Monograph 2 ~ Fundamentals of Case Management
 
   
Monograph 2

Fundamentals of Initial Case
Management Following Trauma


By R. C. Schafer, DC, PhD, FICC
Manuscript Prepublication Copyright 1997

Copied with permission from  ACAPress


Introduction
  The Approach
     Physician Responsibilities

Basic Diagnostic and Support Procedures
  Early Case Management Plan
  The History Interview
  Typical Early Findings
   Spine-Board Transportation of the Injured
   Emergency Immobilization by Splints
   Roentgenology
   Skin and Tendon Reflexes
Pain: General Considerations
   Significance of Hyperalgesia
   Characteristics of Extremity Pain
   Characteristics of Neuralgia

References and Bibliography




Without a doubt, no other health-care approach equals the efficacy of chiropractic in the general field of conservative neuromusculoskeletal rehabilitation.

For many centuries, therapeutic rehabilitation was a product of personal experience passed on from clinician to clinician. In the last 20 years, however, it has become an applied science. In its application, of course, much empiricism remains that can be called an intuitive art --and this is true for all forms of professional health care.


      INTRODUCTION

The word trauma means more than the injuries so common with falls, accidents, and contact sports. Taber1 defines it as "A physical injury or wound often caused by an external force or violence" or "an emotional or psychologic shock that may produce disordered feelings or behavior." This is an extremely narrow definition for trauma can also be caused by intrinsic forces as seen in common strain. In addition to its cause being extrinsic or intrinsic, with a physical and emotional aspect, it also can be the result of either a strong overt force or repetitive microforces. This latter factor, so important in treating a unique patient's specific pathophysiology, is too often neglected outside the chiropractic profession.

Taber1 states rehabilitation is "The process of treatment and education that lead the disabled individual to attainment of maximum function, a sense of well being, and a personally satisfying level of independence. The person requiring rehabilitation may be disabled from a birth defect or from an illness. The combined effects of the individual, family, friends, medical, nursing, allied health personnel, and community resources make rehabilitation possible." It is surprising that Taber excludes trauma as a prerequisite for rehabilitation for it is the most common factor involved.

Other authors define rehabilitation strictly in terms of exercise and restorative therapeutic modalities and regimens. Some limit the term to preventing or reversing the noxious effects of the inactivity or lessened activity associated with the healing process. While it is true that these definitions hold significant components of clinical reconditioning and restoration, the scope of rehabilitation means much more to the chiropractic physician.

It has been the custom of the majority health-care profession not to consider rehabilitative procedures until late in case management. Like Welch2, allopaths generally place it 6th in the cycle of managing the body's response to injury:

(1) injury
(2) pain, bleeding and traumatized tissue
(3) inflammation
(4) repair and regeneration
(5) atrophy
(6) rehabilitation.

This author asks, "Why wait for signs of atrophy to begin rehabilitation? Nonparalytic atrophy beacons a neglected patient."

Throughout many of my manuscripts, emphasis is placed on minimizing the noxious effects of fibrosis. Fibrosis parallels atrophy and leads to
(1) impaired cellular nutrition and drainage,
(2) stiff, shortened soft tissues,
(3) trigger-point development,
(4) adhesion development, and (5) articular fixations restricting normal ranges of motion.

Restricted joint mobility, in turn, encourages further atrophy, stasis, and a lack of mechanoreceptor input. Thus, a vicious cycle is established leading to a greater risk of residual impairment, reinjury, and progressive degeneration. After bleeding and pain are controlled, a primary objective is the normalization of soft-tissue flexibility, elasticity, and pliability as soon as possible.

Posttraumatic rehabilitative procedures ideally begin at the time the doctor first sees the patient. Hopefully, this will be an early stage --one occurring soon after injury. Alert care will usually control the ill effects of inflammation, enhance repair and regeneration mechanisms, and halt, if not nullify, the progress of atrophy and the formation of fibrosis. In many cases, customary surgery may be avoided. With individualized care, the result is a greater likelihood of obtaining an optimal goal of full function, strength, power, resistance, agility, and endurance.


      THE APPROACH

Experienced clinicians recognize the need to treat the entire kinematic chain and related functions involved in an injury and not a particular joint or part manifesting acute symptoms. Protocols, templates, and regimens are used throughout many manuscripts simply as guidelines. They should not be considered "the standard" or "the only way to do it." Every person is unique in many ways. The way each responds to trauma and pain and its treatment is no exception. Thus, a "cookbook" approach to rehabilitative therapy is irrational if suggestions are taken as a directive rather than a framework for thought --a framework, not a cage.

Most texts concerning rehabilitative therapy directed to allied health-care professions appear to be developed from the standpoint of a perfectly healthy individual who has suffered an injury. The young practitioner should keep in mind that this is rarely the case. The typical traumatized patient presents with an array of underlying overt and subclinical pathologic, dyfunctional, and emotional disorders that must be considered in arriving at a practical treatment plan.

An examiner should keep in mind that trauma is not always the cause of all an injured patient's complaints. A painful injury may only be the precipitating factor bringing the patient to the doctor's office. Trauma produces overstress, and overstress frequently brings out subclinical disorders because of the tax on the immunologic system and other body reserves. The differentiation of the immediate from predisposing factors is just one component of the clinical art.


Physician Responsibilities

If a doctor were to concern himself solely with injury prevention, care, and rehabilitation, his role would be much easier. But many factors are involved. For instance, consider patient motivation and cooperation -without which case management is an uphill battle.

The average patient bears many pressures. These pressures may blind the patient to the fact that continuing usual activities at this time may make a minor condition worse or that the continuation of treatment after pain has subsided is necessary to reach optimal goals.

Physical activity beyond the point of exhaustion or tissue strength or continuing stressful activity with an injury where further insult may lead to permanent injury is illogical from a clinical viewpoint but common behavior. And for various reasons, some people may avoid reporting injury or even try to hide its effects.

The attending physician should mentally target that he is only responsible to the patient and his professional code of conduct. He is not responsible to any other person except the parent of a minor or a legal guardian. Thus the questions must be asked: Who has the authority to return an injured employee to work: the attending physician, the company doctor, or the patient's employer? Who has the authority to return an injured athlete to play or practice: the attending physician, the trainer, or the coach?



      BASIC DIAGNOSTIC AND SUPPORT PROCEDURES

This and other monographs in this series describe basic diagnostic procedures, offer a brief review of fundamental disorders, and explain the basic clinical template on which all subsequent papers are framed. The topic begs an explanation of physiologic performance, conditioning rationale, and exclusion criteria for potentially harmful activity.


Early Case Management Plan

Each doctor usually has a general case management plan that can be readily adapted to the situation at hand. An example is listed below.

Survey the situation for a medical emergency, and take whatever first-aid measures are necessary, record patient status and vital signs, and record as much of a detailed history as logical under the circumstances.

Record findings of inspection and tolerated palpation and movement of the part involved. Auscultate involved areas for crepitus; observe abnormal limb, spinal, pelvic, and rib positions suggesting fracture or dislocation; and seek signs of CNS injury or internal hemorrhage.

Record integrity of normal superficial and deep reflexes and occurrence of pathologic reflexes, and order roentgenography if fracture or dislocation is suspected.

Record findings of involved joint range of motion studies and muscle strength to the degree possible at the stage existing at the time of examination, order electromyographic and/or thermographic studies as indicated, and order pertinent laboratory studies.

Coordinate findings, patient's objectives, and prognosis, and set clinical goals, treat and monitor, periodically reassess patient progress with the working diagnosis and clinical goals, and retest when confirmation is necessary.

Recording oral temperature, comparing extremity pulses and limb blood pressure, and auscultating the heart and lungs should be a common routine in any examination. Traumatic injury is no exception. However, the state of the patient must set priorities.


The History Interview

The personal data collected should be similar to that recorded routinely such as name, address, date of birth, age, sex, present complaints, present and past occupations, type of work and the number of hours, recreational activities, medical and surgical history, accidents and injuries history, drug and food sensitivities, allergies, congenital difficulties, diet, smoking and drinking habits, insurance data, etc. The history should also define the types of primary and secondary physical activities, the number of hours involved, the level of achievement, the age at which active involvement began, etc.

A thorough history forms the basis for differentiating acute from chronic disorders. See Table 1.


Table 1. Differentiation of Acute and Chronic Disorders

Clinical Finding Acute Inflammation Chronic Inflammation
Pain Relatively constant; likely referred over a diffuse segmental area. In intrinsic disorders, pain is increased on movement in any direction. In periarticular disorders, pain is increased on movement only in certain planes. Increased by specific movements, relieved by rest; likely to be relatively localized near, but not necessarily over, the site of the lesion.
Passive motion Muscle spasm or empty end-feel at the end of motion. No muscle spasm or empty end-feel at the end of motion, possible blocking.
Tenderness Severe. From slight to moderate.
Skin temperature Measurable increase. No measurable increase.
Sleeping pattern Difficulty in falling asleep, staying asleep, or both. No sleeping difficulty unless a hip or shoulder is involved.


Typical Early Findings

Typical overt changes (traumatic or nontraumatic) commonly discovered in disorders of the musculoskeletal system include:

  • Color changes such as ecchymosis and redness
  • Local heat
  • Swelling from synovial thickening, periarticular edema, nodules, or bony enlargement
  • Deformity from abnormal bone angulation or subluxation
  • Wasting from atrophy or dystrophy
  • Tenderness on palpation
  • Pain on motion
  • Limitation of motion
  • Joint instability
  • Carriage and gait abnormalities.

In examining a patient in pain, certain types of pain are clinically significant. For example, a sharp severe pain associated with muscle changes and sensory disturbances radiating along the distribution of a nerve is characteristic of acute nerve compression. Pain from fracture is severe, throbbing, and acutely aggravated by movement of the part.


Spine-Board Transportation of the Injured

Moving an injured person frequently requires extreme care. In moving a severely injured person from one location to another, a spine board is more appropriate than the common stretcher because the board helps to prevent further aggravation of a possible vertebral or spinal cord lesion. Craig 3 warns that transporting an injured athlete from the field must be well-planned, orderly, and conducted in an unhurried manner. Four general steps are involved in transporting any injured person:

  1. The patient should be placed supine with care taken that the head, neck, and spine are in normal alignment. The spine board is placed close and parallel to the patient's body. Note, however, that a conscious patient with a painful disorder is understandably reluctant to change a position that seems comfortable, thus tending to favor a position usually involving minimum movement.

  2. Usually, the patient's arm next to the board is placed at the subject's side and the patient's other arm is extended over the head if it is not injured. The patient is then gently rolled onto the side opposite the patient's extended arm. The patient should be rolled like a "log" to maintain body alignment. An exception to this would be suspicion of a spinal fracture, whereon the player should be kept on the side and not rolled supine. This may require seven people in a spinal or head injury, otherwise two people will usually suffice unless the player is extremely large.

  3. The spine board is inserted under the back of the patient (not under the patient's side). Then, gently roll the patient onto the spine board. In cases of unconsciousness, facial or mouth fractures, bleeding from the mouth or nose, the patient is kept laterally recumbent to allow drainage and an open airway.

  4. Assure that the injured person is in a comfortable position, then snug straps around the board and patient to secure the injured person to the spine board during transportation. If possible, remove rings from injured hands before swelling occurs.


Emergency Immobilization by Splints

To prevent further damage during referral, a fractured bone should be immobilized by immediately splinting the joints above and below the fracture because movement of these joints would disturb the bony segments. The splint should be well padded to protect the skin from injury, loss of circulation, inflammation, and infection.

A pneumatic inflatable splint is especially useful in limb fracture because it allows both immobilization and compression to minimize effusion and hemorrhage. It must be applied only snug enough to support any fracture fragments without inhibiting circulation.

To immobilize a fractured bone in the thigh or hip, an improvised splint must extend from the groin and the armpit to several inches below the foot. Padding should extend over the ends of the splint at the groin and the armpit. The bandages or straps used to secure a splint must not be applied so tightly that they impair circulation even for a few minutes. A bluish discoloration of the nailbeds or skin of the affected limb would suggest that one or more bandages are too taut. Security bandages should never be tied directly across the site of injury.

A dislocation is immobilized during referral in the same way as a fracture: close to the joint. Area ligaments are usually torn and may require surgical repair. Cold compresses can be applied to the area to relieve pain and reduce swelling. The patient's temperature must not be lowered because hyperthermia invites shock.

Postreduction immobilization of a dislocation in the lower extremity usually requires 6 weeks and in the upper extremity requires 3 weeks. Inadequate care, especially for ankle and shoulder dislocations, leads to chronic weakness, movement restrictions, instability, and recurrent dislocation in which subsequent surgery has a poor prognosis in restoring preinjury status. Except for recurring dislocations, almost all overt dislocations require anesthesia before reduction.


Roentgenology

Roentgenography should be used to confirm or dispose of suspicions arising during the history and physical examination, and not used as the sole basis of the diagnosis. When a film is used alone to confirm a prior clinical opinion, other clues exhibited on a view may be missed that indicate a different approach. This occurs when an outstanding feature, visible at a distance, overwhelms a desire to seek other evidence. Nevertheless, whatever is presented on the film must be evaluated; eg, an asymptomatic chronic disease process may be underlying an acute injury.

X-ray films are often helpful in determining dislocations, overt fractures, stress fractures, joint-space alterations, ossification, calcification, and sometimes cartilage fractures, fat pad alterations, and masses and swelling. Common radiographic signs of various bone lesions are shown in Table 2. Once relevant features classify an abnormality, a search should be made for details enabling it to be distinguished from others in the same class. This takes careful evaluation of frequently subtle soft-tissue changes which confirm osseous alterations.


Table 2. Radiologic Signs of Various Bone Lesions

Infection Singular Malignant Bone Lesion
Formation of sequestration and involucrum Permeactive or moth-eaten destruction (wide transition zone)
Irregular periosteal reaction frequent, no speculation Extraosseous extension with soft-tissue mass, occasional fluffy calcifications
Diaphyseal site most common Irregular (sometimes spiculated) periosteal reaction
Variable bone destruction Metaphyseal area is the most common site
Destruction of adjacent cartilage crossing joints (most malignancies lack this trait)

 

Metastatic Lesions Benign Bone Lesions
Moth-eaten destruction of cortex and medulla Enlargement of an intact cortex
Pathologic fractures Homogeneous periosteal reaction
Diaphyseal site most common Sclerotic margins (narrow transition zone)
Periosteal reaction absent Multiple bone involvement


The examiner must be well acquainted with the nature of all substances visible on a film. This is a medicolegal responsibility. Healthy tissue features and common variances should be recognized at a glance. Joint abnormalities show significant alterations in structure, symmetry, continuity, positional relations, length and breadth, cartilaginous joint space, and density. Calcareous density is much greater than muscle density, fat density is much less than muscle density, and gas density is far less than that of fat density.

In addition to roentgenography of one or more distressed joints, spinal and chest films are almost always included if the possibility of referred pain or systemic symptoms is involved.


Skin and Tendon Reflexes

Evaluation of pertinent superficial and deep tendon reflexes should be checked as a standard procedure. Upper-limb tendon and periosteal reflexes are supplied essentially by C5T1 segments of the cord; lower-limb reflexes, essentially by the L2 S3 segments. A summary of normal reflexes is shown in Table 3.


Table 3. Summary of Normal Reflexes

Superficial Reflex Afferent Nerve Center Efferent Nerve
Anal Pudendal S3S5 Pudendal
Consensual Optic Midbrain Oculomotor
Corneal Trigeminal Pons Facial
Cremasteric Femoral L1 Genitofemoral
Lower abdominal T10T12 Cord level T10T12
Nasal (sneeze) Trigeminal Brainstem,
  upper
  cord
Cranial V, VII, IX,
X and spinal
nerves of
respiration
Plantar Tibial S1S2 Tibial
Upper abdominal T7T10 Cord level T7T10
Uvular Glossopha-
ryngeal

Medulla Vagus
Tendon or Periosteal Reflex Afferent Nerve Center Efferent Nerve
Achilles Tibial S1S2 Tibial
Biceps Musculocu-
taneous
C5C6 Musculocutan-
eous
Jaw jerk Trigeminal Pons Trigeminal
Patellar Femoral L2L4 Femoral
Radial Radial C6C8 Radial
Triceps
Radial
C6C7
Radial
Visceral Reflex Afferent Nerve Center Efferent Nerve
Accommodation Optic Occipital Oculomotor
Bulbocavernous Pudendal S2S4 Pudendal
Carotid sinus Glossopha-
ryngeal
Medulla Vagus
Ciliospinal Sensory nerve T1T2 Cervical sympa-
thetics
Light Optic Midbrain Oculomotor
Oculocardiac Trigeminal Medulla Vagus



      PAIN: GENERAL CONSIDERATIONS

All joints contain nociceptors in their ligaments, tendon insertions, periosteum, fibrocartilages (sparsely), capsules, and vascular walls. Authorities differ whether or not synovia contains nociceptors; most believe that it does not.

An extremely "ticklish" person is one whose superficial reflexes (skin and muscle) are very lively, thus a low pain and temperature threshold can be anticipated.


Significance of Hyperalgesia

A painful tenderness produced by external pressure frequently results from traumatic lesions of sensitive subdermal tissue, trigger points, the development of a toxic accumulations, or a deep-seated inflammatory irritation. Pottenger pointed out that hyperalgesia of soft tissues is not uncommon in the areas that have been the seat of reflex sensory pain. For example, subcutaneous soreness within the shoulder and upper arm muscles is often associated with inflammatory diseases of the lungs. He also reported that cutaneous hyperalgesia is a common finding in visceral disease. Hyperalgesic skin frequently overlies an area of pleurisy, a tubercular cavity, a peptic ulcer, or an inflamed ovary. Zones of hyperalgesia (often associated with precapillary vasoconstriction and hypermyotonia) are more often associated with acute and subacute visceral disease than with chronic disorders.


Characteristics of Extremity Pain

The cause of limb pain may be of mechanical, chemical, thermal, toxic, nutritional, metabolic, or circulatory origin, or a combination of several of these factors depending on the pathologic or traumatic process involved. Peripheral nerve disease will sometimes reveal a history of an entrapment neuropathy. Nutritional disorders can result in a polyneuropathy because of unfavorable metabolic activities within the neural apparatus.

When an inflammatory process involves sensory fibers, the pain is frequently perceived along the total course of the nerve. The pain may be referred along a somatic dermatome because of visceral inflammation, ischemia, or a tumor (eg, the shoulder-arm pain associated with myocardial infarction or angina). Such pains have two major features in common:
(1) their distribution is limited to an anatomical dermatomal pattern and
(2) interruption of the nerve s function by any means alleviates the symptoms (at least temporarily).


Characteristics of Neuralgia

Neuralgia is any sharp, severe, stabbing, paroxysmal, remittent pain with temporary abatement in severity that travels along the course of one or more nerves. It is usually associated with tenderness along the course of the nerve and violent episodic spasms in the muscles innervated.

Pain accentuated by heat points to neuritis or congestion. In contrast, pain that is relieved by heat suggests something producing abnormal myotonia or possibly ischemia. Pain of intrinsic neurologic origin is generally accompanied by paresthesias and root signs. When throbbing pain occurs, vascular engorgement, crush syndrome, a vasomotor disturbance, or possibly Paget s disease should be the first suspicions. It s difficult for the patient to describe its character because it is unlike any other type of pain and usually is a combination of painful sensations.

Neuralgia is provoked by any peripheral stimulation in the involved zone, and stimulated trigger points cause spontaneous paroxysms. Morphologic changes cannot be detected early in a pure neuralgia or neurodynia syndrome. The term neurodynia describes a similar pain that is less severe; ie, a deep ache. The patient vigilantly guards the involved part and shows great apprehension. The pain manifests in the involved nerve s distribution superficially or deep. It usually radiates, and there is an exorbitant response to stimulation.

Neuralgia rarely subsides spontaneously. It is often so severe that the victim becomes totally incapacitated and frequently addicted to narcotics. Depression is often associated, and suicidal tendencies sometimes arise.


REFERENCES

1. Thomas CL (ed): Taber's Cyclopedic Medical Dictionary, ed 14. Philadelphia, F.A. Davis, 1981.

2. Welch B: The Injury Cycle. Sports Medicine Update, 1:1, 1986.

3. Craig TT (ed): Athletic Injuries and First Aid: Comments in Sports Medicine. Chicago, American Medical Association, 1973.



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