Acupuncture combined with multidisciplinary care for recovery after traumatic multiple rib fractures: a prospective feasibility cohort study.

INTRODUCTION: Acute pain significantly delays early physiological recovery and results in chronic functional disability in patients with traumatic multiple rib fractures (MRFs). This prospective cohort study aimed to investigate the feasibility of acupuncture combined with multidisciplinary care during recovery in patients with traumatic MRFs. METHODS: Twenty patients with traumatic MRFs who were admitted to a regional trauma centre in South Korea were enrolled. A combination of acupuncture and multidisciplinary inpatient ward management was provided at the trauma ward. Patients were permitted to continue acupuncture treatments at outpatient clinics for 3 months after the traumatic events. Clinical outcomes, including pain, acute physiological recovery, quality of life, patient satisfaction with the care provided, respiratory function and use of opioids, were evaluated up to 6 months after trauma. RESULTS: Seventeen (85%) participants completed the 6-month follow-up. One patient withdrew consent during admission due to discomfort after three sessions of acupuncture. The proportion of patients with above-moderate level of pain decreased from 95% at baseline to 41% at 6 months. Quality of life appeared to deteriorate consistently throughout the study period. Around 80% of respondents expressed satisfaction with the acupuncture treatments and stated that they found acupuncture to be acceptable. Over 94% of respondents reported slight or considerable improvement. CONCLUSION: The provision of acupuncture combined with multidisciplinary care for recovery in patients with traumatic MRFs was feasible in a regional trauma centre in South Korea. Randomised trials are needed to investigate the role of acupuncture combined with multidisciplinary care in the future. TRIAL REGISTRATION NUMBER: KCT0002911 (Clinical Research Information Service).

Assessing outcome measures used after rib fracture: A COSMIN systematic review.

PURPOSE: The incidence of invasive treatment of rib fracture has increased significantly over the last decade however the evidence of improved patient outcomes to support this is lacking. A systematic review was performed to identify patient reported outcome measures (PROMs) used in the assessment of outcomes following chest wall injury. The quality of evidence for the psychometric properties of the identified PROMs was graded using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology. METHODS: Rib fracture studies measuring patient reported outcomes were identified using PubMed/Medline, EMBASE, AMED and PsycINFO. Methodological quality of measurement properties was evaluated with the COnsensus-based Standards for selection of health status Measurement INstruments (COSMIN) checklist. RESULTS: A total of 64 studies were identified including 19 different PROM instruments. Domains included in the reported PROMs included pain, breathlessness, general health quality of life, physical function and physiological health. No rib fracture specific PROM was identified. The most frequently reported instrument was the SF-36 reporting overall quality of life (HRQoL) although there was very low quality evidence for its content validity. There was low quality evidence to support good content validity for the Medical Research Council (MRC) dyspnoea scale, Brief Pain Index (BPI) and McGill Pain Questionnaire (MPQ). No PROM had undergone validation in a rib fracture population. The overall quality of the PROM development studies was poor. While we were unable to identify a clear "gold standard", based on the limited current evidence, we recommend that the EQ-5D-5L is used in combination with the MRC and BPI or MPQ for future rib fracture studies. CONCLUSION: The lack of validated outcome measures for rib fracture patients is a significant limitation of the current literature. Further studies are needed to provide validated outcome measures to ensure accuracy of the reported results and conclusions. As interventions for rib fractures have become more common in both research and clinical practice this has become an urgent priority.

Challenges experienced during rehabilitation after traumatic multiple rib fractures: a qualitative study.

BACKGROUND: People with multiple rib fractures rarely receive rehabilitation aimed specifically at their chest wall injuries. This research explores patient perceptions of rehabilitation and recovery. MATERIALS AND METHODS: A qualitative study exploring how a purposive sample of 15 people with traumatic multiple rib fractures at a Major Trauma Centre in the United Kingdom make sense of their recovery. Data collected during one-to-one interviews 4 to 9 months after injury. Transcripts analysed using Interpretative Phenomenological Analysis. RESULTS: Struggling with breathing and pain: Difficulties with breathing and pain were initially so severe ?it takes your breath away? and people felt scared they may not survive. These symptoms gradually improved but feeling "out of puff" often persisted. Life on hold: Healing was considered a natural process which people couldn't influence, creating frustration whilst waiting for injuries to heal. Many believed they would never fully recover and accepted limitations. Lucky to be alive: All participants expressed a sense of feeling lucky to be alive. The seriousness of injury prompted a change in attitude to make the most of life. CONCLUSION: Rib fractures can be painful, but also frightening. A rehabilitation intervention promoting pain management, normalises trauma and restores physical activity may improve recovery. Implications for Rehabilitation Patients identified challenges with rehabilitation throughout the entire recovery journey, and their rehabilitation needs evolved with time. People find it difficult to regain pre-injury fitness even after their fractures heal and pain subsides. A belief there is nothing that can be done to help rib fractures contributed to people lowering their expectations of achieving a full recovery and developing a sense of "making do". Rehabilitation and patient education after traumatic multiple rib fractures should focus on improving pain management, respiratory fitness and emotional well-being.

Predictors of Dependency in Geriatric Trauma Patients with Rib Fractures: A Population Study.

The geriatric trauma population is unique. These patients are at risk of being discharged to rehabilitation or a skilled nursing facility, instead of being returned to their homes, placing a significant burden on both the patient families and society. This study evaluated which patient characteristics increase the likelihood of a previously independent geriatric blunt trauma becoming functionally dependent and being discharged to a location other than home. Data were extracted from the National Trauma Data Bank from 2012 to 2014 for blunt trauma patients ≥65 years old, admitted from home, with one or more rib fractures. Primary outcomes were discharge home versus a facility. Subgroup analysis evaluated disposition to acute short-term rehabilitation or subacute rehabilitation or skilled nursing facility. Multivariable analysis was used to calculate probabilities of disposition based on the above variables, controlling for comorbidities. Sixteen thousand six hundred thirty-two patients were included. Only 58 per cent were discharged home. Increased age, ≥4 rib fractures, white race, and female gender were found to increase the risk of discharge to a facility. In addition, patients with chronic renal failure, history of diabetes, obesity, or heart failure were less likely to be discharged home. This study shows that age, gender, race, and the number of rib fractures are statistically significant in predicting which patients are less likely to be discharged home. This reinforces the need for the development of triage and treatment protocols in this higher risk population, to decrease the social and financial burden of these injuries.

Rib fracture fixation in the 65 years and older population: A paradigm shift in management strategy at a Level I trauma center.

BACKGROUND: Rib fractures after chest wall trauma are a common injury; however, they carry a significant morbidity and mortality risk. The impact of rib fractures in the 65-year and older patient population has been well documented as have the mortality and pneumonia rates. We hypothesize that patients 65 years and older receiving rib plating (RP) have decreased mortality, complication rates, and an accelerated return to normal functional states when compared with controls. METHODS: With institutional review board approval, a retrospective review analyzed patients 65 years and older with rib fractures admitted from 2009 to 2015 receiving RP (RP group) (n = 23) compared to nonoperative, injury-matched controls admitted from 2003 to 2008 (NO group) (n = 50). Patients were followed prospectively with regard to lifestyle and functional satisfaction. Independent variables analyzed included Injury Severity Score (ISS), number of rib fractures, mortalities, hospital days, intensive care unit days, pneumonia development, respiratory complications, readmission rates, need for and length of rehabilitation stay time. Comparisons were by χ tests/Fisher's exact tests, Student's t tests and Wilcoxon rank sum tests. RESULTS: From 2003 to 2008, 50 NO patients were admitted with ages ranging 65 to 97 years, average ISS of 18.47 (14.28-22.66) versus ages ranging from 63 to 89 years, average ISS of 20.71 (15.7-25.73) for the RP group (n = 23). Average hospital days were 16.76 (10.35-23.18) and 18.36 (13.61-23.11) in the NO and RP groups, respectively. Average intensive care unit days were 11.65 (6.45-16.85) and 8.29 (5.31-11.26) days in the NO and RP groups, respectively. Four respiratory readmissions, two deaths, seven pneumonias, seven pleural-effusions, and 19 recurrent pneumothoraces were encountered in the NO group versus 0 in the RP group (p < 0.001). An equal percentage of patients in both groups entered rehabilitation facilities with average stay time of 18.5 and 28.53 days for the RP and NO groups, respectively. CONCLUSION: RP in the 65-year and older trauma population demonstrates a measurable decrease in mortality and respiratory complications, improves respiratory mechanics, and permits an accelerated return to functioning state. LEVEL OF EVIDENCE: Therapeutic/care management study, level IV.

Epidural analgesia for blunt thoracic injury--which patients benefit most?

INTRODUCTION: Epidural analgesia for blunt thoracic injury has been demonstrated to be beneficial for pulmonary function, analgesia, and subjective pain; however the optimal patient selection and timing of thoracic epidural placement have not been well studied. We hypothesised that early (<48h) epidural analgesia (EA) as compared with usual care involving oral and intravenous narcotics delivered by patient-controlled analgesia (PCA) in patients with blunt thoracic trauma (>3 ribs fractured) is associated with fewer pulmonary complications and lower resource utilisation as measured by ICU and hospital length of stay. METHODS: This is a retrospective review of all non-intubated patients suffering from blunt thoracic injury with 3 or more rib fractures requiring hospital admission for >24h over a recent 5-year period. Pulmonary complications were defined as pneumonia, empyema, hypoxia, and need for delayed intubation. Logistic regression was utilised to analyse patient and injury characteristics associated with pulmonary complications. RESULTS: 187 patients were included in the analysis; early thoracic epidural was utilised in 18% (n=34). There was no difference in age, ISS, ICU length of stay (LOS), or pulmonary complications between patients who received an epidural (EPI) compared with those who did not (NO EPI). A significantly increased incidence of pulmonary complications was noted in patients who required tube thoracostomy (p=0.017). CONCLUSION: In our experience, insertion of a thoracic epidural catheter early post-injury failed to reduce the incidence of pulmonary complications, ICU and hospital LOS. However, since pulmonary complications are more frequent in patients requiring tube thoracostomy, the cost-effectiveness of epidural analgesia in these patients warrants further investigation.

The impact of incident fractures on health-related quality of life: 5 years of data from the Canadian Multicentre Osteoporosis Study.

UNLABELLED: Using prospective data from the Canadian Multicentre Osteoporosis Study (CaMos), we compared health utilities index (HUI) scores after 5 years of follow-up among participants (50 years and older) with and without incident clinical fractures. Incident fractures had a negative impact on HUI scores over time. INTRODUCTION: This study examined change in health-related quality of life (HRQL) in those with and without incident clinical fractures as measured by the HUI. METHODS: The study cohort was 4,820 women and 1,783 men (50 years and older) from the CaMos. The HUI was administered at baseline and year 5. Participants were sub-divided into incident fracture groups (hip, rib, spine, forearm, pelvis, other) and were compared with those without these fractures. The effects of both time and fracture type on HUI scores were examined in multivariable regression analyses. RESULTS: Men and women with hip fractures, compared to those without, had lower HUI measures that ranged from -0.05 to -0.25. Both women and men with spine fractures had significant deficits on the pain attributes (-0.07 to -0.12). In women, self-care (-0.06), mobility and ambulation (-0.05) were also negatively impacted. Women with rib fractures had deficits similar to women with spine fractures, and these effects persisted over time. In men, rib fractures did not significantly affect HUI scores. Pelvic and forearm fractures did not substantially influence HUI scores. CONCLUSION: The HUI was a sensitive measure of HRQL change over time. These results will inform economic analyses evaluating osteoporosis therapies.

[Pseudoarthrosis of the first rib in a patient who practices yoga. A case report]. / Seudoartrosis de la primera costilla en una practicante de yoga. Presentación de un caso.

INTRODUCTION: Pseudoarthrosis of the first rib is a rare condition that may occur in athletes as a result of repetitive activities, mainly overhead. The usual clinical presentation is pain in the neck or the ipsilateral shoulder. CASE REPORT: This is the case of a 19-year-old female patient who had sudden pain of the base of the neck while doing yoga. Pseudoarthrosis of the first rib was diagnosed with X-rays and CAT scan. Treatment consisted of a rehabilitation and physical therapy program that was successful despite the persistence of the pseudoarthrosis. DISCUSSION: Cases of first rib fractures have been reported in athletes practicing multiple activities; however, pseudoarthrosis cases are rare since most of them progress to bone healing. This is the first reported case of a fracture or pseudoarthrosis in a patient practicing yoga. As in most reported cases, conservative treatment was successful. CONCLUSION: Fractures and pseudoarthrosis of the first rib are rare in athletes and should be included in the differential diagnosis of athletes presenting with shoulder and neck pain. Conservative treatment is successful in most cases.

Acupuncture for central pain affecting the ribcage following traumatic brain injury and rib fractures--a case report.

This case report describes the use of acupuncture in the management of chronic central pain in a 51 year old man following severe traumatic brain injury and multiple injuries including rib fractures. The patient reported rapid and significant improvements in pain and mood during a course of acupuncture treatment. Chronic pain following traumatic brain injury is a significant problem. Chronic pain after rib fractures is also commonly reported. Acupuncture is widely used in the management of pain but its use has been reported rarely in the traumatic brain injury literature. This case report suggests that acupuncture may be a useful option to consider in these patients. Outcome was assessed formally using a 0-10 verbal numerical rating scale for pain, and the Hospital Anxiety and Depression Scale (HADS) for psychological status before and after the course of treatment. These scales are widely used in clinical practice as well as in research involving patients with traumatic brain injury, although they have not been validated in this population. The changes in this patient's outcome scores were not consistent with the benefits he reported. Treatment of this patient highlighted the difficulties of using standardised self rating scales for patients with cognitive impairment. The report also discusses the effects of acupuncture on this patient's mood.

I.V. alfentanil analgesia for physiotherapy following rib fractures.

A case is presented in which intermittent i.v. alfentanil was titrated to meet the analgesic requirements in a patient with extensive rib fractures, during each session of intensive chest physiotherapy. This method of analgesia is discussed and compared with other analgesic techniques.

Use of the air-inflated jacket in football.

Injuries to the rib cage are common in football, but little has been done to protect this area. This paper discusses the effectiveness and usefulness of a protective jacket in football. The jacket is highly durable, constructed of urethane-coated nylon, and heat-sealed to take on the shape of several cylinders interconnected by fabric valves which constrict in response to a sudden blow. Its exterior is covered by a 1/8-inch thick Lexan (General Electric, Toledo, OH) shield. The jacket weighs 6.5 oz. It showed impressive results when tested. Testing was done by forcefully swinging a baseball bat against the rib cage protected by the jacket. By digitization of high speed movie filming at 500 frames/second, we were able to determine the speed, velocity, and area of contact. The amount of force deflection was calculated to be 587.6 psi. To inflict this force, a player would have to be traveling 60 miles/hour and strike his opponent with the heel. This lightweight, air-inflated, padded jacket has protected and prevented rib cage injuries in professional athletes. It is accepted well by players. This suggests that similar protective equipment for other areas would be useful and represents an advancement in preventing injury.