Burn rehabilitation-a team approach

Effects of mobility training on severe burn patients in the BICU: A retrospective cohort study

PURPOSE

To assess the effects of mobility training on severe burn patients in the Burn Intensive Care Unit (BICU).

METHODS

This was a retrospective cohort study. Severe burn patients with equal to or more than 50% Total Body Surface Area (TBSA) burns who received early rehabilitation in the BICU were included in this study. Based on the different early rehabilitation strategies during the two periods, patients admitted to the BICU from January 2011 to April 2013 were identified as the passive training cohort (n=49) while patients admitted to the BICU from May 2013 to December 2013 were identified as the mobility training cohort (n=24). Data on length of BICU stay, length of hospital stay, length of rehabilitation in the BICU, ventilator dependent days, strict bed rest time, range of motion (ROM), the Barthel Index (BI) and the Functional Independence Measure (FIM) were collected.

RESULTS

Compared with the passive training cohort, patients in the mobility training cohort had significantly shorter length of BICU stay (p=0.002), length of hospital stay (p=0.010), strict bed rest time (p<0.001) and length of rehabilitation in the BICU (p=0.026) with improved ROM of shoulder, wrist, hip, knee and ankle joints.

CONCLUSIONS

Mobility training in the BICU was shown to be feasible and effective in achieving better outcomes than passive training for severe burn patients.

Orofacial Contracture Management: Current Patterns of Clinical Practice in Australian and New Zealand Adult Burn Units

Burn injury to the face can lead to scarring and contractures that may impair oral competence for articulation, feeding, airway intubation access, oral/dental hygiene, aesthetics, and facial expression. Although a range of therapy interventions has been discussed for preventing contracture formation, there is minimal information on current practice patterns. This research examined patterns of clinical practice for orofacial burns management during a 4-year period to determine the nature and extent of clinical consistency in current care. Allied health clinicians involved in orofacial contracture management in Australia and New Zealand were surveyed at two time points (2010 and 2014). Twenty and 23 clinicians, respectively, across a range of allied health professions completed the surveys. Both surveys revealed multiple allied health disciplines, predominantly occupational therapy, speech language pathology, and physiotherapy, were involved orofacial burn management. A high degree of variation was observed across clinical practices in the 2010 survey. In the 2014 survey, although, greater consistency in practice patterns was observed with more clinicians commencing intervention earlier, with greater treatment intensity observed and more treatment modalities being used. Furthermore, in 2014, there was an increased use of assessment tools and clinical indicators to guide patient treatment. Agreement regarding clinical practice pathways for orofacial contracture rehabilitation is still emerging, and treatment continues to be predominantly guided by clinical experience. There is an urgent need for treatment efficacy research utilizing validated outcome measure tools to inform clinical consensus and practice guidelines.

Burn rehabilitation and research: proceedings of a consensus summit

Burn rehabilitation is an essential component of successful patient care. In May 2008, a group of burn rehabilitation clinicians met to discuss the status and future needs of burn rehabilitation. Fifteen topic areas pertinent to clinical burn rehabilitation were addressed. Consensus positions and suggested future research directions regarding the physical aspects of burn rehabilitation are shared.

Effect of exogenous growth hormone and exercise on lean mass and muscle function in children with burns

We tested the hypothesis that the administration of recombinant human growth hormone (rHGH) and exercise would increase lean body mass (LBM) and muscle strength in burned children to a greater extent than rHGH or exercise separately. Children, ages 7-17 yr, with >40% body surface area burned, were randomized into groups. One group (GHEX, n = 10) participated in a 12-wk in-hospital physical rehabilitation program supplemented with an exercise program and received 0.05 mg. kg(-1). day(-1) of rHGH. A second exercising group (SALEX, n = 13) received saline. A third group (GH, n = 10) received a similar dose of rHGH as GHEX and participated in a 12-wk, home-based physical rehabilitation program without exercise. The fourth group (Saline, n = 11) received saline and participated in a 12-wk, home-based physical rehabilitation program without exercise. The mean (+/-SE) percent change in lean body mass after 12 wk was not significantly different between GHEX (9.0 +/- 2.1%), SALEX (5.4 +/- 1.6%), and GH (5.8 +/- 1.8%) groups (P = 0.33). However, the mean percent change in muscle strength was significantly greater in the GHEX (36.2 +/- 5.4%) and SALEX (42.6 +/- 10.0%) groups than in the GH (-7.4 +/- 4.7%) or Saline (6.7 +/- 4.4%) groups (P = 0.008). In summary, rHGH GHEX, SALEX, and GH alone produced similar improvements in LBM. However, muscle strength was only increased via exercise.

Effect of a supervised exercise and physiotherapy program on surgical interventions in children with thermal injury

Continuous body growth and rigidity of scars in children are significant contributors to burn scar contractures (BSCs). BSCs decrease a patient's range of motion and their ability to perform activities of daily living. A benefit of exercise is an increase the patient's ability to perform and sustain activities of daily living. Therefore, we investigated whether patients who were involved in a supervised, hospital-based exercise program, in addition to physical and occupational therapy (PTEX), would have fewer surgical interventions than a nonexercise group receiving home-delivered physical and occupational therapy (PT) alone. We examined 53 patients at 6, 9, 12, 18, and 24 months postburn. The PTEX group (n = 27) completed a 12-week supervised exercise program starting at 6 months postburn. Exercise sessions were held three times per week, with duration of 60 to 90 minutes per session. Resistance and aerobic exercises were performed at 70 to 85% of the patient's maximal effort. In contrast, the PT group (n = 26) received a home rehabilitation program with no supervised exercise. Patients were evaluated at 3-month intervals for scar formation, range of motion, and need for surgery. At 12, 18, 24 months postburn, the number of patients in the PTEX group needing release of BSC was significantly lower than the number of patients in the PT group. The results indicate that patients would receive a significant benefit if enrolled in a supervised exercise and physiotherapy program with the exercise portion consisting of an aerobic and resistance-training component. This type of program is beneficial in decreasing the number of surgical interventions and should be incorporated as part of a postburn outpatient rehabilitation.

The effects of exercise programming vs traditional outpatient therapy in the rehabilitation of severely burned children

The purpose of this study was to compare the efficacy and effects of exercise programming (Study group, n = 11) vs traditional outpatient therapy (Home group, n = 10) in burned children (> 40% body surface area). This was a prospective, randomized, controlled trial in a hospital-based children's wellness center. Twenty-one patients (13 boys and 8 girls) averaging 10.6 +/- 0.9 years and TBSA = 59.7 +/- 3.1% were evaluated 6 and 9 months postburn. Moderate intensity, progressive resistance and aerobic exercise conducted 3 times weekly for 1 hour were a supplement to standard therapy over 12 weeks. Muscular strength and functional outcome significantly increased in both groups (P < .05). Improvements in strength (80.1 vs 37.7%) and distance walked (39.5 vs 12.5%) were significantly greater for Study vs Home groups, respectively, P < .05. We conclude that exercise programming may be safely included in rehabilitation programs for severely burned children and can be effective in increasing muscular strength and functional outcome.

Behavioral observation and analysis of pain behavior in critically burned patients

Although patients who have been critically burned obviously suffer significant levels of pain, they also appear to engage in adaptive behaviors with greater frequency than previously documented. Observers trained in the use of an objective, reliable coding system recorded 5 min samples of behavior during treatment procedures. Typically, patients report severe pain during procedures such as wound debridement, dressing changes, physical therapy, etc., and many dread having to undergo them. The coding system allowed for the concurrent recording of staff reactions to patients' pain behaviors, well-being behaviors (discussing progress, future plans, complying with therapeutic instructions, etc.), criticism and praise of the hospital and the staff, and focusing on other patient's problems. Results indicate that: (1) patients exhibit a significant higher frequency of psychological and somatic well-being than psychological and somatic complains, even in the context of an intense, typically painful, treatment procedure; (2) differences in the frequency of pain behaviors and of well-beings behaviors were not systematically related to the expected burn-related variables, e.g., total body surface area burned, site of burn, days since onset; and (3) nursing staff who have not received specific training in the behavioral analysis and treatment of pain respond to most patient behaviors with positive reinforcement regardless of whether such reinforcement is therapeutically indicated. Behavioral implications for the theory and treatment of pain are discussed.