Early Exercise in Blunt Chest Wall Trauma

I have quite an interest in the management of blunt chest wall trauma. Seeing patients from point of injury on HEMS, right the way through to rehab has shown me just how much these injuries can influence mortality and morbidity. One of my jobs is as a major trauma consultant on the major trauma ward in Virchester. That’s a bit like being an HDU consultant for our MT cohort and it’s a really fascinating job. One of the most common interventions we do on the ward is in managing blunt chest trauma with a whole variety of analgesic strategies including, oral, IV, transdermal routes and also local anaesthetic blocks and surgical fixation. We are also highly reliant on an incredibly skilled team of OT/PT therapists who work with our patients to get them moving and hopefully speed their recovery.

Getting people moving with the therapy team and specifically in the chest with incentive spirometry are really important aspects of our treatment plans and I do believe this makes a difference. I’ve also seen chest injuries managed at a very early stage by putting patients on exercise bikes in the ED to encourage deep breathing and chest drainage. Now, that was some time ago in South Africa (are they still doing this?), and it was young penetrating chest trauma patients, but arguably there are some common principles there that early movement and mobilisation are positive interventions for our patients.

Does early exercise work though in the cohort of patients that we see in Virchester with blunt chest trauma? In my practice they are a bit of a mixed bag, but arguably quite different to those I saw on exercise bikes in Cape Town nearly a decade ago.

This week we have an interesting paper from Prof. Battle and her excellent research team based in Wales who have a great track record in blunt chest trauma research. This paper focuses on the key issue of an early exercise approach, specifically on what the impact of early thoracic and shoulder girdle exercises are on chronic pain and health-related quality of life in patients with blunt chest wall trauma (the ELECT2 Trial). his trial investigates whether an early exercise programme can alter these outcomes, addressing a gap in physiotherapy and emergency medicine practice. The abstract is below, but as always do read the full papert yourself and come to your own conclusions.

We should also be mindful as emergency physicians that we have fairly limited follow-up care for chest trauma patients in the UK and that has almost certainly led to a lack of consensus on effective rehabilitation strategies. Some of these patients will develop chronic pain and poor health-related quality of life, but I’m still a little unclear which patients will and which will make great recoveries. My traditional impression was that rib fractures resolve within six to eight weeks, but do they and what are the longer term sequelae?

Abstract

Introduction: The aim of this trial was to investigate the impact of early thoracic and shoulder girdle exercises on chronic pain and Health-Related Quality of Life in patients with blunt chest wall trauma, when compared to normal care.

Methods: A multi-centre, parallel, randomised controlled trial, in which adult patients presenting to hospital with blunt chest wall trauma were allocated to either control or intervention group. The intervention was an exercise programme consisting of four simple thoracic and shoulder girdle exercises, completed for one week. Outcomes measures included prevalence and severity of chronic pain using the Brief Pain Inventory, health-related quality of life using EQ-5D-5 L, and cost effectiveness, measured at initial presentation and three months post-injury.

Results: 360 participants were recruited. Participants’ mean age was 63.6 years (standard deviation (SD): 17.9 years) and 213 (59.8%) were men. After loss-to-follow-up, the survey response rate at three months was 73.0% (251/344 participants). The primary analysis, for chronic pain prevalence at three months post-injury, found no statistically significant differences between intervention and control groups, with lower rates in the control (intervention: 35/126 (27.8 %), control: 20/117 (17.1 %); adjusted odds ratio 1.862; 95 % CI: 0.892 to 3.893, p = 0.098). There were no statistically significant differences between intervention and control groups for pain severity at three months post-injury, (intervention mean (SD): 2.15 (2.49), control: 1.81 (2.10); adjusted dif- ference 0.196, 95 % CI: 0.340 to 0.731; p= 0.473); or Health-Related Quality of Life (intervention mean (SD): 0.715 (0.291), control: 0.704 (0.265); adjusted difference: 0.030; 95 % CI: 0.033 to 0.094; p = 0.350). The health economic analysis found the intervention was associated with higher costs compared to normal care.

Conclusion: The results of this trial did not support a ‘one-size fits all’ simple, early exercise programme for patients with blunt chest wall trauma. Future research should consider the impact of a personalised exercise programme, commenced by the patient at least one week post-injury.
Ceri Battle, et al. EarLy Exercise in blunt Chest wall Trauma: A multi-centre, parallel randomised controlled trial (ELECT2 Trial), Injury, 2024, 112075, ISSN 0020-1383, https://doi.org/10.1016/j.injury.2024.112075. (https://www.sciencedirect.com/science/article/pii/S0020138324008192)

What Kind of Study is This?

The ELECT2 Trial is a multi-centre, parallel, randomised controlled trial (RCT) conducted across six hospitals in Wales and England. The study investigated the impact of a simple exercise programme initiated within one week of injury compared to usual care. It’s great to see an RCT on this topic as the exercise programme is an intervention and is best tested in that way within an RCT design. Making it multicentre, albeit just 6 centres, also strengthens the design.

The design was registered in advance and followed SPIRIT guidelines for design

The study’s aim was to evaluate the prevalence and severity of chronic pain, health-related quality of life, and cost-effectiveness of the intervention. The robust design provides a strong foundation for the analysis.

Tell Me About the Patients

The trial recruited adult patients presenting with blunt chest wall trauma, including bruising or rib fractures, with or without lung injury. Patients were recruited both in the ED and as in patients. About 80% of patients were admitted, roughly 20% were discharged from the ED after recruitment. About 60% had 3 or more rib fractures on imaging. About 25% of patients had a frailty score 4-9 which reflects my experience in Virchester. A lot of the patients who struggle are quite elderly and frail.

Inclusion criteria: Patients aged 16 or older, able to give informed consent, complete the exercise programme, and participate in follow-up.
Exclusion criteria: Concurrent injuries precluding exercise or hospitalised prisoners were excluded to maintain focus on the target population.
Population characteristics: The mean age was 63.6 years, with a slight male predominance (59.8%). Mechanisms of injury varied but included falls (most common), road traffic collisions, and sporting injuries.

Participants were well-balanced across demographic and injury-related characteristics, ensuring comparability between groups. However, older adults and those with frailty scores above three formed a notable proportion of the cohort.

Tell me about the outcomes

In my EM/MTW practice, I’m most interested in the management of acute severe pain, and we’ve looked at this in past blogs with interventions such as local anaesthetic blocks and lignocaine patches, but in this stud,y the authors took a longer view assessing both clinical and economic outcomes over a three-month period:

Primary outcomes:
- Prevalence of chronic pain using the Brief Pain Inventory (pain severity ≥3.5).
- Health-related quality of life using the EQ-5D-5L.
Secondary outcomes:
- Pain severity and interference with activities.
- Cost-effectiveness measured in quality-adjusted life years (QALYs).

Outcomes were measured at baseline and three months post-injury through patient surveys.

What Are the Main Results?

In terms of the primary outcomes then chronic pain was higher in the intervention group (27.8%) compared to the control group (17.1%), though this was not statistically significant (adjusted odds ratio 1.862; 95% CI: 0.892–3.893, p = 0.098). In terms of health-related quality of life, it was slightly better in the intervention group (mean EQ-5D utility value 0.715) than in controls (0.704), but again not significant (p = 0.350).

For the secondary outcomes the authors found that pain severity and interference scores were marginally higher in the intervention group, with no significant differences. They also found that the intervention was associated with higher NHS and societal costs, without corresponding improvements in QALYs.

So, somewhat surprisingly to me (and I do love to be proved wrong), these results indicate that the early exercise programme did not significantly improve clinical or economic outcomes compared to usual care.

How robust are the results?

This is a pretty well-designed study, but as with every study, there are factors that may influence the results. As an RCT we like the design of the study and an inclusion of health economics over a longer time period is a good way of addressing the whole patient journey, something that’s often missed in short term studies of pain in chest wall injury. Similarly having patient functional outcomes is really great to see as ultimately that’s what really matters to patients.

That said, there are a few concerns, notably that this cannot be a blinded intervention and that may have influenced results. There was also a fairly high attrition rate (27%) and that may well have influenced the results. We also need to consider how different the intervention was from standard therapy, and whether there might have been contamination between groups as they would all have been working in the same space. It’s even possible that patients could cross-contaminate the interventions as many on our MTW stay for quite some time, and they do talk to each other.

We must also consider whether a generic approach here is what we need, or whether a more bespoke approach is required owing to the wide variability of patients and injury characteristics. Overall I think the study’s findings are robust within the limits of its design, but external factors such as adherence challenges and variability in injury presentation should be considered.

Should We Change Practice Based on This Study?

The results suggest that a “one-size-fits-all” early exercise programme may not benefit patients with blunt chest trauma, so no on this occasion there is nothing here to change my practice as we already provide. amore bespoke service to our patients. Routine implementation of the studied intervention is not supported by the findings, but personalised approaches may hold promise. It’s also worth saying a big thank you to our therapy teams who do amazing work with our patients on the major trauma service.

I’m also somewhat surprised that so little benefit was seen. I would be interested to learn more about subgroups in this study as a hypothesis generating exercise, and in particular those patients who were discharged from the ED directly.

Summary

The ELECT2 Trial did not show benefit for an early exercise programme in reducing chronic pain or improving quality of life at three months post-injury. Additionally, the intervention was not cost-effective compared to usual care.

While this study does not support a change in practice, it adds to the growing understanding of post-trauma care and sets the stage for future research into tailored rehabilitation strategies. It’s another great paper from Prof. Ceri Battle and colleagues in Wales who have done so much work in this area and who are advancing care on chest wall injury.

References and further reading

Ceri Battle, Timothy Driscoll, Deborah Fitzsimmons, Shaun Harris, Fiona Lecky, Claire O’Neill, Alan Watkins, Jane Barnett, Susan Davies, Hayley Anne Hutchings, Kate Jones, Andrew Eglington, Sophie Place, Hannah Toghill, Katie Foster, Bethan Uzzell, Elizabeth Ford, Mark Baker, Sophie Lewis, Sara Davies, Sarah Nicholls, Amy Charnock, Claire Watkins, Sarah-Jane Garside, Jeannie Bishop, Thomas Dawson, Jessica Pendlebury, Reece Doonan, EarLy Exercise in blunt Chest wall Trauma: A multi-centre, parallel randomised controlled trial (ELECT2 Trial), Injury, 2024, 112075, ISSN 0020-1383, https://doi.org/10.1016/j.injury.2024.112075. (https://www.sciencedirect.com/science/article/pii/S0020138324008192)
Simon Carley, “Lidocaine Patches for Elderly Patients with Rib Fractures: A Feasibility Study,” in St.Emlyn’s, July 22, 2024, https://www.stemlynsblog.org/lidocaine-patches/.
Clout M, Turner N, Clement C, Braude P, Benger J, Gagg J, et al. The RELIEF feasibility trial: topical lidocaine patches in older adults with rib fractures. Emerg Med J. 2024;0:1-10.
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Simon Carley, “Torso Trauma tips and the BASICS North West conference 2018. St Emlyn’s,” in St.Emlyn’s, June 21, 2018, https://www.stemlynsblog.org/torso-trauma-tips-and-the-basics-north-west-conference-2018-st-emlyns/.
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