube.com/watch?v=kzxVHdTrAxE [last accessed 22/4/2024]
  17. ↑ Jiménez-Del-Barrio S, Cadellans-Arróniz A, Ceballos-Laita L, Estébanez-de-Miguel E, López-de-Celis C, Bueno-Gracia E, Pérez-Bellmunt A. The effectiveness of manual therapy on pain, physical function, and nerve conduction studies in carpal tunnel syndrome patients: a systematic review and meta-analysis. Int Orthop. 2022 Feb;46(2):301-312.
  18. ↑ 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.
  19. ↑ Kind S, Otis JD. The Interaction Between Chronic Pain and PTSD. Curr Pain Headache Rep. 2019 Nov 28;23(12):91.
  20. ↑ 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.
  21. ↑ Martinez-Calderon J, Jensen MP, Morales-Asencio JM, Luque-Suarez A. Pain Catastrophizing and Function In Individuals With Chronic Musculoskeletal Pain: A Systematic Review and Meta-Analysis. Clin J Pain. 2019 Mar;35(3):279-293.
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