CARDIOPULMONARY PHYSIOTHERAPY IN TRAUMA: AN EVIDENCE-BASED APPROACH

Contents
Preface
	Bibliography
List of Contributors
Chapter 1 Physiological Response to Trauma
	1.1. Human Immunity and its Response to Injury and Inflammation
		1.1.1. Haemostasis
		1.1.2. Fibrinolysis
		1.1.3. Non-specific defence systems
		1.1.4. Specific defence systems
		1.1.5. Activation of the body’s defence systems
			1.1.5.1. Cytokines
			1.1.5.2. Systemic inflammatory response syndrome and sepsis
		1.1.6. Musculoskeletal changes associated with inflammation
			1.1.6.1. Muscle protein breakdown and atrophy
			1.1.6.2. Muscle weakness
	1.2. Shock and its Effects on the Human Body
		1.2.1. What is shock?
		1.2.2. Organ responses to blood loss
			1.2.2.1. Cardiovascular system
			1.2.2.2. Central nervous system
			1.2.2.3. Pulmonary system
			1.2.2.4. Peripheries
			1.2.2.5. Renal system
			1.2.2.6. Skeletal and splanchnic systems
		1.2.3. Types of shock
			1.2.3.1. Cardiogenic shock
			1.2.3.2. Hypovolaemic shock
			1.2.3.3. Distributive shock
			1.2.3.4. Obstructive shock
			1.2.3.5. Refractory shock
		1.2.4. Management of shock
	1.3. Factors that Influence Blood Oxygen Content
	1.4. Effect of Trauma on Blood Glucose Levels
	1.5. Clinical Case Scenario
	1.6. Classification of Patients with Traumatic Injuries
		1.6.1. Severity of illness scoring systems
			1.6.1.1. APACHE II and SAPS III
			1.6.1.2. Anatomic and physiologic scores
			1.6.1.3. TRISS and ASCOT scores
		1.6.2. Morbidity scoring systems
			1.6.2.1. SOFA score
		1.6.3. Paediatric scoring systems
	1.7. Conclusion
	Bibliography
Chapter 2 Not Just ‘Small Adults’: Paediatric Anatomy and Physiology in Relation to Trauma
	2.1. Introduction
	2.2. Anatomical and Physiological Differences between the Adult and Child
		2.2.1. General
		2.2.2. The airway
		2.2.3. The chest, lungs and breathing
			2.2.3.1. Signs of paediatric respiratory distress
			2.2.3.2. Signs of inadequate respiratory effort
		2.2.4. The heart and circulation
		2.2.5. Head, neck and central nervous system
		2.2.6. The abdomen
		2.2.7. Musculoskeletal system
		2.2.8. Temperature regulation
	2.3. Conclusion
	Bibliography
Chapter 3 Trauma and Immunosuppressive Diseases
	3.1. Introduction
	3.2. Pathogenesis of HIV and AIDS
	3.3. HIV and AIDS and the Pulmonary System
		3.3.1. Chronic obstructive pulmonary disease
			3.3.1.1. Emphysema
			3.3.1.2. Bronchiectasis
			3.3.1.3. Implications for physiotherapy
		3.3.2. Mycobacterium infections
			3.3.2.1. Mycobacterium tuberculosis
			3.3.2.2. Mycobacterium xenopi
			3.3.2.3. Extrapulmonary tuberculosis
			3.3.2.4. Implications for physiotherapy
		3.3.3. Pulmonary complications associated with antiretroviral therapy
		3.3.4. Restrictive pulmonary disease
			3.3.4.1. Implications for physiotherapy
		3.3.5. Paediatric pulmonary disease
	3.4. Extrapulmonary Complications Associated with HIV and Antiretroviral Therapy
		3.4.1. Allergic skin reactions
		3.4.2. Lipodystrophy syndrome
		3.4.3. Peripheral neuropathy
		3.4.4. Other antiretroviral therapy-related complications
		3.4.5. Surgical site infection
		3.4.6. Implications for physiotherapy
	3.5. Conclusion
	Bibliography
Chapter 4 Physiotherapy Modalities, Markers and Outcome Measures
	4.1. Early Mobilisation and Graded Exercise Therapy
		4.1.1. Early mobilisation
		4.1.2. Exercise therapy
			4.1.2.1. Mental health benefits
			4.1.2.2. Physical health benefits
			4.1.2.3. Exercise prescription
	4.2. Cardiopulmonary Physiotherapy Techniques
		4.2.1. Breathing exercises
			4.2.1.1. Localised thoracic expansion exercises
			4.2.1.2. Active cycle of breathing technique
			4.2.1.3. Breath-stacking
			4.2.1.4. Glossopharyngeal breathing
			4.2.1.5. Respiratory muscle training
		4.2.2. Devices
			4.2.2.1. Incentive spirometry
			4.2.2.2. Intermittent positive pressure breathing
			4.2.2.3. Mechanical insufflation-exsufflation
			4.2.2.4. Positive expiratory pressure therapy
			4.2.2.5. Percussive ventilation
		4.2.3. Positioning
			4.2.3.1. Body positioning
			4.2.3.2. Gravity-assisted positioning ( postural drainage)
		4.2.4. Manual chest therapy techniques
			4.2.4.1. Percussion
			4.2.4.2. Vibration
			4.2.4.3. Shaking
			4.2.4.4. Contraindications and precautions for the use of manual chest therapy techniques
		4.2.5. Assisted and supported coughing
			4.2.5.1. Manually assisted cough
			4.2.5.2. Supported cough
		4.2.6. Hyperinflation techniques
			4.2.6.1. Manual hyperinflation
			4.2.6.2. Ventilator hyperinflation
		4.2.7. Airway suctioning
			4.2.7.1. Suction of artificial airways
			4.2.7.2. Nasotracheal and orotracheal suctioning
			4.2.7.3. Contraindications and precautions for suction
			4.2.7.4. Complications associated with suction (Moffatt, 2011)
	4.3. Markers and Outcome Measures
	4.4. Conclusion
	Bibliography
Chapter 5 Blunt and Penetrating Injuries
	5.1. Causes and Mechanisms of Injury
		5.1.1. Penetrating injuries
			5.1.1.1. Low-velocity injuries
			5.1.1.2. High-velocity injuries
		5.1.2. Abdominal injury
			5.1.2.1. Abdominal injury in adults
			5.1.2.2. Abdominal injury in paediatrics
		5.1.3. Thoracic injury
			5.1.3.1. Thoracic injury in adults
			5.1.3.2. Thoracic injury in paediatrics
	5.2. Causes of Fatality after Abdominal or Thoracic Injuries
	5.3. Medical and Surgical Management of Survivors of Abdominal or Thoracic Trauma
		5.3.1. Primary survey and resuscitation of vital functions
			5.3.1.1. The lethal six injuries as a result of thoracic trauma
			5.3.1.2. Abdominal trauma
		5.3.2. Secondary survey as adjunct to primary survey
			5.3.2.1. The hidden six injuries that result from thoracic trauma
		5.3.3. Definitive care
			5.3.3.1. Abdominal injury
			5.3.3.2. Thoracic injury
		5.3.4. Prolonged intensive care unit stay
			5.3.4.1. Tracheostomy care
	5.4. Physiotherapy Aims of Management
		5.4.1. Paediatric considerations
		5.4.2. Functional assessment prior to discharge
	5.5. Precautions and Contraindications related to Physiotherapy Management
		5.5.1. General precautions to physiotherapy in intensive care
		5.5.2. Precautions and contraindications related to abdominal injuries
			5.5.2.1. Adult patients
			5.5.2.2. Paediatric patients
		5.5.3. Precautions and contraindications related to thoracic injuries
			5.5.3.1. Adult patients
			5.5.3.2. Paediatric patients
	5.6. Physiotherapy Interventions
		5.6.1. Respiratory system management
			5.6.1.1. Oxygenation
			5.6.1.2. Humidification
			5.6.1.3. Management of pulmonary secretions
			5.6.1.4. Lung capacity and volumes
			5.6.1.5. Respiratory muscle training
			5.6.1.6. Paediatric considerations
		5.6.2. Neuromusculoskeletal system management
			5.6.2.1. Pain
			5.6.2.2. Joint range of motion
			5.6.2.3. Muscle strength
			5.6.2.4. Functional activities and mobilisation
			5.6.2.5. Exercise endurance
			5.6.2.6. Paediatric considerations
		5.6.3. Patient response to treatment
	5.7. Clinical Case Scenarios
		5.7.1. Adult clinical case scenarios
			5.7.1.1. Case 1
			5.7.1.2. Case 2
		5.7.2. Paediatric case scenario
			5.7.2.1. Discussion
	5.8. Suggested Reading Material for Further Study
	5.9. Conclusion
	Bibliography
Chapter 6 Burn Injuries
	6.1. Causes and Mechanisms of Burn Injury
		6.1.1. Injury in adults
		6.1.2. Injury in paediatrics
	6.2. Types of Burn Injuries
		6.2.1. Chemical burns
		6.2.2. Electrical burns
		6.2.3. Inhalation burns
			6.2.3.1. Upper airway injury
			6.2.3.2. Lower airway and lung parenchyma injury
			6.2.3.3. Systemic toxicity
		6.2.4. Thermal burns
	6.3. Systemic Effects of a Burn Injury
		6.3.1. Burn shock
		6.3.2. Immune system responses
		6.3.3. Metabolic responses
		6.3.4. Thermoregulatory system
	6.4. Classification of Burn Injuries
		6.4.1. Depth of tissue injury
			6.4.1.1. Superficial burns
			6.4.1.2. Partial thickness burns
			6.4.1.3. Full thickness burns
		6.4.2. Extent of burn wounds
	6.5. Medical and Surgical Management
		6.5.1. Primary survey and resuscitation of vital functions
		6.5.2. Secondary survey as adjunct to primary survey
		6.5.3. Definitive care
			6.5.3.1. Care provided over the first 24 hours
			6.5.3.2. Surgery
			6.5.3.3. Wound management
	6.6. Physiotherapy Aims of Management
		6.6.1. Paediatric considerations
		6.6.2. Functional assessment prior to discharge
	6.7. Precautions and Contraindications Related to Physiotherapy Management
		6.7.1. General precautions to physiotherapy in intensive care
		6.7.2. Specific precautions and contraindications to physiotherapy in patients with burn injuries
			6.7.2.1. Adult patient with burn injury
			6.7.2.2. Paediatric patient with burn injury
	6.8. Physiotherapy Interventions
		6.8.1. Education
		6.8.2. Pain
		6.8.3. Respiratory system management
			6.8.3.1. Oxygenation
			6.8.3.2. Humidification
			6.8.3.3. Management of pulmonary secretions
			6.8.3.4. Lung capacity and volumes
			6.8.3.5. Respiratory muscle training
			6.8.3.6. Paediatric considerations
		6.8.4. Neuromusculoskeletal system
			6.8.4.1. Joint range of motion
			6.8.4.2. Splinting
			6.8.4.3. Muscle strength
			6.8.4.4. Functional activities and mobilisation
			6.8.4.5. Exercise endurance
			6.8.4.6. Paediatric considerations
		6.8.5. Rehabilitation strategies for the management of complications associated with burn injuries
			6.8.5.1. Exposed tendons
			6.8.5.2. Heterotopic ossification
			6.8.5.3. Hypertrophic scars
		6.8.6. Patient response to treatment
	6.9. Clinical Case Scenarios
		6.9.1. Case scenario of an adult patient
			6.9.1.1. Discussion
		6.9.2. Case scenario of a paediatric patient
			6.9.2.1. Discussion
	6.10. Suggested Reading Material for Further Study
	6.11. Conclusion
	Acknowledgement
	Bibliography
Chapter 7 Multiple Orthopaedic Injuries
	7.1. Causes and Mechanisms of Injury
		7.1.1. Causes of injury in adults
		7.1.2. Causes of injury in paediatrics
		7.1.3. Mechanism of injury in adults
		7.1.4. Mechanism of injury in paediatrics
	7.2. Types of Fractures
	7.3. Orthopaedic Injuries Commonly Encountered in the Polytrauma Patient
		7.3.1. Shoulder girdle
		7.3.2. Humerus
		7.3.3. Radius and ulna
		7.3.4. Hand and wrist
		7.3.5. Pelvis
		7.3.6. Acetabulum
		7.3.7. Hip dislocation
		7.3.8. Femur
		7.3.9. Knee dislocation
		7.3.10. Patella injury
		7.3.11. Floating knee injury
		7.3.12. Tibial plateau
		7.3.13. Tibia and fibula
		7.3.14. Foot
	7.4. Classification of Fractures
		7.4.1. Long bones
		7.4.2. Pelvis
		7.4.3. Acetabulum
		7.4.4. Floating knee
		7.4.5. Tibial plateau
		7.4.6. Physeal fractures in children
		7.4.7. Open fractures
	7.5. Complications Associated with Orthopaedic Injuries
		7.5.1. Avascular necrosis
		7.5.2. Myositis ossificans
		7.5.3. Fat embolism
	7.6. Mechanism of Bone Healing
		7.6.1. Phases of bone repair
			7.6.1.1. Reactive phase
			7.6.1.2. Reparative phase
			7.6.1.3. Remodelling phase
		7.6.2. Abnormal bone healing
			7.6.2.1. Malunion
			7.6.2.2. Delayed union
			7.6.2.3. Non-union
	7.7. Medical and Surgical Management
		7.7.1. Primary survey and resuscitation of vital functions
		7.7.2. Secondary survey as adjunct to primary survey
		7.7.3. Definitive care
			7.7.3.1. Care provided in the ICU
			7.7.3.2. Non-surgical interventions
			7.7.3.3. Surgical interventions
	7.8. Physiotherapy Aims of Management
		7.8.1. Paediatric considerations
		7.8.2. Functional assessment prior to discharge
	7.9. Precautions and Contraindications Related to Physiotherapy Management
		7.9.1. General precautions related to physiotherapy in intensive care
		7.9.2. Specific precautions related to physiotherapy in patients with multiple orthopaedic injuries
			7.9.2.1. Adult patients
			7.9.2.2. Paediatric patients
	7.10. Physiotherapy Intervention
		7.10.1. Respiratory system
		7.10.2. Neuromusculoskeletal system
			7.10.2.1. Pain
			7.10.2.2. Joint range of motion
			7.10.2.3. Muscle strength
			7.10.2.4. Functional activity, mobilisation and exercise endurance
			7.10.2.5. Paediatric considerations
		7.10.3. Patient response to treatment
	7.11. Clinical Case Scenarios
		7.11.1. Case scenario of an adult patient
			7.11.1.1. Discussion
		7.11.2. Case scenario of a paediatric patient
			7.11.2.1. Discussion
	7.12. Suggested Reading Material for Further Study
	7.13. Conclusion
	Bibliography
Chapter 8 Spinal Cord Injury
	8.1. Structure of the Spinal Cord
	8.2. Causes and Mechanisms of Injury
		8.2.1. Causes of injury in
		8.2.2. Mechanisms of injury in adults
			8.2.2.1. Primary mechanisms of injury to the spinal cord
			8.2.2.2. Secondary mechanisms of injury to the spinal cord
		8.2.3. Causes and mechanisms of injury in paediatrics
	8.3. Spinal Cord Lesions and Classification of the Level of Injury
		8.3.1. Types of spinal cord lesions
			8.3.1.1. Complete lesion of the spinal cord
			8.3.1.2. Incomplete lesion of the spinal cord
		8.3.2. Location of injury
			8.3.2.1. Paraplegia
			8.3.2.2. Tetraplegia
		8.3.3. Classification of the level of injury
	8.4. Respiratory System Complications following Spinal Cord Injury and Changes in Respiratory Muscle Function
		8.4.1. Spinal cord injury and respiratory muscle function
		8.4.2. Respiratory complications following spinal cord injury
			8.4.2.1. Complications encountered in the early phase after spinal cord injury
			8.4.2.2. Complications encountered in the later stages following spinal cord injury
		8.4.3. Recovery of respiratory function following spinal cord injury
		8.4.4. Spinal cord injury not associated with respiratory compromise
	8.5. Complications Related to Other Bodily Systems following Spinal Cord Injury
	8.6. Medical and Surgical Management
		8.6.1. Primary survey and resuscitation of vital functions
		8.6.2. Secondary survey as adjunct to primary survey
		8.6.3. Definitive care
			8.6.3.1. Surgical interventions
			8.6.3.2. Conservative management
			8.6.3.3. Care provided in the ICU or the spinal unit
	8.7. Physiotherapy Aims of Management
		8.7.1. Paediatric considerations
		8.7.2. Functional assessment prior to discharge
	8.8. Precautions and Contraindications Related to Physiotherapy Management
		8.8.1. General precautions related to physiotherapy in intensive care
		8.8.2. Specific precautions and contraindications related to physiotherapy in patients with spinal trauma
			8.8.2.1. Adult patient
			8.8.2.2. Paediatric patient
	8.9. Physiotherapy Interventions
		8.9.1. Respiratory system
			8.9.1.1. Oxygenation
			8.9.1.2. Humidification
			8.9.1.3. Management of pulmonary secretions
			8.9.1.4. Lung capacity and volumes
			8.9.1.5. Respiratory muscle training
			8.9.1.6. Paediatric considerations
		8.9.2. Neuromusculoskeletal system
			8.9.2.1. Pain
			8.9.2.2. Joint range of motion
			8.9.2.3. Muscle strength
			8.9.2.4. Functional activity, mobilisation and exercise endurance
			8.9.2.5. Paediatric considerations
		8.9.3. Patient response to treatment
	8.10. Clinical Case Scenarios
		8.10.1. Case scenario of an adult patient
			8.10.1.1. Discussion
		8.10.2. Case scenario of a paediatric patient
			8.10.2.1. Discussion
	8.11. Suggested Reading Material for Further Study
	8.12. Conclusion
	Bibliography
Chapter 9 Traumatic Brain Injury
	9.1. Causes and Mechanisms of Injury
		9.1.1. Injury in adults
		9.1.2. Injury in paediatrics
		9.1.3. Forces related to traumatic brain injury
	9.2. Types of Traumatic Brain Injury
		9.2.1. Open or closed injury
		9.2.2. Focal or diffuse injury
			9.2.2.1. Focal injury
			9.2.2.2. Diffuse injury
	9.3. Primary and Secondary Injury Associated with Traumatic Brain Injury
		9.3.1. Intracranial pressure
		9.3.2. Cerebral perfusion pressure
	9.4. Severity of Injury
	9.5. Medical and Surgical Management
		9.5.1. Primary survey and resuscitation of vital functions
		9.5.2. Secondary survey as adjunct to primary survey
		9.5.3. Definitive care
			9.5.3.1. Care provided in the ICU
			9.5.3.2. Surgical interventions
			9.5.3.3. Brain stem death
	9.6. Physiotherapy Aims of Management
		9.6.1. Functional assessment prior to discharge
	9.7. Precautions and Contraindications Related to Physiotherapy Management
		9.7.1. General precautions related to physiotherapy in intensive care
		9.7.2. Specific precautions related to physiotherapy in patients with traumatic brain injury
			9.7.2.1. Adult patients
			9.7.2.2. Paediatric patients
	9.8. Physiotherapy Interventions
		9.8.1. Respiratory system
			9.8.1.1. Oxygenation
			9.8.1.2. Humidification
			9.8.1.3. Management of pulmonary secretions
			9.8.1.4. Lung capacity and volumes
			9.8.1.5. Respiratory muscle training
			9.8.1.6. Paediatric considerations
		9.8.2. Neuromusculoskeletal system
			9.8.2.1. Patient orientation
			9.8.2.2. Altered muscle tone
			9.8.2.3. Joint range of motion
			9.8.2.4. Muscle strength
			9.8.2.5. Functional ability, mobilisation and exercise endurance
			9.8.2.6. Paediatric considerations
		9.8.3. Patient response to treatment
	9.9. Clinical Case Scenarios
		9.9.1. Adult case scenario
			9.9.1.1. Discussion
		9.9.2. Paediatric case scenario
			9.9.2.1. Discussion
	9.10. Suggested Reading Material for Further Study
	9.11. Conclusion
	Bibliography
Chapter 10 Quality of Life of Survivors of Trauma
	10.1. Definition of Quality of Life
	10.2. Assessment of Quality of Life
		10.2.1. SF-36 questionnaire
		10.2.2. EQ-5D questionnaire
		10.2.3. PedsQL questionnaire
	10.3. Quality of Life of Survivors of Critical Illness
		10.3.1. Physical function-related components of quality of life
		10.3.2. Mental health-related components of quality of life
		10.3.3. Posttraumatic stress disorder in survivors of critical illness
	10.4. Quality of Life of Survivors of Trauma and Critical Illness
		10.4.1. Physical function-related components of quality of life
			10.4.1.1. Survivors of blunt or penetrating trauma
			10.4.1.2. Survivors of burn injury
			10.4.1.3. Survivors of multiple orthopaedic injuries
			10.4.1.4. Survivors of spinal cord injury
			10.4.1.5. Survivors of traumatic brain injury
		10.4.2. Mental health-related components of quality of life
			10.4.2.1. Survivors of blunt or penetrating trauma
			10.4.2.2. Survivors of burn injury
			10.4.2.3. Survivors of multiple orthopaedic injuries
			10.4.2.4. Survivors of spinal cord injury
			10.4.2.5. Survivors of traumatic brain injury
		10.4.3. Posttraumatic stress disorder in survivors of trauma
			10.4.3.1. Adult population
			10.4.3.2. Paediatric population
	10.5. Rehabilitation of Survivors of Critical Illness
	10.6. Suggestions for Exercise Rehabilitation for Survivors of Trauma and Critical Illness
		10.6.1. Exercise prescription for children and adolescents who have suffered trauma
	10.7. Potential Challenges Associated with Exercise Rehabilitation of Survivors of Trauma
	10.8. Conclusion
	Bibliography
Appendix I
	Normal Values for Paediatrics
Appendix II
	Bedside Measures to Establish the Oxygenation Status of Critically Ill Patients
Appendix III
	Functional Recovery of Patients with Spinal Cord Injury
	Bibliography
Index