Controversies in Spinal Motion Restriction
Every so often, a concept that has been passed down for generations of first responders is questioned, and surprising new data potentially changes one of the most basic, accepted treatment options in the industry.
David Wampler, PhD, LP, FAEMS, is currently challenging one such long-accepted practice with his studies into the efficacy of the long spine board. As Associate Professor of Emergency Health Services at UT Health San Antonio School of Health Professions, Wampler teaches fourth-year medical students as well as experienced paramedics who are continuing their education, and also looks for improved treatment options through his research.
“Sometimes we were trained in a certain way because our teachers were trained that way. We are trying to break dogma,” Wampler explains on the university website. “Sacred cows are delicious and make good hamburger.”
Questioning the Long Board
In his efforts to apply evidence-based medicine to discover more effective treatment, Wampler has been delving into the history and current use cases of the long board after traumatic injuries with potential spinal cord injuries. He recently presented his findings and progress at the ESO Wave 2019 conference in a session titled, “Controversies in Spinal Motion Restriction.”
Wampler opened his session pointing out that not much has changed in the design of a long board since its first documented use cases around 1967, where a smooth wooden board with holes was employed as an extraction device – not necessarily a transportation device – to remove victims from dangerous accident scenes.
“Today’s smart phone has more computing power than the Apollo 11 that landed on the moon,” explained Wampler. “If you look at the progress with the long board over the last 47 years, we today have a plastic version. And not much else has changed.”
Wampler explained that while serious spinal cord injuries are relatively rare (around 54 occurrences per 1 million cases), when they do occur, they are extremely serious and life-altering. While Wampler was initially was looking for ways to “build a better board,” he instead discovered some surprising study results and potential solutions during his research.
Two Existing Approaches
Medical professionals can agree that one of the most important goals after a trauma with potential spinal cord injury is to protect the neurological tissue, blood flow, oxygen delivery, and reduce edema and hypertension. However, the best way to accomplish this can be a point of dissension. Wampler began by identifying the two opposing theories around spinal injuries that would direct the treatment options after trauma.
- Initial trauma to the spine is the cause of cord injury. Moving it later causes minimal further injury
- Improper transport can cause additional, secondary injury to the spinal cord.
His initial look into existing studies revealed that immobilizing trauma patients is not always necessary, and that it can, in fact, create additional problems like tissue pressure, discomfort, difficulty in swallowing, and serious breathing problems. One particular study compared American protocols in a New Mexico community, to a community in Malaysia providing similar hospital care but very different pre-hospital care.
In the Malaysian patients, where no pre-hospital immobilization occurred, there was significantly less neurologic disability reported (almost 2:1 better). Wampler admitted that while this was not a perfect study and there were other factors, the surprising bottom line was that Malaysian patients actually did better without pre-hospital care.
A Surprising Solution
These references, along with numerous other studies, led Wampler to begin a search for a more effective alternative to the long board. “In my work, I discovered that we already have a better alternative, and it’s one that almost everyone in the industry is already an expert in using,” explained Wampler. “It’s the stretcher.”
Introduced in 1958, the stretcher has evolved significantly over the years. Wampler hypothesized that while long boards can still be a useful tool in extraction, using them for transport can actually cause delays to treatment and thereby increase mortality. By transferring the patient as soon as possible from the long board to a stretcher (while weighing the risk of the time that transfer would take), first responders can actually reduce the problems caused by intense immobilization.
Testing the Theory
Wampler was interested, also, in comparing the amount of movement encountered by a patient in the back of a bus, especially when comparing a long board to a stretcher. With a team of researchers, he created a test device that used lasers to measure how much a patient on a stretcher moved during transport compared to a stretcher. In every case, the body moved more on the long spine board than on a stretcher. And even more concerning, when strapped down on the long board, the patient’s torso moved even more than the head, directing torque to the spine and cervical area. High BMI patients moved even more than low BMI patients.
Wampler’s next study created a more sophisticated test system using two geo-spatial motion-capture suits with 17 sensors each. The team took a single, healthy person and used 10 different transport iterations such as spine board, stretcher, stretcher with various levels of head elevation, with and without c collar straps, and head blocks. They then looked at how much the sensor on the head moved compared to the torso. while driving around their local community.
The results of the study led the team to form recommendations on best practices for EMS agencies transporting patients after trauma, including:
- Patients should not be transferred on a long board, with rare exceptions.
- Consider transferring a patient to a stretcher as soon as possible, taking into consideration the impact of time that the transfer will take versus transport to the nearest treatment facility. Hospitals should be trained and equipped to remove a patient from a long board as quickly as possible.
- Head blocks are essential in increasing the stability of a patient during transport.
- Elevate the head of the stretcher up to 30 degrees as tolerated to help increase stability. However, keep in mind that once you pass 45 degrees of elevation, motion increases.
- Spinal motion restriction on a long board has no place with penetrating trauma patients.
- Look into the driving habits of the ambulance, as the studies also showed that a patient’s body receives more movement during deceleration and turns, compared to acceleration and other driving.
Wampler hopes that in light of these results and more discussion with the industry, EMS teams and hospitals can help reduce the devastating effects of spinal injuries, especially concerning secondary injuries or problems that can occur after the initial trauma.
To watch Wampler’s full session presentation, click here now.