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 Table of Contents  
Year : 2020  |  Volume : 5  |  Issue : 1  |  Page : 22-28

Preliminary feasibility of a physical therapy protocol following surgical stabilization of rib fractures

Division of Trauma and Surgical Critical Care, Intermountain Medical Center, Salt Lake City, UT, USA

Date of Web Publication24-Dec-2020

Correspondence Address:
Christina Pelo
Division of Trauma, Intermountain Medical Center, Salt Lake City, UT
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jctt.jctt_3_20

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Background: Surgical stabilization of rib fractures (SSRFs) is increasing in popularity. During the operation, disruption of the chest wall musculature occurs, which may affect chest wall and glenohumeral–scapular movement. Although postoperative physical therapy (PT) is widely recommended, specific, validated, protocols for SSRF patients do not exist. The purpose of this study was to evaluate the feasibility and safety of a PT protocol specifically designed for SSRF patients.
Methods: This was a pilot study of all SSRF patients admitted to a single level-I trauma center between December 2017 and February 2019. Included patients received a PT evaluation within 72 h of operation. This evaluation included implementation of specific PT interventions and a written home exercise program. Objective measures included: patient reported pain scores, shoulder strength, chest expansion, spirometry, and the disabilities of the arm, shoulder, and hand (DASH) survey. These measures were obtained at initial inpatient evaluation, 1–week and 1–month post discharge in an outpatient visit, and at 3 months through telephone DASH survey.
Results: Nineteen patients were analyzed. Patients were primarily male (74%), suffering from blunt trauma, with a median 8 (interquartile range [IQR]: 7–10) rib fractures and Injury Severity Score (ISS) of 17 (12–23). The median (IQR) time from SSRF to PT evaluation was 1 (1–2) day. Median chest expansion doubled from PT evaluation to 1–month follow–up (1.9 cm PT evaluation; 2.5 cm 1 week; 4.5 cm 1–month, P = 0.014). The median age-predicted spirometry improved from 29% preoperatively, to 38% at PT evaluation and to 86% at 1-month postdischarge (P ≤ 0.05 for the trend). Shoulder strength improved from PT evaluation to 1–month follow–up. The median DASH scoring improved at all follow–up intervals, with no clinically significant functional impairments at 3 months (86 on PT evaluation; 56 at 1–week, 21 at 1–month; 8 at 3–month phone interview).
Conclusion: A specific, novel, PT protocol for patients after SSRF appears to be feasible and safe. Our results demonstrate a significant decrease in patient-perceived disability, improved shoulder strength, chest expansion, and spirometry compared to immediate postoperative levels. Although we cannot determine the effect of the protocol on recovery, our results provide the preliminary data on which to base a larger, randomized trial to determine if a beneficial effect of the protocol is present.

Keywords: Physical therapy, rib fracture, surgical stabilization of rib fracture

How to cite this article:
Pelo C, Kay AB, Morris DS, White TW, Majercik S. Preliminary feasibility of a physical therapy protocol following surgical stabilization of rib fractures. J Cardiothorac Trauma 2020;5:22-8

How to cite this URL:
Pelo C, Kay AB, Morris DS, White TW, Majercik S. Preliminary feasibility of a physical therapy protocol following surgical stabilization of rib fractures. J Cardiothorac Trauma [serial online] 2020 [cited 2022 May 28];5:22-8. Available from: https://www.jctt.org/text.asp?2020/5/1/22/304865

  Introduction Top

Rib fractures are among the most common injuries sustained after blunt trauma, occurring in approximately 10% of patients admitted to trauma centers, and carry significant morbidity and mortality risks.[1],[2] Conventionally, the mainstay of treatment for chest wall injuries has been nonsurgical management with analgesia, aggressive pulmonary toilet, and ventilator support when necessary.[3] Current literature and clinical practice have shown benefits of surgical stabilization of rib fractures (SSRFs) including pain reduction, decreased intensive care unit (ICU) and hospital length of stay (LOS), improved pulmonary function, and improved quality of life compared to nonoperative management.[1],[2],[3],[4],[5],[6] This benefit is particularly notable in patients who have flail chest or significantly displaced fractures.[4]

In 2017, a consensus statement was published by the Chest Wall Injury Society on the overall management of the SSRF patients that emphasized the importance of early mobility after surgery, specifically endorsing the incorporation of physical therapy (PT).[1] The statement made no specific recommendation as to what type of PT regimen should be performed nor what objective measures of success should be recorded. Indeed, there is currently no objective evidence to show that PT after SSRF is beneficial. There are some who maintain that aggressive, early PT might adversely affect hardware failure rates or increase wound healing complications. There is no objective evidence to show that this is the case, either, however.

Prior to embarking on a randomized controlled trial of PT after SSRF, we first sought to evaluate the feasibility and safety of a PT protocol specifically designed for patients post SSRF. We hypothesized that a specific PT protocol post SSRF would not cause more hardware or wound complications and would result in reduced patient-perceived disability, as well as improved pain management and improved pulmonary function and shoulder specific strength compared to immediately postinjury.

  Methods Top

Study population

All patients aged 18–90-year-old who underwent SSRF at a single level-I ACS-verified trauma center from December 2017 to February 2019 were considered for enrollment. Exclusion criteria included patients <18 years or >90 years, moderate or severe traumatic brain injury defined as intracranial hemorrhage >8 mm documented on brain computed tomography (CT) and/or Glasgow Coma Scale <12 at the time of consideration for enrollment, ipsilateral humerus fracture, spinal cord injury higher than L1, mechanical ventilation >72 h post SSRF, spinal fractures requiring Thoracic-lumbar-sacral orthosis (TLSO), or incarceration and/or in police custody at the time of consideration for enrollment. The Intermountain Central Institutional Review Board approved and monitored the conduct of this study.

Study design

Patients were selected for SSRF according to the institutional protocol. The operation itself was left to surgeon discretion with regard to incision placement, hardware system used, number and location of rib fractures repaired, and use of long-acting intercostal nerve blocks. Muscle-sparing techniques were used in all SSRF procedures. In all patients, a pleural drain (24 Fr Blake drain) was inserted, and the pleural space was irrigated to remove any residual hemothorax. This drain was left in place postoperatively until any residual pneumothorax had resolved and the output was <200 ml per 24 h. Depending on the extent of subcutaneous tissue injury and surgeon preference, some patients received an additional subcutaneous or submuscular drain (19 Fr Blake drain) and/or long-acting bupivacaine intercostal injections.

A standardized multimodal pain protocol was implemented, which included scheduled acetaminophen (650 mg) orally every 6 h, lidocaine patch 12 h on/12 h off, ibuprofen (600 mg) orally every 6 h, and gabapentin (300 mg) orally every 8 h. Additional pain management interventions, including opioid use, were administered at the discretion of the trauma provider. No study patients received an epidural catheter.

Postoperatively, patients were required to receive an initial PT evaluation, preferably within 72 h after operation. The initial PT evaluation included standard PT interventions such as bed mobility, gait training, and instructions on assistive devices if needed. In addition to the standard PT evaluation variables, physical therapists recorded rib-specific pain level, shoulder strength, chest expansion, and incentive spirometry. The subsequent follow-up treatment frequency and number of sessions were individualized by the physical therapist based on patient needs. All patients underwent at least the initial evaluation session and one follow-up session. Specific PT interventions implemented at the follow-up sessions included scapular mobilization, proprioceptive neuromuscular facilitation (PNF) patterns with scapular resistance, mirror therapy, and a written home exercise program (HEP), emphasizing active and passive UE range of motion [Appendix 1].

Outcome measures

The primary endpoint was to determine improvement in patient-perceived disability after SSRF using the disabilities of the arm, shoulder, and hand (DASH). The DASH is a validated 30-item, self-reported questionnaire designed to measure physical function and symptoms in patients with both single or multiple musculoskeletal disorders of the upper limb.[7] The questionnaire was originally designed to help to describe the disability experienced by people with upper-limb disorders while completing activities of daily living and monitor changes in symptoms and function over time. The items address (1) degree of difficulty with performing various physical activities, (2) severity of symptoms of pain, tingling, weakness, and stiffness, (3) problems effect on social activities, work, and sleep, and (4) psychological impact.[8],[9] The DASH is scored in two components: The disability/symptom section (30 items, scored 1–5) and the work section (4 items, scored 1–5). Scores from each of the sections are calculated into a 0–100 scale, with a higher score indicating greater disability.

The secondary outcomes included incentive spirometry volume (measured best out of three trials), circumferential chest expansion at the xiphoid process, shoulder flexion/abduction/adduction/external rotation manual muscle testing, and localized rib pain on a traditional scale 0–10. Opioid use, measured as morphine milligram equivalents (MMEs), was recorded for both the 24-h period prior to discharge as well as the outpatient clinic follow-up appointment. Compliance with HEP was self-reported as “very compliant” (>75% of days), “moderately compliant” (50%–74%), or “noncompliant” (≤49%). Objective measures were repeated at 1 week and 1 month post discharge in person at the trauma clinic follow-up visit. In addition to completing the DASH on initial postoperative evaluation, patients completed the DASH at 1 week and 1 month submitted during their clinic visits and at 3 months with a telephone interview. The results are described as mean (± standard deviation) or median (interquartile range [IQR]) as appropriate. Each subject acted as his/her own control, with outcomes compared to baseline postsurgery control. Patients were not included in all follow-up data time points if they were lost to follow-up and/or had missing information.

  Results Top

During the study period, 524 patients were admitted to the trauma service with rib fractures. Thirty-two (6.1%) of these underwent SSRF. Nineteen (59% of SSRF cohort) patients met study inclusion criteria and were enrolled [Figure 1], Flow Diagram]. Complete patient demographics are presented in [Table 1]. Patients were primarily middle-aged (median age: 58 years [45–66]), predominantly male (14, 74%), all suffering from blunt trauma, with motor vehicle accidents as the most common mechanism (38%). The median Injury Severity Score (ISS) was 17 (12.5–23) with a chest Abbreviated Injury Scale score of 3 (3–4). From the emergency department, 53% (n = 10) were originally admitted to the ICU and 47% (n = 9) were admitted to surgical floor. Overall, 68% (n = 13) sustained ipsilateral fractures: 4 clavicle fractures (2 treated nonoperatively and 2 with open reduction and internal fixation) and 11 scapula fractures (all treated nonoperatively).
Figure 1: Patient inclusion chart

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Table 1: Patient demographics

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Chest wall injury information is presented in [Table 2]. The median (IQR) time from admission to SSRF was 1 (1–2) day. The median number of rib fractures was 8 (7–10), with 58% (n = 11) of patients with radiographic flail chest. The median of 5 (4–5) ribs per patient was plated during surgery. The median time from SSRF to PT evaluation was 1 (1–2) day. All patients had the institutional pain protocol appropriately implemented postoperatively. The overall median hospital LOS was 8 (6–9) days, with 68.4% of patients discharging to home. One patient was readmitted to the hospital for pleural effusion (21 days after SSRF) and later expired 28 days post injury, after a transition to hospice care. There were no reported cases of wound complications and no reports of fracture nonunion. A single case of plate fracture was identified in a patient with osteogenesis imperfecta.
Table 2: Chest wall injury

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Disabilities, of the arm, shoulder, and hand questionnaire

The median DASH score at original inpatient postoperative PT evaluation was 86 (83–90), significantly improving to 56 (51–82) at 1-week (P = 0.008), 21 (10–59) at 1-month (P = 0.014), and 8 (2–11) at 3-month phone interview (not enough data at 3 months to calculate statistical significance compared to 1-month value [Figure 2]).
Figure 2: Disabilities of the arm, shoulder, and hand scoring

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Respiratory data

The median change in chest expansion at xiphoid process with maximal inhalation to maximal exhalation was 1.9 cm (1.3–2.3) at initial PT evaluation, 2.5 cm (2–3) at 1–week follow-up not significant (NS), and 4.5 cm (3.5–4.8) at 1–month follow-up (P = 0.014) [Figure 3]. The median age–predicted spirometry improved from 29% (22.5–41) preoperatively, to 38% (24–46) at PT evaluation (P = 0.035), to 68% (50–72) at 1-week post SSRF (P = 0.011), and to 86% (78.5–94) at 1–month post–discharge (not enough 1-month data to calculate statistical significance [Figure 4].
Figure 3: Chest expansion

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Figure 4: Age-predicted incentive spirometry

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Strength testing

Shoulder strength in ipsilateral SSRF limb demonstrated improvement in all planes of movement from PT evaluation to 1–month follow–up [Table 3].
Table 3: Manual muscle testing

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Pain and opioid use

All patients were initiated on the postoperative pain protocol. Our pain protocol emphasizes nonopioid multimodal analgesia, but opioids are prescribed when nonopioid strategies fail to achieve adequate patient pain scores. No epidural analgesia was utilized. On a numerical rating scale 0–10, median patient reported pain at initial PT evaluation was 6.0 (5–7.5), 4.5 (3–7) at 1-week clinic follow-up (NS), and 4 (2–5) (P = 0.049) at 1-month clinic follow-up. At hospital discharge, median 24-h MME was 41 (19–60). At 1-week clinic follow-up, the median 24-h MME was 15 (15–30) (NS) and 0 (0–15) (P = 0.02) MME at 1-month clinic follow-up [Figure 5].
Figure 5: Opioid use

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  Discussion Top

The role of PT after SSRF makes intrinsic sense to most clinicians, and indeed, has been recommended in general terms.[1] But what does PT look like for SSRF patients? Which protocols should be followed? How will these protocols be tolerated? Will PT disrupt hardware or cause problems with healing or nonunion? Despite qualitative research in patients with traumatic rib fractures that suggests a patient-perceived need for a specific rehabilitation intervention,[10] the answers to these questions are unknown, likely due to the relative novelty of SSRF.

Our results imply that early implementation of a specific, PT protocol post SSRF is safe, feasible, and does not increase risk of hardware failure or complications. To our knowledge, this is the first study to evaluate the implementation of a specific PT protocol in patients after SSRF.

Standardized PT protocols are routinely utilized for major orthopedic trauma. For this study, the physical therapists completed focused PT interventions geared toward scapular mobilization and deterrence from maladaptive compensatory mechanisms that predispose patients to impaired upper extremity (UE) function and pulmonary compromise. Our protocol was designed to focus on the most commonly impacted muscles during SSRF: the serratus anterior and latissimus dorsi. Anterior chest wall musculature (pectoralis major and/or minor) or posterior musculature (trapezius) may also be affected by SSRF. Even if these muscles are not transected, they are frequently affected by deep dissection and/or prolonged retraction. Understanding that this is likely a source of UE dysfunction postoperatively, our PT protocol focused heavily PNF UE therapeutic exercises to restore range of motion and motor control via functional movements. Scapular stability allows proper positioning of the scapula on the thorax during UE movements and directly influences glenohumeral arthrokinematics.[11]

We opted to test strength instead of range of motion, as very few activities of daily living require extremes of shoulder range of motion, and weakness or pain would more likely negatively impact the quality of life. In addition, manual muscle testing was chosen in this study over shoulder range of motion due to the possibly of competing injury restrictions (i.e., clavicular fractures) imposed by the orthopedic surgeons at our institution who prefer restricting shoulder flexion >90°.

Currently, there is no standardized qualitative measure of disability after chest wall trauma with or without SSRF. The benefit of the DASH questionnaire is that it is a validated, widely studied tool in traumatic and polyorthopedic conditions, with strong test–retest reliability and importantly, it does not target one specific joint but is rather body region specific.[7],[12],[13] The 95% minimally detectable change (MDC95) proposed by its developers is 13, with an overall score of ≤10.1 correlating with no clinically significant functional impairment.[6],[8] At all follow-up intervals, our patients' average DASH scores in our study population decreased by greater than the MDC95 and all scored <10.1 at the 3-month follow-up. Returning to full function by 3 months, with no residual UE functional impairments, demonstrates the success of the primary goal of our protocol.

With regard to pulmonary function, the research has demonstrated that surgical fixation of rib fractures results in decreased ventilator days, ICU LOS, and overall hospital LOS.[1],[2],[3],[4],[5],[6] Our study offered the ability to look at pulmonary function beyond the initial hospitalization. For 15 of our patients, we were able to compare their preoperative age-predicted incentive spirometry values to those obtained during the postoperative course. There was a 18.39% increase from pre- to postoperative incentive spirometry at PT evaluation, a 90.40% increase at 1-week postoperative, and 155.99% overall increase at 1 month. These results are likely a combination of both standardized pain protocol, stabilization of fractures, and the PT protocol. We additionally looked at thoracic range of motion by measuring circumferential chest expansion at the xiphoid process. All of our patients' chest expansion at 1 month fell within healthy age-related normative values.[14] A 2016 study by Olsén et al. also looked at chest expansion in patients who underwent SSRF at 1 year post SSRF. Patients did not receive any standardized inpatient PT nor formal breathing exercises to improve thoracic range of motion. At 1 year, they demonstrated a circumferential chest expansion change of 4.3 cm at the xiphoid process.[15] The earlier chest expansion in our study may be attributed to the early scapular mobilization and chest wall expansion exercises. This is a critical finding, as it reinforces the importance and safety of engaging the surgical limb in an effort to force chest wall expansion and avoid possible maladaptive compensations that lead to long-term disability.


The major limitation of this study is its small sample size and the lack of a nonoperative comparator group. Without such a group, we are unable to determine how much SSRF contributed to the improvements in function we observed and whether similar improvements would occur in patients who did not receive SSRF or who did not participate in the formal PT protocol. Our major focus for this preliminary feasibility study was simply to see if the protocol we implemented was able to be accomplished without additional PT staffing and if it was safe to perform without hardware or wound problems. This initial study will be used as a foundation to design future prospective randomized trials to more clearly elucidate its effectiveness compared to the current PT practices in our hospital. Additionally, follow-up at both 1 month in outpatient clinic and phone communication at 3 months were overall poor. Of our 19 included patients, 13 (68%) completed the 1-week follow-up, with only 9 (47%) patients completing both the 1 month and 3-month follow-ups. This limits the ability to detect improvements/differences between specific variables and the implication on long-term outcomes.

  Conclusion Top

Functional limitations after rib fractures and SSRF are manifested primarily by pulmonary function and UE disability. Our SSRF-specific PT protocol appears to be feasible without adding additional PT workload and appears to be safe in regard to hardware or wound complications. Although we did not have a comparator group, and therefore, cannot make firm conclusions about efficacy, the improvement seen in decreased patient-perceived disability, improved shoulder strength, chest expansion, and spirometry is encouraging. Our data provide the foundation for larger prospective studies.

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Conflicts of interest


  References Top

1. Pieracci FM, Majercik S, Ali-Osman F, Ang D, Doben A, Edwards JG, et al. Consensus statement: Surgical stabilization of rib fractures rib fracture colloquium clinical practice guidelines. Injury 2017;48:307-21.  Back to cited text no. 1
2. Witt CE, Bulger EM. Comprehensive approach to the management of the patient with multiple rib fractures: A review and introduction of a bundled rib fracture management protocol. Trauma Surg Acute Care Open 2017;2:e000064.  Back to cited text no. 2
3. May L, Hillermann C, Patil S. Rib fracture management. BJA Educ 2016;16:26-32.  Back to cited text no. 3
4. de Moya M, Nirula R, Biff W. Rib fixation: Who, what, when?. Trauma Surg Acute Care Open 2017;2:1-4.  Back to cited text no. 4
5. Pieracci FM, Lin Y, Rodil M, Synder M, Herbert B, Tran DK, et al. A prospective, controlled clinical evaluation of surgical stabilization of severe rib fractures. J Trauma Acute Care Surg 2016;80:187-94.  Back to cited text no. 5
6. Majercik S, Cannon Q, Granger SR, VanBoerum DH, White TW. Long-term patient outcomes after surgical stabilization of rib fractures. Am J Surg 2014;208:88-92.  Back to cited text no. 6
7. Kennedy CA, Beaton DE, Solway S, McConnell S, Bombardier C. The DASH Outcome Measure user's Manual. 3rd ed.. Toronto: Institute for Work and Health; 2011. Available from: http://www.dash.iwh.on.ca. [Last accessed on 2020 Jan 10].  Back to cited text no. 7
8. Franchignoni F, Vercelli S, Giordano A, Sartorio F, Bravini E, Ferriero G. Minimal clinically important difference of the disabilities of the arm, shoulder and hand outcome measure (DASH) and its shortened version (QuickDASH). J Orthop Sports Phys Ther 2014;44:30-9.  Back to cited text no. 8
9. Mcclure P, Michener L. Measures of adult shoulder function: The American shoulder and elbow surgeons standardized shoulder form patient self report section (ASES), disabilities of the arm, shoulder, and hand (DASH), shoulder disability questionnaire, shoulder pain and disability index (SPADI), and simple shoulder test. Arthritis Rheumatism 2003;49:S50-8.  Back to cited text no. 9
10. Claydon J, Maniatopoulos G, Robinson L, Fearon P. Challenges experienced during rehabilitation after traumatic multiple rib fractures: A qualitative study. Disabil Rehabil 2018;40:2780-9.  Back to cited text no. 10
11. Dayle RB. Proprioceptive neuromuscular facilitation for the scapula, Part 1: Diagonal 1. Athletic Therapy Today 2005;10:54-6.  Back to cited text no. 11
12. Katz JN, Beaton DE, Fossel AH, Wright JG, Bombardier C, Tarasuk V. Measuring the whole or the parts? J Hand Ther 2012;14:128-42.  Back to cited text no. 12
13. Dimitroulias A, Molinero KG, Krenk DE, Muffly MT, Altman DT, Altman GT. Outcomes of nonoperatively treated displaced scapular body fractures. Clin Orthop Relat Res 2011;469:1459-65.  Back to cited text no. 13
14. Finsbäck C, Mannerkorpi K. Spinal and thoracic mobility – Age-related reference values for healthy men and women. Nordisk Fysioterapi. 2005;9:136–43.  Back to cited text no. 14
15. Fagevik Olsén M, Slobo M, Klarin L, Caragounis EC, Pazooki D, Granhed H. Physical function and pain after surgical or conservative management of multiple rib fractures A follow-up study. Scand J Trauma Resusc Emerg Med 2016;24:128.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2], [Table 3]


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