Gunshot Injuries Assessment and Treatment Considerations

Original Editor - Zafer Altunbezel

Top Contributors - Ewa Jaraczewska and Jess Bell  

Introduction

Gunshot injuries in civilian and military populations can have serious long-term health and socioeconomic consequences. Primary injuries following ballistic trauma include soft-tissue damage and loss, haemorrhage, bone fracture, nerve and vascular injuries and pain. These injuries can lead to disability, extended hospitalisations, and reduced quality of life. Identification and management of firearm-related impairments require a team approach and individual skills to prioritise interventions and enhance outcomes. This page provides an in-depth review of the Pain and Disability Drivers Model, which can be used to assess and treat gunshot injuries.

General Management Principles for Individuals with Gunshot Injuries

• Build trust and a therapeutic alliance with your patient
• Explain your role and abilities
• Be realistic and set your patient's expectations
• Agree on mutual goals and responsibilities with your patient
• Collect comprehensive information related to your patient's history (e.g. history of injuries, previous surgical interventions, presence of retained fragments, past complications, previous treatments etc.)
• Use a trauma-informed approach
• Avoid re-traumatisation of your patient
• Be sensitive to unrevealed stories of captivity or torture

Pain and Disability Drivers Model

Having an assessment framework to standardise rehabilitation approaches to complex injuries can be useful. The Pain and Disability Drivers Model (PDDM) was developed for the comprehensive management of low back pain, but it can be adapted to gunshot injuries. The PDDM "identifies the domains driving pain and disability to guide clinical decisions." It also incorporates the multidimensional elements from the International Classification of Functioning, Disability and Health Framework (ICF).

The PDDM includes the following five biopsychosocial domains that drive pain and disability:

1. nociceptive pain drivers
2. nervous system dysfunction drivers
3. comorbidity factors
4. cognitive and behavioural drivers
5. contextual drivers (social and environmental)

Each domain is divided into two categories: (1) modifiable drivers of pain and disability and (2) more complex and / or less modifiable elements. Based on the assessment results, the provider can weigh up the relative contribution of each domain in the patient’s profile.

Pain and Disability Drivers Model and Gunshot Injuries

Gunshot injuries can be complex, and people who survive gunshot injuries may live with long-term disabilities:

• pain or neurologic deficits associated with gunshot injury can be severe and long-lasting
• anxiety, depression or other signs of stress affect 50% of patients with gunshot injuries while they are in hospital, but these conditions are "poorly identified and treated in the acute hospital phase despite their effect on physical health"
• disfigurement following a gunshot injury can cause further complications and mental health issues
• gunshot injuries can affect sleeping, eating, working, and other daily activities

The PDDM helps give a comprehensive picture of a patient's clinical presentation.

When using the PDDM to manage complex gunshot injuries, it may be difficult to know where to start. In these cases, it may be easier to follow the PDDM in reverse order, beginning with contextual drivers:

#5. Nociceptive pain drivers

#4. Nervous system dysfunction drivers

#3. Comorbidity factors

#2. Cognitive and behavioural drivers

#1. Contextual drivers (social and environmental)

General Assessment and Intervention Principles in Gunshot Injuries

1. Choose an assessment framework to standardise your approach: the PDDM is one example of a framework that can be used for the assessment and treatment of gunshot injuries
2. Use outcome measures when appropriate
3. Focus on ensuring self-capacity or self-management in patients and refer them to additional services as needed
4. Select relevant treatment tools based on the findings in the PDDM (or other relevant framework)
5. When time is limited, prioritise the domains that most impact an individual's recovery and try to provide them with some management tools and relief

General Aim of Rehabilitation

Our general aim is to ensure compliance and sustainability of rehabilitation activities "because in most gunshot injury cases, the treatment will take some [...] time, and you alone won't be able to allocate that time for all your patients. So, patients should be able to deal with [their] own situation in the mid and long term after their discharge from your rehabilitation setting." -- Zafer Altunbezel

Nociceptive Pain Drivers

Modifiable factors:

• functional mobility deficits that are due to reversible joint limitations after immobilisation or impaired myofascial flexibility
• functional stability deficits due to muscle imbalance or impaired movement patterns

Less modifiable factors:

• structural mobility deficits in the form of fixed deformity after complex fractures or excessive scarring around the gunshot injury (may cause neural or vascular compromise)
• structural stability deficits due to joint, ligament and tendon injury or muscle wasting
• general deconditioning, especially after prolonged treatment / immobilisation

Nociceptive Pain Drivers Therapeutic Management

• Patient education:
  • explain how rehabilitation (e.g. physiotherapy, occupational therapy, etc.) and your suggested intervention work
  • explain what the patient needs to do to get results
  • provide education on the importance of the patient's active participation in treatment
  • emphasise the need for them to exercise to regain strength and function
• Modalities might include:
  • transcutaneous electrical nerve stimulation (TENS) for pain control
  • cold in initial stages - please note that evidence on the use of ice for soft tissue injuries is evolving, but it has been shown to have pain-relieving effects for post-operative pain
  • heating agents as a supportive tool for addressing joint and soft tissue stiffness
• Manual therapy:
  • joint traction and glides to address joint stiffness
  • scar mobilisation where indicated
• Exercise

Nervous System Dysfunction Drivers

Gunshot injuries are highly likely to have a neural component because the cavitation effect can easily disturb the surrounding nerves.

Modifiable factors:

• radiculopathy or radicular symptoms due to nerve root compromise
• abnormal impulse-generating sites (AIGS):
  • demyelinated axonal zones develop along the nerve tract, especially around the gunshot injury zone, because of excessive scarring, excessive pressure or excessive tension in this area
  • characterised by spontaneous upward and downward pain radiation
  • can lead to the development of central sensitisation
  • AIGS can be identified through neurodynamic tests

Less modifiable factors:

• peripheral nerve injuries
• neuropathic pain as a direct result of the gunshot injury or surgeries related to the injury
• central sensitisation

Nervous System Dysfunction Drivers Assessment

The neurological assessment should include the following components:

• general sensory and motor examination
• neurodynamic tests
• neuro palpation
• outcome measures:
  • DN4 (Douleur Neuropathique en 4 Questions)
  • LANNS (Leeds Assessment of Neuropathic Symptoms and Signs)
  • CSI (Central Sensitisation Inventory)

Nervous System Dysfunction Drivers Therapeutic Management

• Patient education on pain neuroscience
• Modalities, such as TENS
• Manual therapy, scar mobilisation, and soft tissue interventions for nerve compromise associated with internal scarring. Warning: be careful about any retained fragments. It can be risky to mobilise some fragments, and you must get approval from the surgical team before attempting these techniques.
• Mirror therapy, graded motor imagery for neuropathic pain or central sensitisation
• Referral to specialist services for medical or surgical management

Comorbidity Drivers

Modifiable factors:

• sleep disturbance: patients who have post-traumatic stress disorder, depression or anxiety are at high risk of developing sleep issues
• musculoskeletal problems

Less modifiable factors:

• diabetes: can lead to nervous system dysfunctions, such as diabetic neuropathy
• visceral damage in the thoracic / abdominal areas from gunshot injuries

Comorbidity Drivers Assessment

• Outcome measures:
  • Pittsburgh Sleep Quality Index (PSQI) for a sleep disturbance
  • Harvard Trauma Questionnaire for PTSD
  • Hospital Anxiety and Depression Scale

Comorbidity Drivers Management

• Patient education
• Relaxation for sleep disturbance
• Relevant lifestyle modifications / interventions for diabetes, smoking or substance abuse
• Exercise
• Referral to appropriate services: internal disease specialist, psychiatrist, psychologist, etc.

Cognitive and Behavioural Drivers

• Unhelpful beliefs and thoughts that can be related to pain, the injury, or treatment received
• Pain catastrophising might cause an excessive fear of movement and pain
• Passive coping style

Cognitive and Behavioural Drivers Assessment

• Observation during interventions
• Informal talk during treatment sessions
• Outcome measures:
  • Pain Catastrophizing Scale
  • Tampa Scale of Kinesiophobia

Cognitive and Behavioural Drivers Management

• Patient education
• Pain diaries
• Cognitive behavioural therapy (CBT)
• Referral to an appropriate mental health and psychosocial support specialist (MHPSS) when necessary

Contextual Drivers (Social or Environmental Factors)

• Factors related to being a military-combatant, including:
  • extreme fear of being sent back to the frontline
  • having unrealistic expectations about recovery fuelled by a motivation to get back to the frontline
• Livelihood concerns
• Concerns about basic needs being met during and after treatment (e.g. shelter, food, etc.)
• Poor family or social support
• Losses experienced (e.g. patient's family members or loved ones)

Contextual Drivers Management

• Referral to appropriate services as needed

Resources

• Gray H, Stern M. Risky dis/entanglements: Torture and sexual violence in conflict. European Journal of International Relations 2019; 25(4): 1035-1058.
• Clark ME, Bair MJ, Buckenmaier III CC, Gironda RJ, Walker RL. Pain and combat injuries in soldiers returning from Operations Enduring Freedom and Iraqi Freedom: implications for research and practice. Journal of Rehabilitation Research & Development. 2007 Mar 1;44(2).