Provider perspectives on rehabilitation of patients with polytrauma

Friedemann-Sánchez G, Sayer NA, Pickett T. Provider perspectives on rehabilitation of patients with polytrauma.

Objectives

To describe, from the perspective of U.S. Department of Veterans Affairs (VA) polytrauma rehabilitation providers, (1) patients with combat-related polytrauma and their rehabilitation, (2) polytrauma patient family member involvement in rehabilitation, and (3) the impact on providers of providing polytrauma rehabilitation.

Design

Qualitative study based on rapid assessment process methodology, which included semistructured interviews, observation, and use of a field liaison.

Setting

The 4 VA polytrauma rehabilitation centers (PRCs).

Participants

Fifty-six purposefully selected PRC providers and providers from consulting services.

Interventions

Not applicable.

Main Outcomes Measures

Provider self-report of polytrauma patient characteristics, polytrauma patient family member involvement in rehabilitation, and the impact of polytrauma rehabilitation on providers themselves.

Results

According to PRC providers, polytrauma patients are younger than VA rehabilitation patients. Strong military identities affect rehabilitation needs and reactions to severe injury. The public and the media have particular interest in war-injured patients. Patients with blast-related polytrauma have unique constellations of visible (including amputations, craniectomies, and burns) and invisible (including traumatic brain injury, pain, and posttraumatic stress disorder) injuries. Providers have adjusted treatment strategies and involved services outside of rehabilitation because of this clinical complexity. Family members are intensely involved in rehabilitation and have service needs that may surpass those of families of rehabilitation patients without polytrauma. Sources of provider stress include new responsibilities, media attention, increased oversight, and emotional costs associated with treating severely injured young patients and their families. Providers also described the work as deeply rewarding.

Conclusions

The VA should prioritize the identification or development and implementation of strategies to address family member needs and to monitor and ensure that PRC providers have access to appropriate resources. Future research should determine whether findings generalize to patients injured in other wars and to people who sustain polytraumatic injuries outside of a war zone, including victims of terrorist attacks.     

Nursing Leadership Collaboration for Rehabilitation of Polytrauma Patients

This article describes a variety of nursing issues that emerged over a 3‐year period on polytrauma rehabilitation nursing units and the leadership roles and strategies that were used to meet the rehabilitation needs of newly injured servicemembers who served in Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom (OIF). Nursing's leadership responsibilities focus on three primary areas: patient advocacy, family centeredness, and advocacy for staff. Collaboration among the four national polytrauma rehabilitation centers (PRCs) run by the U.S. Department of Veterans Affairs has enhanced the skill set for nursing staff members. These rehabilitation nurses possess the strong skills necessary to assess complex patient cases involving blast injuries, as well as strengthened interpersonal competencies in family dynamics, family education, and team function.     

Communicating information to families of polytrauma patients: a narrative literature review

Family caregivers of U.S. servicemembers with polytraumatic injuries (injuries to multiple body systems) need support and information to care for their family members. Providing information to patients'families may reduce stress and increase coping abilities. Because the field of polytrauma research is new and evidence is lacking, providers rely on traumatic brain injury (TBI) research to guide their practice. This article presents a narrative literature review on the information needs of families of patients with TBI. It summarizes the types of needed information, the most appropriate time to provide information, and the best approaches for providing information. Future research on information needs is critical if polytrauma rehabilitation providers are to effectively support families in their caregiving roles. Such research likely will benefit caregivers of patients with polytrauma who acquire their injuries as civilians, as well. Research gaps are identified with regard to the information needs of families of patients with TBI; these gaps also are applicable to polytrauma caregivers. Additional research areas are highlighted in light of the new polytrauma population.     

Characteristics and rehabilitation outcomes among patients with blast and other injuries sustained during the Global War on Terror

Sayer NA, Chiros CE, Sigford B, Scott S, Clothier B, Pickett T, Lew HL. Characteristics and rehabilitation outcomes among patients with blast and other injuries sustained during the Global War on Terror.

Objective

To describe characteristics and rehabilitation outcomes among patients who received inpatient rehabilitation for blast and other injuries sustained in Iraq and Afghanistan during the Global War on Terror.

Design

Observational study based on chart review and Department of Veterans Affairs (VA) administrative data.

Setting

The 4 VA polytrauma rehabilitation centers (PRCs).

Participants

Service members (N=188) admitted to a PRC during the first 4 years of the Global War on Terror for injuries sustained during Operation Iraqi Freedom or Operation Enduring Freedom.

Intervention

Multidisciplinary comprehensive rehabilitation program.

Main Outcomes Measures

Cognitive and motor FIM instrument gain scores and length of stay (LOS).

Results

Most war-injured patients had traumatic brain injury, injuries to several other body systems and organs, and associated pain. Fifty-six percent had blast-related injuries, and the pattern of injuries was unique among those with injuries secondary to blasts. Soft tissue, eye, oral and maxillofacial, otologic, penetrating brain injuries, symptoms of post-traumatic stress disorder, and auditory impairments were more common in blast-injured patients than in those with war injuries of other etiologies. The mechanism of the injury did not predict functional outcomes. LOS was variable, particularly for those with blast injuries. Patients with low levels of independence at admissions made the most progress but remained more dependent at discharge compared with other PRC patients. The rate of gain was slower in this low-functioning group.

Conclusions

Blasts produce a unique constellation of injuries but do not make a unique contribution to functional gain scores. Findings underscore the need for assessment and treatment of pain and mental health problems among patients with polytrauma and blast-related injuries. Patients with polytrauma have lifelong needs, and future research should examine needs over time after community re-entry.     

Nociceptive and Cognitive Changes in a Murine Model of Polytrauma

Polytrauma commonly involves concussion (mild traumatic brain injury [mTBI]) and peripheral trauma including limb fractures. Interactions between mTBI and peripheral injuries are poorly understood, both leading to chronic pain and neurobehavioral impairments. To elucidate these interactions, a murine polytrauma model was developed. mTBI alone resulted in similar increased mechanical allodynia in male and female mice. Female fracture and polytrauma groups displayed greater increases in hind paw tactile hypersensitivity for weeks after injury than did the respective male groups. Capsaicin-evoked spontaneous pain behaviors were greater in fracture and polytrauma female mice compared with male mice. The mTBI and polytrauma male mice displayed significant deficits in spatial working memory. All fracture, mTBI, or polytrauma groups had deficits in object recognition memory. Only male mTBI or polytrauma mice showed greater agitation and increased risk-taking behavior in open field testing as well as zero maze tests. Additionally, impaired diffuse noxious inhibitory control was observed in all mTBI and polytrauma mice. The model presented offers clinically relevant features useful for studying persistent pain as well as cognitive and other behavioral changes after TBI including polytrauma. A better understanding of nervous system dysfunction after TBI and polytrauma might help prevent or reduce persistent pain and disability in these patients.

"To care for him who shall have borne the battle and for his widow and his orphan" (Abraham Lincoln): the Department of Veterans Affairs polytrauma system of care

Sigford BJ. “To care for him who shall have borne the battle and for his widow and his orphan” (Abraham Lincoln): the Department of Veterans Affairs Polytrauma System of Care.The initiation of combat in Iraq and Afghanistan has resulted in a new cohort of active-duty service members and veterans seeking rehabilitation care through the U.S. Department of Veterans Affairs (VA). Service members injured in combat most often sustain multiple injuries (polytrauma) and require a unique service delivery model to meet their needs. The VA recognized this need and responded with the development of the Polytrauma System of Care (PSC). This national system of care balances access and expertise to provide specialized life-long care to the combat injured. The PSC is comprised of: 4 specialized regional rehabilitation centers that are accredited in brain injury by the Commission on Accreditation of Rehabilitation Facilities; 21 specialized outpatient and subacute rehabilitation programs; designated polytrauma teams at smaller, more remote VA facilities; and a point of contact at all other VA facilities. In addition, the PSC has developed a proactive case-management model, a specialized telehealth network, guidelines for long-term follow-up, and services for those individuals who are unable to return home. The following commentary and articles provide additional detail on this new and unique system of care.     

Expanding the Scope of Staff Education: Brain Injury to Polytrauma

Staff members who care for the polytrauma population need diverse educational programs even if they have many years of experience working in the brain‐injury rehabilitation field. This article explores key concepts that help guide rehabilitation nursing practice, strengthen clinical skills, increase family involvement, and identify educational resources.     

De la blessure à la réparation : parcours croisé du blessé de guerre américain et français

Both France and the United States of America are currently engaged in asymmetric conflicts, with new modes of fight and use of armaments, which have generated an unexpected influx of a new generation of wounded soldiers. These wounded soldiers present severe and complex pathologies: polytrauma, amputations, blast, traumatic brain injuries, with many sequelae and comorbidities, in particular post-traumatic stress disorders, requiring long and multidisciplinary care to meet their needs. Even though the number of soldiers engaged and wounded are not comparable, both countries had to face the same problem, and to adapt their military health system to this new cohort of combat injured. Because of the double engagement of the USA in Iraq and Afghanistan, and of the large number of wounded soldiers seeking rehabilitation care, the American experience regarding rehabilitation and reintegration of these soldiers is considerable. The objective of this work is to present the American and the French medical care of the wounded soldiers in operations, from the initial care on the battlefield, to their process of rehabilitation on the national territory. This comprehensive report makes it possible to introduce the possible actions to be taken by the French military health system, to improve the rehabilitation and return to active duty of the wounded soldiers and to assume the moral duty represented by the medical support of our army.     

Incorporating the prosthetic: Traumatic,limb-loss,rehabilitation and refigured military bodies

In this article, I look at the role that context of injury plays in the rehabilitation of military patients who sustained a limb amputation as a result of blast injury trauma in Afghanistan and Iraq. This article contrasts the technologically driven model of rehabilitation produced by the US Armed Forces Amputee Patient Care Program at Walter Reed Army Medical Center with a person centered approach building on work in medical anthropology. In this article, two case studies are contrasted illustrating the reasons behind the rejection of an upper extremity prosthetic device in one example and the acceptance of one in another. I argue that even in light of the incredible advances in medical technique and prosthetic technology, a body and functionality focussed rehabilitation must also pay attention to the subjective experiences of individual patients in terms of their present and their past.     

Working toward exposure thresholds for blast-induced traumatic brain injury: Thoracic and acceleration mechanisms

Research in blast-induced lung injury resulted in exposure thresholds that are useful in understanding and protecting humans from such injury. Because traumatic brain injury (TBI) due to blast exposure has become a prominent medical and military problem, similar thresholds should be identified that can put available research results in context and guide future research toward protecting war fighters as well as diagnosis and treatment. At least three mechanical mechanisms by which the blast wave may result in brain injury have been proposed—a thoracic mechanism, head acceleration, and direct cranial transmission. These mechanisms need not be mutually exclusive. In this study, likely regions of interest for the first two mechanisms based on blast characteristics (positive pulse duration and peak effective overpressure) are developed using available data from blast experiments and related studies, including behind-armor blunt trauma and ballistic pressure wave studies. These related studies are appropriate to include because blast-like pressure waves are produced that result in neurological effects like those caused by blast. Results suggest that injury thresholds for each mechanism are dependent on blast conditions, and that under some conditions, more than one mechanism may contribute. There is a subset of blast conditions likely to result in TBI due to head acceleration and/or a thoracic mechanism without concomitant lung injury. These results can be used to guide experimental designs and compare additional data as they become available. Additional data are needed before actual probabilities or severity of TBI for a given exposure can be described.     

Incorporating the prosthetic: Traumatic,limb-loss,rehabilitation and refigured military bodies

Abstract

In this article, I look at the role that context of injury plays in the rehabilitation of military patients who sustained a limb amputation as a result of blast injury trauma in Afghanistan and Iraq. This article contrasts the technologically driven model of rehabilitation produced by the US Armed Forces Amputee Patient Care Program at Walter Reed Army Medical Center with a person centered approach building on work in medical anthropology. In this article, two case studies are contrasted illustrating the reasons behind the rejection of an upper extremity prosthetic device in one example and the acceptance of one in another. I argue that even in light of the incredible advances in medical technique and prosthetic technology, a body and functionality focussed rehabilitation must also pay attention to the subjective experiences of individual patients in terms of their present and their past.     

多发伤并发持续炎症-免疫抑制-分解代谢综合征患者的临床特征及预后分析

目的:研究多发伤并发持续炎症-免疫抑制-分解代谢综合征(persistent inflammation, immunosuppression and catabolism syndrome, PICS)患者的临床特征及预后。方法:分析2019年1月至2020年7月间收治于同济医院创伤外科的1 083例多发伤患者的临床资...     

Safety of rFVIIa in hemodynamically unstable polytrauma patients with traumatic brain injury: <Emphasis Type="Italic">post hoc</Emphasis>analysis of 30 patients from a prospective,randomized, placebo-controlled,double-blind clinical trial

Background  

Trauma is a leading cause of mortality and morbidity, with traumatic brain injury (TBI) and uncontrolled hemorrhage responsible for the majority of these deaths. Recombinant activated factor VIIa (rFVIIa) is being investigated as an adjunctive hemostatic treatment for bleeding refractory to conventional replacement therapy in trauma patients. TBI is a common component of polytrauma injuries. However, the combination of TBI with polytrauma injuries is associated with specific risk factors and treatment modalities somewhat different from those of polytrauma without TBI. Although rFVIIa treatment may offer added potential benefit for patients with combined TBI and polytrauma, its safety in this population has not yet been assessed. We conducted a post hoc sub analysis of patients with TBI and severe blunt polytrauma enrolled into a prospective, international, double-blind, randomized, placebo-controlled study.     

A Telerehabilitation Model for Victims of Polytrauma

The Low Activities of Daily Living Monitoring Program (LAMP) at the North Florida/South Georgia Veterans Health System is a telerehabilitation program that promotes independence for veterans experiencing difficulties with activities of daily living by focusing on a combination of care coordination, assistive technology/adaptive equipment, and home environmental modifications. Initially designed to serve elders at risk of institutionalization, LAMP now is being adapted to the needs of veterans living with the effects of multisystem polytrauma. This article provides an overview of telehealth, explains the LAMP model, and presents a case history of a veteran who sustained complete tetraplegia and traumatic transfemoral amputation as the result of a blast injury and who lives successfully at home with the support of LAMP. A recent cost analysis of LAMP patients compared to a matched cohort receiving standard care also is presented. The LAMP model shows promise as a method for home‐based management of combat‐wounded veterans who experience multisystem polytrauma.     

Rehabilitation outcomes for veterans with polytrauma treated at the Tampa VA

Returning soldiers from Iraq and Afghanistan who have sustained polytrauma have a combination of complex physical and mental morbidities that require extensive therapy and rehabilitation. This study examined the effect of rehabilitation on 116 polytrauma patients with service-connected injuries treated at the Tampa VA; improvements in functional and cognitive abilities were measured using the Functional Independence Measure (FIM) scores and healthcare costs for rehabilitation treatment were also assessed. Intensive rehabilitation therapy increased functional ability in this cohort with an average improvement in total FIM scores of 23 points. Total inpatient costs for these patients exceeded $4 million in approximately 3 years. Rehabilitation nurses face challenges providing quality care to this target patient population, including characterizing war-related polytrauma, providing surveillance, coordinating care, synchronizing care for patients with multiple injuries, and conducting evidence-based pain management.     

Rehabilitation of the severely brain-injured patient: a community-based, low-cost model program

Survival from severe traumatic head injury requires long-term, comprehensive rehabilitation services. While acute, hospital-based rehabilitation services are becoming plentiful, low-cost community educational and socialization services are still rare. Cognitive impairments and behavioral disinhibitions frequently are so severe that traditional community agencies cannot effectively serve them. A unique low-cost program model has been developed and successfully implemented to prepare the most severely head injured for more traditional programs. Individualized programming is provided in a highly structured social setting by a professional teacher and many trained volunteers.     

A qualitative study adopting a user-centered approach to design and validate a brain computer interface for cognitive rehabilitation for people with brain injury

ABSTRACT

Cognitive rehabilitation is established as a core intervention within rehabilitation programs following a traumatic brain injury (TBI). Digitally enabled assistive technologies offer opportunities for clinicians to increase remote access to rehabilitation supporting transition into home. Brain Computer Interface (BCI) systems can harness the residual abilities of individuals with limited function to gain control over computers through their brain waves.

This paper presents an online cognitive rehabilitation application developed with therapists, to work remotely with people who have TBI, who will use BCI at home to engage in the therapy. A qualitative research study was completed with people who are community dwellers post brain injury (end users), and a cohort of therapists involved in cognitive rehabilitation. A user-centered approach over three phases in the development, design and feasibility testing of this cognitive rehabilitation application included two tasks (Find-a-Category and a Memory Card task). The therapist could remotely prescribe activity with different levels of difficulty. The service user had a home interface which would present the therapy activities. This novel work was achieved by an international consortium of academics, business partners and service users.     

细胞因子生物标志物在爆炸致急性肺损伤检测中的应用

爆炸冲击伤在现代战争、民用爆破及恐怖袭击中的发生比例日益增加,肺脏作为爆炸冲击伤的最敏感靶器官之一,在冲击伤发生发展过程中最具有代表性。原发肺冲击伤导致急性肺损伤和急性呼吸窘迫综合征是其主要死亡原因。根据肺冲击伤病情发展的不同阶段,目前可以通过相关的生物标志物的检测来进行诊断与评估,笔者就目前爆炸致急性肺损伤检测的主要生化标志物进行综述,为爆炸冲击伤发展过程的动态观测提供依据。