Northern Trauma System Regional Conference 2014 High quality trauma care from ‘Roadside to Recovery’

The Role of Specialist Rehabilitation in Polytrauma Management Dr James Graham (Consultant Radiologist) Dr Rachel Reaveley (SPR in Neurological Rehabilitation)

Objectives  By the end of this case presentation we will have covered…  Radiology of the case  Specialist Rehabilitation Interventions How the specialist rehabilitation process worked from acute referral through to outpatient review and inpatient admission Summary of causes of dizziness in the rehabilitation setting Assessing the psychological impact of poly-trauma in the context of concurrent head injury Reflect together on potential gaps in the service

Case History  50 year old driving instructor  High speed head on collision 10/10/12  Brought to MTC

Trauma CT

Case History - summary  50 year old driving instructor  High speed head on collision 10/10/12  Right haemo-pnuemothorax and lung contusion with rib fractures –  Left pneumothorax  Jejunal perforation and terminal ileum mesenteric injury- requiring laparotomy, repair and end ileostomy  Complications – chest sepsis, need for high inotropic support, abnormal kidney function, LFTs & amylase – 19 days in ICU

A few days later…  Gradual clinical deterioration  Lactate 1.3  Amylase 439  WCC 20  CRP 116  Bilirubin 63  ALP 335  ALT 282

Follow up CT

Gastric appearances

Angiogram

Endoscopy

What Happened next?

Rehabilitation Assessment & Planning First seen by Rehabilitation Consultant on General Surgery Ward 21/11/12 Referred by Head Injury Sister – small frontal contusion Dizziness Nausea Back pain ? Change in personality

Dizziness and nausea  When moving from sitting to standing and from lying to sitting  Documented drop in BP on standing  Contributory factors  Medications – opioids  Fluid depletion (nausea)  Coeliac axis injury – damage to autonomic nerve supply to splanchnic bed  ? BPPV

Benign Paraoxysmal Positional Vertigo

Orthostatic Hypotension

Coeliac Plexus Kambadakone A et al. CT-guided Celiac Plexus Neurolysis: A Review of Anatomy, Indications, Technique, and Tips for Successful Treatment. RadioGraphics 2011; 31: Sir Roger Bannister. Autonomic Failure. A Textbook of Clinical Disorders of the Autonomic Nervous System. Second Edition.

Rehabilitation Medicine Review as Outpatient May 2013  Dizziness - diagnosed with BPPV – treated with Epley’s manoeuvre  Nausea and vomiting improved - Awaiting surgical reversal of ileostomy  Significant back pain – remained under surgical review with plan for follow up physiotherapy – referral made to health psychology to support through this.  Low mood – body image issues  Character change

Epley’s Manouvre

People involved/pending procedures  Mr B Griffiths – General surgery – awaiting ileostomy reversal  Mr G Wynne Jones – Orthopaedics  Mr Waldron – ENT Sunderland  Sister Hastie – Head Injury  GP – commenced sertraline for low mood  Dr J Lawson - Falls & Syncope Service  Mr Jenkins - Urologist UHND – admitted with urinary sepsis shortly after discharge from RVI – 4x unsuccessful TWOC as inpatient

Out patient Review: May 2013  Assessment of frontal brain injury vs mood disturbance:- Subtle changes in character Loss of sense of humour Concrete thinking Short term memory impairment Easily provoked by loud noises and crowds Lack of initiation

Rehabilitation Actions & further Progress  Ileostomy reversal – health psychology at RVI requested to provide peri-operative support  Complicated by further sepsis/leakage requiring readmission via UHND  On-going back pain – waiting for orthopaedic review and physiotherapy  Continued family concerns around change in personality (short term memory and increased irritability)  Referred to neuropsychology as outpatient ( long waiting list….)

In Patient Admission to WGP Cognitive Assessment Bed February 2014 Increasing concern about ongoing depressive episodes with psychological trauma- type symptoms post RTA

Psychology and Psychiatry Input Changes in cognition reported largely explained by mood disorder Concrete thinking Slowness in mental speed both associated with depression Anxiety also may have contributed to under- performance Cognitive assessment noted only very mild problems in verbal abstract reasoning. Working memory unimpaired

Other Therapies  OT assessment: independent with route finding, money handling and road safety. independent and safe at problem solving in the kitchen. Written instructions for more complex tasks  SALT assessment Cognitive communication skills largely intact, however some reading comprehension difficulties With prompting to slow down his reading rate and check his responses, accuracy improved

Limitations of current processes ‘We’ve had no help at all since being at home” Comment from patient’s wife at first rehab OP review  Lack of co-ordinated follow up on discharge from MTC unless head injury severe enough to require ongoing inpatient follow up or community therapies needed specific to TBI  Predictable problems – ongoing dizziness and need for Dix Hallpike. Catheter issues – reassurance of empty bladder/UTI prevention/onward referral  Mood disorder - psychological complications can be significant following trauma. Services to address these issues currently very limited – differences between psychological trauma and brain injury effect

Summary  Interesting case of patient with multi- trauma and complications  Long period of rehabilitation including inpatient stay required  Illustrates that not all changes in behavior following head injury are related to injury

Thank you!

Northern Trauma System Regional Conference 2014 High quality trauma care from ‘Roadside to Recovery’

NHS | Presentation to [XXXX Company] | [Type Date]35 Transforming Trauma Rehabilitation Recommendations for the North East Region Sharon Smith Paula Dimarco

Overview of talk Purpose of project Background of project Best practice pathway Key findings Recommendations

Purpose of project On behalf of NE SHA Provide information and recommendations Develop a best practice pathway Support commissioning for development of rehabilitation services following major or serious trauma

The Project Regional steering group Two work streams, JCUH and RVI Review of MSK and neurological rehabilitation Map of current pathway Data collection and analysis Stakeholder consultations Identify models of best practice Gap analysis

Best practice pathway

Key findings

No consultants in Rehabilitation Medicine in MSK and insufficient within neurotrauma National Standards Recommend: 6 WTE per million population No single handed consultants Current Regional Provision: 3.8 WTE in level 1 Services 3 WTE in level 2 services all working single handed There is a 2/3 Shortfall on the national standards.

Lack of communication, co-ordination and leadership across the pathway leading to disjointed care and inadequate management of patients RVI has head injury nurse specialist JCUH has acquired brain injury coordinator No formal coordinated MDT rehab specifically for TBI at either MTC No coordinator for MSK at either MTC Rehabilitation needs to be well planned across the whole pathway, including TUs and community services

No specialist inpatient beds for MSK rehabilitation resulting in longer lengths of stay in acute beds or transfer to inappropriate settings Case example: 55 year old male – MSK polytrauma including ITU stay MTC also patient’s local hospital NWB for 6 months, remained on an acute ortho ward Transferred to intermediate care at 7 months – little experience of younger patients and ortho rehab

No specialist community MDT for MSK rehabilitation leading to sub-optimal outcomes and longer lengths of rehabilitation If there were community MSK trauma rehab teams, the outcome of the previous example may have been somewhat different

Insufficient level 1 and 2 inpatient rehabilitation facilities for neurotrauma patients BSRM guidelines recommend 60 level 2 beds per million population Currently 47 in the North East and Cumbria Level 1 facility is Walkgate Park = 35 beds

Insufficient specialist community teams for neurotrauma patients Only available in 3 areas: Northumberland (3 therapies in one team) Gateshead (no physiotherapy) Cumbria Different models at each locality All teams work across health and social care

No robust system for data collection to indicate the number of patients requiring specialist and non-specialist Recovery, Rehabilitation and Reablement TARN can provide a list of injuries and ISS, but these don’t tell us what the patient’s rehabilitation needs are and are retrospective UKROC not used by all aspects of the pathway Rehabilitation prescription yet to function as a data recording tool

Lack of vocational rehabilitation resulting in no focus on reablement, return to work and social integration No vocational rehab for MSK trauma Limited for neurotrauma All have access to statutory services – not always appropriate Momentum for neuro patients

No standardised or consistent approach to the use of outcome measures which makes it difficult to evaluate rehabilitation Different emphasis at each stage of rehab, therefore a variety of outcome measures are used No standardised approach Work is being undertaken to determine best outcome measures to use

Recommendations

Provide additional Consultant level leadership in rehabilitation in order to promote inter-speciality working and improve patient management and outcomes e.g. Consultants in Rehabilitation Medicine/Consultant Allied Health Professionals.

Recommendations 2.Explore workforce options to improve coordination and communication across the whole pathway for example Rehabilitation Coordinators/Facilitators. 3.Devise robust, flexible, fit for purpose systems to collect data and inform future commissioning and service provision.

Recommendations 4.Develop specialist rehabilitation inpatient beds for major trauma MSK patients. This would also ensure the capacity to provide intensive therapy. Further work is recommended to identify the number of beds required. 5.Create specialist MDTs which would deliver specialist rehabilitation for MSK major and serious trauma patients (inpatient and outpatient/community).

Recommendations 6.Provision of more level 1 and 2 rehabilitation beds for Neurotrauma patients in line with national recommendations. 7.Increase the current number of specialist community teams for rehabilitation of Neurotrauma patients to cover all areas.

Recommendations 8.Undertake robust and committed service redesign to deliver a best practice pathway, with particular focus on strengthening Recovery, Rehabilitation and Reablement services. 9.Ensure regional implementation of the rehabilitation prescription process for all major trauma patients across all services, from injury to re-enablement. This should include the redesign of the current Rehabilitation Prescription.

Recommendations 10.Integrate vocational rehabilitation into the trauma pathway. 11.Undertake further work to develop recommendations for the use of outcome measures for the trauma rehabilitation pathway.

Recommendations 12.Develop a Directory of Rehabilitation Services with identified administrative support to maintain and update. Implementation of these recommendations requires a coordinated approach involving commissioners, expert clinicians and service users.

Mr Yogendra Jagatsinh MBBS. M.S. (Tr & Orth), MRCS Ed Consultant in Rehabilitation medicine

“Amputation : one of the meanest, and yet one of the greatest operations in surgery; mean when resorted to where better may be done great, as the only step to give comfort and prolong life.” Sir Willliam Ferguson 1865

“ The principle of a patient receiving specialist care appropriate for their injuries is fundamental to Networks of Trauma care. To abandon this at the point at which rehabilitation is required is illogical and compromise patient outcomes. It is wrong to assume that specialist rehabilitation techniques will be carried out on a general orthopaedic or general surgical ward in DGH” Regional Network for Trauma NHS CAG Report

Incidence and Prevalence Prevalence=62000; Incidence : 5000/year LL=92%, UL=5% & Cong def=3% 50% of all amputees are > 65 yrs & 25 % > 75yrs Females=30%, median age of males=66 & females = 69 50% of all referrals are transtibial amputees 72% of all referrals are PVD & 41% of them diabetic 60% of UL referrals are < 55 yrs old.

Trauma Amputations 30% of new amputations industrial accidents, farming accidents, or motor vehicle accidents, which include automobiles, motorcycles and trains War amputations-complicated, multiple Younger and active populations

Levels of Amputations

Phases of Rehabilitation 1. Pre amputation consultation 2. Healing and Starting Physiotherapy 3. Visiting the Prosthetist 4. Choosing an Artificial Limb 5. Learning to Use your Artificial Limb 6. Life as a New Amputee

Goals of Rehabilitation optimize health status, Function Independence Quality of life of patients Participation in society

Post operative Rigid Dressings-Why Use Them? Control edema- that otherwise would – Delay healing – Cause pain – Complicate prosthetic fitting Shape the limb for optimal socket fitting Protects wound/incision Some can allow for early weight bearing Get the patient used to the idea of caring for the residual limb – Never too early to begin educating on volume management – Training in compliance Some can help prevent a joint contracture Desensitization Can absorb drainage

Pain Management Perioperative pain control Pain after healing-Bony causes -Soft tissue causes Pain caused by prosthesis-Pressure, friction or skin tractioning Phantom limb pain Decrease dependence on narcotic medication

Physical Health Reduce the risk of adverse effects due to periods of prolonged immobilization: a. Decrease contractures b. Decrease incidence of pressure ulcers c. Decrease incidence of deep vein thrombosis Improve physical status (e.g., balance, normal range of motion especially at the hips and knees; increase strength and endurance to maximize efficient use of a prosthesis)

Function Improve functional status (e.g., independent bed mobility, independent transfer, wheelchair mobility, gait and safety) Improve ambulation (e.g., distance of ambulation, hours of prosthetic wearing, use of an assistive device, and ability to ascend/descend stairs) Improve quality of life/decrease activity limitation (e.g., activities of daily living [ADL], recreation, physical activity beyond ADL, community re-integration; and return to home environment)

Energy use in Amputation

Psychological adjustment Overwhelming feeling of lack of control Feeling of complete change Change in body image Grieving process-five stages denial, bargaining, anger, depression and acceptance.

Traumatic amputation Co-morbidity from multiple trauma Additional injuries of peripheral nerves, disrupted blood vessels, retained shrapnel, heterotopic ossification, contaminated wounds, burns, grafted skin, and fractures. Requires modified rehabilitation strategies in the training of activities of daily living (ADL) and ambulation.

Rehabilitation and the long-term outcomes of persons with trauma-related amputations. OBJECTIVE: To examine the long-term outcomes of persons undergoing trauma-related amputations and the role of inpatient rehabilitation in improving such outcomes. PARTICIPANTS: Principal or secondary diagnosis of a trauma-related amputation to the lower extremity. Spinal cord injury or traumatic brain injury were excluded. RESULTS: 146 patients 9% died during the acute admission and 3.5% died after discharge 87%-Males. 80% <40 yrs age Health profile (n = 78, 68% response rate) was systematically lower than that of the general US population for all SF-36 scores.

25 % - severe problems with the residual limb, including phantom pain, wounds, and sores. Number of inpatient rehabilitation nights – directly related to function in their physical roles, increased vitality, and reduced bodily pain. Inpatient rehabilitation- improved vocational outcomes. Pezzin LE et al. Rehabilitation and the long-term outcomes of persons with trauma-related amputations. Archives of Physical Medicine & Rehabilitation, 01 March 2000, vol./is. 81/3( ).

Carlisle Murrison Centre Consultant Led Service Team of Prosthetic, physiotherapy, rehabilitation assistant, exercise therapist, Occupational therapist, Orthotist, Psychologist, rehabilitation engineer, Podiatrist –all in one roof.

Role of Rehabilitation Consultant Perioperative consultation-best outcomes Issues with pain, sexual function and pain-early period Physical complications such as pain, skin disorders, sweating, infections and venous thromboses, psychological complications such as depression and ‘catastrophising’ Secondary or tertiary prevention is also a key function with regard to skin and foot pathology, cardiovascular disease,osteoporosis and drug complications

vocational rehabilitation, provision of wheelchairs, special seating, orthoses and assistive technologies.

This is the opportunity for the us all to take the Rehabilitation out of the ranks of being a "Cinderella Speciality"