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Parry I, Bell J. Associations between burn care services and impairment at discharge after burn injury: Analysis of the Global Burn Registry. Burns 2024; 50:813-822. [PMID: 38503574 DOI: 10.1016/j.burns.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 02/15/2024] [Accepted: 03/02/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND Throughout the world, burn injury is a major cause of death and disability. In resource-limited countries, burn injury is one of the leading causes of permanent disability among children who survive traumatic injuries, and burn injury is the fourth leading cause of disability worldwide. This study applied Andersen's model of health care access to evaluate if patient characteristics (predisposing factors), burn care service availability (enabling factors) and injury characteristics (need) are associated with physical impairment at hospital discharge for patients surviving burn injuries globally. Specifically, access to rehabilitation, nutrition, operating theatre, specialized burn unit services, and critical care were investigated as enabling factors. The secondary aim was to determine whether associations between burn care service availability and impairment differed by country income level. METHODS This is a cross-sectional secondary analysis of prospectively collected data from the World Health Organization, Global Burn Registry. The outcome of interest was physical impairment at discharge. Simple and multivariable logistic regressions were used to test the unadjusted and adjusted associations between the availability of burn care services and impairment at hospital discharge, controlling for patient and injury characteristics. Effect modification was analyzed with service by country income level interaction terms added to the models and, if significant, the models were stratified by income. RESULTS The sample included 6622 patients from 20 countries, with 11.2% classified with physical impairment at discharge. In the fully adjusted model, patients had 89% lower odds impairment at discharge if the treatment facility provided reliable rehabilitation services compared to providing limited or no rehabilitation services (OR.11, 95%CI.08,.16, p < .01). However, this effect was modified by county income with the strong and significant association only present in high/upper middle-income countries. Sophisticated nutritional services were also significantly associated with less impairment in high/upper middle-income countries (OR=.04, 95% CI 0.203, 0.05, p < .01), but significantly more impairment in lower middle/low-income countries (OR=2.01, 95% CI 1.50, 2.69, p < .01). Patients had 444% greater odds of impairment if treated at a center with specialty burn unit services (OR 5.44, 95%CI 3.71, 7.99, p < .01), possibly due to a selection effect. DISCUSSION Access to reliable rehabilitation services and sophisticated nutritional services were strongly associated with less physical impairment at discharge, but only in resource-rich countries. Although these findings support the importance of rehabilitation and nutrition after burn injury, they also highlight potential disparities in the quantity or quality of services available to burn survivors in poorer countries.
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Affiliation(s)
- Ingrid Parry
- University of California, Davis, School of Nursing and Health Care Leadership, California, USA.
| | - Janice Bell
- University of California, Davis, School of Nursing and Health Care Leadership, California, USA
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Parry I, Mandell SP, Hoarle KA, Bailey JK, Dissanaike S, Harrington DT, Holmes JH, Cartotto R. American Burn Association Strategic Quality Summit 2022: Setting the Direction for the Future. J Burn Care Res 2023; 44:1051-1061. [PMID: 37423718 DOI: 10.1093/jbcr/irad092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
The American Burn Association (ABA) hosted a Burn Care Strategic Quality Summit (SQS) in an ongoing effort to advance the quality of burn care. The goals of the SQS were to discuss and describe characteristics of quality burn care, identify goals for advancing burn care, and develop a roadmap to guide future endeavors while integrating current ABA quality programs. Forty multidisciplinary members attended the two-day event. Prior to the event, they participated in a pre-meeting webinar, reviewed relevant literature, and contemplated statements regarding their vision for improving burn care. At the in-person, professionally facilitated Summit in Chicago, Illinois, in June 2022, participants discussed various elements of quality burn care and shared ideas on future initiatives to advance burn care through small and large group interactive activities. Key outcomes of the SQS included burn-related definitions of quality care, avenues for integration of current ABA quality programs, goals for advancing quality efforts in burn care, and work streams with tasks for a roadmap to guide future burn care quality-related endeavors. Work streams included roadmap development, data strategy, quality program integration, and partners and stakeholders. This paper summarizes the goals and outcomes of the SQS and describes the status of established ABA quality programs as a launching point for futurework.
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Affiliation(s)
- Ingrid Parry
- Shriners Hospitals for Children, Northern California, 2425 Stockton Blvd. Sacramento, CA 95817, USA
| | - Samuel P Mandell
- UT Southwestern Medical Center, Section Chief, Burn Surgery, Medical Director, Parkland Burn Center, Medical Director, Surgical Quality, Parkland, USA
| | | | | | | | - David Tobin Harrington
- Department of Surgery, Chief Quality Officer for Surgery, Lifespan, Warren Albert School of Medicine at Brown University, USA
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Cartotto R, Dissanaike S, Parry I. Reply: Eslamialiabadi H, Nasiri A, Mahmoudirad G. Iranian Men's Sexual Life Issues After Their Wives' Burn: A Qualitative Content Analysis Study. J Burn Care Res 2023;44(2):452-458. J Burn Care Res 2023; 44:1261. [PMID: 37423710 DOI: 10.1093/jbcr/irad096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Affiliation(s)
| | | | - Ingrid Parry
- Shriners Hospital For Children, Northern California, Sacramento, California, USA
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Yelvington ML, Parry I. Integration of Cutaneous Functional Units Principles in Burn Rehabilitation: A Diffusion of Innovations Assessment. J Burn Care Res 2023; 44:1134-1139. [PMID: 36688492 DOI: 10.1093/jbcr/irad007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Indexed: 01/24/2023]
Abstract
Early recognition of contractures can lead to a more targeted therapy regimen, potentially preventing range of motion losses and improving function and quality of life. Cutaneous functional units (CFUs) allow therapists to explain motion limitations and formulate patient-specific treatment plans. Evidence-based research demonstrates the potential of using these principles to improve the current standard of care. Still, the consistent use of these principles has been slow to diffuse through burn care. Occupational and physical therapists were surveyed to determine the degree to which CFU principles are being integrated into clinical practice. Respondents (297) were occupational therapists (52%) and physical therapists (49%) working in burn units (81%) in North America (70.7%). Most respondents (78.4%) report familiarity with CFU principles. Of those familiar, most respondents reported their knowledge (66.7%) and ability to apply (65.7%) at an intermediate level or greater. A slight majority (59.3%) responded that the concepts influenced their practice, while 40.7% said the concepts did not influence their practice. Forty percent to sixty-nine percent of respondents correctly answered knowledge questions, but only 15% of respondents correctly completed CFUs identification questions. Respondents (77%) report barriers, including difficulty incorporating into practice, time constraints, and the need for more education. Results suggest that diffusion can be improved by developing tools to assist therapists in understanding and incorporating CFUs' principles.
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Affiliation(s)
| | - Ingrid Parry
- University of California, Davis, 2425 Stockton Blvd. Sacramento, CA 95817, USA
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Bettencourt K, Parry I, Yelvington M, Taylor S, Greenhalgh D, James MA. Comparison of Different Methods of Measuring Finger Range of Motion via Telehealth. J Hand Surg Am 2023:S0363-5023(23)00169-7. [PMID: 37269260 DOI: 10.1016/j.jhsa.2023.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 03/07/2023] [Accepted: 03/20/2023] [Indexed: 06/05/2023]
Abstract
PURPOSE This study examined the accuracy and reliability of measuring total motion of the fingers via telehealth using the following three different methods: (1) goniometry, (2) visual estimation, and (3) electronic protractor. Measurements were compared with in-person measurement, which was assumed to be the reference standard. METHODS Thirty clinicians measured finger range of motion from prerecorded videos of a mannequin hand with articulating fingers, which was posed in extension and flexion that simulated a telehealth visit, using a goniometer with results blinded to the clinician (blinded goniometry), visual estimation, and an electronic protractor, in random order. Total motion was calculated for each finger and for all four fingers in sum. The experience level, familiarity with measuring finger range of motion, and opinions of measurement difficulty were assessed. RESULTS Measurement with the electronic protractor was the only method equivalent to the reference standard within 20°. Remote goniometer and visual estimation did not fall within the acceptable error margin of equivalence, and both underestimated total motion. Electronic protractor also had the highest interrater reliability (intraclass correlation [upper limit, lower limit], 0.95 [0.92, 0.95]); goniometry (intraclass correlation, 0.94 [0.91, 0.97]) was nearly identical, whereas visual estimation (intraclass correlation, 0.82 [0.74, 0.89]) was much lower. Clinicians' experience and familiarity with range of motion measurements had no relationship with the findings. Clinicians reported visual estimation as the most difficult (80%) and electronic protractor as the easiest method (73%). CONCLUSIONS This study showed that traditional in-person forms of measurement underestimate finger range of motion via telehealth; a new computer-based method (ie, electronic protractor) was found to be more accurate. CLINICAL RELEVANCE The use of an electronic protractor can be beneficial to clinicians measuring range of motion in patients virtually.
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Affiliation(s)
- Kory Bettencourt
- Department of Clinical Research, Shriners Children's-Northern California, Sacramento, CA.
| | - Ingrid Parry
- Department of Occupational Therapy and Physical Therapy, Shriners Children's-Northern California, Sacramento, CA
| | - Miranda Yelvington
- Department of Rehabilitation, Arkansas Children's Hospital, Little Rock, AK
| | - Sandra Taylor
- Davis Clinical and Translational Science Center, University of California, Sacramento, CA
| | - David Greenhalgh
- Department of Burn Surgery, Shriners Children's-Northern California, Sacramento, CA
| | - Michelle A James
- Department of Orthopedics, Shriners Children's-Northern California, Sacramento, CA
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Palackic A, Rego A, Parry I, Sen S, Branski LK, Hallman TG, Spratt H, Lee JO, Herndon DN, Wolf SE, Suman OE. Effects of Aerobic Exercise in the Intensive Care Unit on Patient-Reported Physical Function and Mental Health Outcomes in Severely Burned Children-A Multicenter Prospective Randomized Trial. J Pers Med 2023; 13:455. [PMID: 36983636 PMCID: PMC10058069 DOI: 10.3390/jpm13030455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 03/05/2023] Open
Abstract
Severe burns are life-altering and can have lasting effects on patients' physical and mental health. Alterations in physical function, changes in appearance, and psychological disturbances resulting from severe burns are especially concerning in children, as they are still in the early stages of identity formation. Exercise in the nonburn population has been shown to improve quality of life and result in better physical and mental status. However, the effect of early exercise on the quality of life in pediatric burn patients requires more research. METHODS Forty-eight children between the ages of seven and seventeen with ≥30% total body surface area (TBSA) burn were randomized in a 1:2 fashion to receive treatment with standard-of-care (SOC) or standard-of-care plus exercise (SOC+Ex). Surveys administered at admission and discharge collected patient-reported information regarding physical and mental health outcomes. The results are given as means +/- standard deviation. Significance was set at p < 0.05. RESULTS The average age of the SOC and SOC+Ex groups were 12 ± 3 and 13 ± 4 years, respectively. The average %TBSA burned in the SOC and SOC+Ex groups were 54 ± 17 and 48 ± 14, respectively. The SOC+Ex group averaged 10 ± 9 exercise sessions (range of 1 to 38 sessions) with an attendance rate of 25% (10 sessions out of 40 BICU days). Both groups demonstrated significant improvement in patient-reported physical and mental outcomes during hospital admission (p < 0.05) However, additional exercise did not exhibit any additional benefits for measured levels. CONCLUSIONS Our recommendation is for all pediatric patients in the BICU to continue with the SOC and consult with their physician over the benefits of additional aerobic exercise. This study suggests that perhaps there is potential for increasing the amount of exercise that can be administered to pediatric burn survivors beyond SOC as we did not find aerobic exercise to be of any harm to any patients if it is performed properly and under supervision.
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Affiliation(s)
- Alen Palackic
- Department of Surgery, School of Medicine, University of Texas Medical Branch, Galveston, TX 77555, USA
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria
| | - Andrea Rego
- Department of Surgery, School of Medicine, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Ingrid Parry
- Department of Surgery, University of California, Davis, CA 95616, USA
| | - Soman Sen
- Department of Surgery, University of California, Davis, CA 95616, USA
| | - Ludwik K. Branski
- Department of Surgery, School of Medicine, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Taylor G. Hallman
- Department of Surgery, School of Medicine, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Heidi Spratt
- Department of Biostatistics and Data Science, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Jong O. Lee
- Department of Surgery, School of Medicine, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - David N. Herndon
- Oxford University Press, Wolters Kluwer N.V., 2400BA Alphen aan den Rijn, The Netherlands
| | - Steven E. Wolf
- Department of Surgery, School of Medicine, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Oscar E. Suman
- Department of Surgery, School of Medicine, University of Texas Medical Branch, Galveston, TX 77555, USA
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Cartotto R, Johnson L, Rood JM, Lorello D, Matherly A, Parry I, Romanowski K, Wiechman S, Bettencourt A, Carson JS, Lam HT, Nedelec B. Clinical Practice Guideline: Early Mobilization and Rehabilitation of Critically Ill Burn Patients. J Burn Care Res 2023; 44:1-15. [PMID: 35639543 DOI: 10.1093/jbcr/irac008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
This Clinical Practice Guideline addresses early mobilization and rehabilitation (EMR) of critically ill adult burn patients in an intensive care unit (ICU) setting. We defined EMR as any systematic or protocolized intervention that could include muscle activation, active exercises in bed, active resistance exercises, active side-to-side turning, or mobilization to sitting at the bedside, standing, or walking, including mobilization using assistance with hoists or tilt tables, which was initiated within at least 14 days of injury, while the patient was still in an ICU setting. After developing relevant PICO (Population, Intervention, Comparator, Outcomes) questions, a comprehensive literature search was conducted with the help of a professional medical librarian. Available literature was reviewed and systematically evaluated. Recommendations were formulated through the consensus of a multidisciplinary committee, which included burn nurses, physicians, and rehabilitation therapists, based on the available scientific evidence. No recommendation could be formed on the use of EMR to reduce the duration of mechanical ventilation in the burn ICU, but we conditionally recommend the use of EMR to reduce ICU-acquired weakness in critically ill burn patients. No recommendation could be made regarding EMR's effects on the development of hospital-acquired pressure injuries or disruption or damage to the skin grafts and skin substitutes. We conditionally recommend the use of EMR to reduce delirium in critically ill burn patients in the ICU.
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Affiliation(s)
- Robert Cartotto
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Laura Johnson
- Burns and Trauma, MedStar Washington Hospital Center, Georgetown University, Washington, DC, USA
| | - Jody M Rood
- Regions Hospital Burn Center, St. Paul, Minneapolis, USA
| | | | - Annette Matherly
- University of Utah Health Burn Center, Salt Lake City, Utah, USA
| | - Ingrid Parry
- Shriners Hospital for Children, Northern California, University of California at Davis, Sacramento, California, USA
| | - Kathleen Romanowski
- Firefighters Burn Institute Regional Burn Center, University of California at Davis, Sacramento, California, USA
| | - Shelley Wiechman
- Regional Burn Center at Harborview, University of Washington, Seattle, Washington, USA
| | | | | | - Henry T Lam
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Shupp JW, Holmes JH, Moffatt LT, Phelan HA, Sousse L, Romanowski KS, Jeschke M, Kowalske KJ, Badger K, Allely R, Cartotto R, Burmeister DM, Kubasiak JC, Wolf SE, Wallace KF, Gillenwater J, Schneider DM, Hultman CS, Wiechman SA, Bailey JK, Powell HM, Travis TE, Supp DM, Carney BC, Johnson LS, Johnson LS, Chung KK, Chung KK, Kahn SA, Gibson ALF, Christy RJ, Carter JE, Carson JS, Palmieri TL, Kopari NM, Blome-Eberwein SA, Hickerson WL, Parry I, Cancio JM, Suman O, Schulman CI, Lamendella R, Hill DM, Wibbenmeyer LA, Nygaard RM, Wagner AL, Carter ADW, Greenhalgh DG, Lawless MB, Carlson DL, Harrington DT. Proceedings of the 2021 American Burn Association State and Future of Burn Science Meeting. J Burn Care Res 2022; 43:1241-1259. [PMID: 35988021 DOI: 10.1093/jbcr/irac092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Periodically, the American Burn Association (ABA) has convened a State of the Science meeting on various topics representing multiple disciplines within burn care and research. In 2021 at the request of the ABA President, meeting development was guided by the ABA's Burn Science Advisory Panel (BSAP) and a subgroup of meeting chairs. The goal of the meeting was to produce both an evaluation of the current literature and ongoing studies, and to produce a research agenda and/or define subject matter-relevant next steps to advance the field(s). Members of the BSAP defined the topics to be addressed and subsequently solicited for nominations of expert speakers and topic leaders from the ABA's Research Committee. Current background literature for each topic was compiled by the meeting chairs and the library then enhanced by the invited topic and breakout discussion leaders. The meeting was held in New Orleans, LA on November 2nd and 3rd and was formatted to allow for 12 different topics, each with two subtopics, to be addressed. Topic leaders provided a brief overview of each topic to approximately 100 attendees, followed by expert-lead breakout sessions for each topic that allowed for focused discussion among subject matter experts and interested participants. The breakout and topic group leaders worked with the participants to determine research needs and associated next steps including white papers, reviews and in some cases collaborative grant proposals. Here, summaries from each topic area will be presented to highlight the main foci of discussion and associated conclusions.
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Palackic A, Abazie S, Parry I, Sen S, Mlack R, Lee J, Herndon D, Branski L, Wolf S, Spratt H, Suman O. Comparison of Six-Minute Walk Test and Modified Bruce Treadmill Test in Paediatric Patients With Severe Burns: A Cross-Over Study. J Rehabil Med 2022; 54:jrm00305. [PMID: 35801864 PMCID: PMC9593470 DOI: 10.2340/jrm.v54.1064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective To compare the six-minute walk test and the Modified Bruce treadmill test in paediatric patients with severe burns. Subjects A total of 67 children, aged 7–17 years, with severe burns. Methods Participants were assigned to perform the six-minute walk test and the Modified Bruce treadmill test in randomized order on discharge from acute burn care. Primary outcome measure was heart rate. Secondary outcome measures were distance walked, Borg’s CR-10 rate of perceived exertion, and maximal oxygen uptake (VO2). Results A total of 67 participants were enrolled. Thirty-eight patients completed both tests. The mean six-minute walk test maximum heart rate was 135 ± 19 bpm (range 97–180 bpm) and the mean Modified Bruce treadmill test maximum heart rate was 148 ± 24 bpm (range 100–197 bpm; p ≤ 0.05), with a weak positive correlation of R² = 0.14. The mean six-minute walk test maximum distance was 294 ± 124 m (range 55 to 522 m) while the mean Modified Bruce treadmill test maximum distance was 439 ± 181 m (range 53 to 976 m; p ≤ 0.05), with no correlation of R² = 0.006. The mean RPE CR-10 score for the six-minute walk test was 3 ± 2.5 (range 0–10) vs a mean RPE CR-10 score of 10 ± 0 for the Modified Bruce treadmill test. Conclusion The Modified Bruce treadmill test challenges the cardiorespiratory system significantly more than the six-minute walk test, as reflected by maximum heart rate measurements, and the perception of effort (i.e. rate of perceived exertion) by the patient. When possible, the Modified Bruce treadmill test should be used to assess cardiovascular functional capacity. However, the six-minute walk test may be more clinically feasible for use with paediatric patients with burns, and provides information about submaximal functional exercise capacity.
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Chao T, Parry I, Palackic A, Sen S, Spratt H, Mlcak RP, Lee JO, Herndon DN, Wolf SE, Branski LK, Suman OE. The effects of short bouts of ergometric exercise for severely burned children in intensive care: A randomized controlled trial. Clin Rehabil 2022; 36:1052-1061. [PMID: 35473409 PMCID: PMC9420547 DOI: 10.1177/02692155221095643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine the effects of short bouts of ergometric exercises on the number of days in the burn intensive care unit (ICU), body mass, and functional ambulation. DESIGN Multi-center, randomized controlled trial. SETTING Burn intensive care unit. PARTICIPANTS Children ages 7-17 with severe burns covering over 30% total body surface area (TBSA). INTERVENTION All patients received standard of care (Control) with the experimental group receiving additional exercise with a cycle ergometer (Exercise). MAIN MEASURES The number of days in the ICU, total weight, lean body mass (LBM), and functional ambulation were taken shortly after randomization and again within one week of the scheduled hospital discharge. Results of outcomes are expressed as median ± interquartile range (IQR), unless otherwise noted (e.g. demographics). RESULTS Fifty-four severely burned children (n = 18 Control, n = 36 Exercise) were included. The average ± standard deviation for age was 12 ± 3 years and TBSA was 48 ± 16%. The median ± IQR ICU days for Control was 46 ± 51 days vs 31 ± 29 days for Exercise. The median total weight loss for Control was 2.2 ± 1.2 kg vs 1.8 ± 1.4 kg in Exercise. Control lost 0.75 ± 0.8 kg of LBM vs 0.46 ± 0.43 kg in Exercise. Both groups showed significant improvement in functional ambulation (p < 0.01). However, exercise did not add additional benefits. CONCLUSION Short bouts of ergometric exercises are feasible for severely burned patients while receiving care in the ICU but did not add additional benefits.
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Affiliation(s)
- Tony Chao
- Department of Physical Therapy, School of Health Professions, 12338University of Texas Medical Branch, Galveston, TX, USA
| | - Ingrid Parry
- 8789University of California-Davis, Shriners Children's Northern California Hospital, Sacramento, CA, USA
| | - Alen Palackic
- Department of Surgery, School of Medicine, 12338University of Texas Medical Branch, Galveston, TX, USA.,Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, 31475Medical University of Graz, Graz, Austria
| | - Soman Sen
- 8789University of California-Davis, Shriners Children's Northern California Hospital, Sacramento, CA, USA
| | - Heidi Spratt
- Office of Biostatistics, 351229Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, TX, USA
| | - Ronald P Mlcak
- 24174Shriners Children's Texas Hospital, Galveston, TX, USA
| | - Jong O Lee
- Department of Surgery, School of Medicine, 12338University of Texas Medical Branch, Galveston, TX, USA
| | - David N Herndon
- 276672Joseph Still Burn Research Foundation, Journal of Burn Care and Research, Augusta, USA
| | - Steven E Wolf
- Department of Surgery, School of Medicine, 12338University of Texas Medical Branch, Galveston, TX, USA
| | - Ludwik K Branski
- Department of Surgery, School of Medicine, 12338University of Texas Medical Branch, Galveston, TX, USA
| | - Oscar E Suman
- Department of Surgery, School of Medicine, 12338University of Texas Medical Branch, Galveston, TX, USA
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11
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Yelvington ML, Parry I, James M, Bettencourt K, Taylor S, Greenhalgh D. 65 Therapist Confidence Utilizing Virtual Range of Motion Methods. J Burn Care Res 2022. [PMCID: PMC8945750 DOI: 10.1093/jbcr/irac012.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction Since the SARS-CoV-2 virus (COVID-19) was officially declared a pandemic, there has been a marked increase in virtual clinical care. Between 2019 and 2020, telehealth (TH) visits, including tele-rehabilitation (TR), increased from 11% to 46%. While many therapy interventions can be performed with verbal guidance or demonstration, objective tool-based outcomes such as goniometrics , a valuable tool to determine burn survivor progress, have proved more challenging. The purpose of this study was to evaluate the level of confidence of therapists using three different remote methods of measuring finger range of motion (ROM). Methods Therapists evaluated finger ROM position of a mannequin model via a simulated TH visit using three different methods: Goniometry (GON), Visual Estimation (VE), and Electronic Protractor (EP). Pre and post-questionnaires were used to assess the participant’s experiences and comfort with each method of measurement. Descriptive statistics are used to report clinician opinions. A linear mixed effect model was used to determine the interaction of bias as a function of clinician characteristics (i.e., experience, familiarity, etc.). Results A total of 30 therapists and one hand surgeon participated. All reported some (30%) or a lot (70%) of familiarity with standard GON, and most reported some (30%)or a lot (40%) of familiarity with finger-specific goniometry. Post-testing, clinicians reported VE (80%) as the most difficult method and EP (73%) as the easiest. Only 7% reported feeling more confident with TR compared to in-person measurements, 27% felt equally confident, and 67% felt less confident. The average time to conduct the remote assessment measurement was 11:45 minutes using GON, 4:27 minutes using VE and 9:47 minutes using EP. There was not a significant relationship between performance bias and years of experience (p=0.587), familiarity with GON (p=0.406), familiarity with finger GON (p=0.709) or profession (p=0.281). Conclusions Despite the transition to virtual care, the mandate for valid and accurate documentation of functional outcome measures, including ROM, remains. Our study showed that the tools used for TR may not be the same as for in-person and clinicians need to adapt their approaches and skillsets. In addition, training with these new tools is essential for clinician confidence. In addition, there was not a relationship between experience and performance, suggesting that TR joint measurement is accessible to clinicians of all experience levels with proper training.
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Affiliation(s)
- Miranda L Yelvington
- Arkansas Children’s Hospital, Little Rock, Arkansas; Shriners Hospitals for Children Northern California, Sacramento, California; Shriners Hospital for Children, Northern California, Sacramento, California; Shriners Hospital for Children, Northern California, Sacramento, California; University of California, Davis, Sacramento, California
| | - Ingrid Parry
- Arkansas Children’s Hospital, Little Rock, Arkansas; Shriners Hospitals for Children Northern California, Sacramento, California; Shriners Hospital for Children, Northern California, Sacramento, California; Shriners Hospital for Children, Northern California, Sacramento, California; University of California, Davis, Sacramento, California
| | - Michelle James
- Arkansas Children’s Hospital, Little Rock, Arkansas; Shriners Hospitals for Children Northern California, Sacramento, California; Shriners Hospital for Children, Northern California, Sacramento, California; Shriners Hospital for Children, Northern California, Sacramento, California; University of California, Davis, Sacramento, California
| | - Kory Bettencourt
- Arkansas Children’s Hospital, Little Rock, Arkansas; Shriners Hospitals for Children Northern California, Sacramento, California; Shriners Hospital for Children, Northern California, Sacramento, California; Shriners Hospital for Children, Northern California, Sacramento, California; University of California, Davis, Sacramento, California
| | - Sandra Taylor
- Arkansas Children’s Hospital, Little Rock, Arkansas; Shriners Hospitals for Children Northern California, Sacramento, California; Shriners Hospital for Children, Northern California, Sacramento, California; Shriners Hospital for Children, Northern California, Sacramento, California; University of California, Davis, Sacramento, California
| | - David Greenhalgh
- Arkansas Children’s Hospital, Little Rock, Arkansas; Shriners Hospitals for Children Northern California, Sacramento, California; Shriners Hospital for Children, Northern California, Sacramento, California; Shriners Hospital for Children, Northern California, Sacramento, California; University of California, Davis, Sacramento, California
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12
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Bui T, Parry I, Ng PW, Romanowski KS, Palmieri TL, Greenhalgh D, Sen S. 67 Transient Dysphagia After Burn Injury in Children: An Under-identified Problem. J Burn Care Res 2022. [PMCID: PMC8945510 DOI: 10.1093/jbcr/irac012.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Introduction Severely burn injured pediatric patients are at risk of dysphagia (difficulty swallowing) due to prolonged intubation or tracheostomy placement. To improve the early identification and treatment of dysphagia, we implemented a swallowing assessment protocol. We hypothesized that the swallowing assessment protocol is effective for identifying and treating dysphagia after prolonged intubation. Methods Between October 2016 and December 2020, pediatric burn patients with facial burn injuries, prolonged mechanical ventilation, tracheostomy, inhalation injury and/or anoxic events were placed on the swallowing protocol. The protocol included a Transitional Swallow Screen (TSS) performed within 24 hours after extubation or decanulation by an advanced practice swallow occupational therapist. If signs of dysphagia were noted, recommendations on diet consistency and treatment for positioning and feeding were implemented. Regular reassessments continued until the patient was determined to have regained premorbid swallowing function. Data on patient demographics, burn characteristics, dysphagia, treatment and outcome were collected. Descriptive statistics were used to describe the population, treatments and outcome. Results A total of 33 pediatric burn patients were included. Mean age was 8.1±5.9 years and TBSA was 48.1±26.8%. Median time from injury to swallow assessment was 45 (21-81) days. The majority of patients suffered from flame burns (70%). Almost all of the patients were intubated (97%) and 85% underwent a tracheostomy. Patients had a facial burn (73%), inhalation injury (24%) or anoxic injury (15%). Transient dysphagia was diagnosed in 79% of patients. Subsequent therapeutic procedures as a result of the TSS included: neurologic re-education (30%), swallow therapy exercises (55%), desensitization (42%), and patient/ family training and supervision (79%). All patients eventually returned to normal swallow and regular diet. This occurred at an average of 72.5+46.7 days post injury and 8.2+18.0 days post swallow assessment. Conclusions Pediatric patients with substantial burn injury may not only be at risk for aspiration but also have other forms of dysphasia that require intervention. Implementation of a swallowing protocol can identify patients who required further therapeutic intervention and can guide the recovery of safe swallowing and functional oral intake.
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Affiliation(s)
- Trang Bui
- Shriners Hospitals for Children Northern California, Sacramento, California; Shriners Hospitals for Children Northern California, Sacramento, California; Shriners Hospital for Children - Northern CA, Sacramento, California; University of California, Davis and Shriners Hospitals for California Northern California, Sacramento, California; UC Davis and Shriners Hospitals for Children Northern Califo
| | - Ingrid Parry
- Shriners Hospitals for Children Northern California, Sacramento, California; Shriners Hospitals for Children Northern California, Sacramento, California; Shriners Hospital for Children - Northern CA, Sacramento, California; University of California, Davis and Shriners Hospitals for California Northern California, Sacramento, California; UC Davis and Shriners Hospitals for Children Northern Califo
| | - Pauline W Ng
- Shriners Hospitals for Children Northern California, Sacramento, California; Shriners Hospitals for Children Northern California, Sacramento, California; Shriners Hospital for Children - Northern CA, Sacramento, California; University of California, Davis and Shriners Hospitals for California Northern California, Sacramento, California; UC Davis and Shriners Hospitals for Children Northern Califo
| | - Kathleen S Romanowski
- Shriners Hospitals for Children Northern California, Sacramento, California; Shriners Hospitals for Children Northern California, Sacramento, California; Shriners Hospital for Children - Northern CA, Sacramento, California; University of California, Davis and Shriners Hospitals for California Northern California, Sacramento, California; UC Davis and Shriners Hospitals for Children Northern Califo
| | - Tina L Palmieri
- Shriners Hospitals for Children Northern California, Sacramento, California; Shriners Hospitals for Children Northern California, Sacramento, California; Shriners Hospital for Children - Northern CA, Sacramento, California; University of California, Davis and Shriners Hospitals for California Northern California, Sacramento, California; UC Davis and Shriners Hospitals for Children Northern Califo
| | - David Greenhalgh
- Shriners Hospitals for Children Northern California, Sacramento, California; Shriners Hospitals for Children Northern California, Sacramento, California; Shriners Hospital for Children - Northern CA, Sacramento, California; University of California, Davis and Shriners Hospitals for California Northern California, Sacramento, California; UC Davis and Shriners Hospitals for Children Northern Califo
| | - Soman Sen
- Shriners Hospitals for Children Northern California, Sacramento, California; Shriners Hospitals for Children Northern California, Sacramento, California; Shriners Hospital for Children - Northern CA, Sacramento, California; University of California, Davis and Shriners Hospitals for California Northern California, Sacramento, California; UC Davis and Shriners Hospitals for Children Northern Califo
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13
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Parry I. Introduction to innovative solutions in burn rehabilitation from around the world. Burns Open 2021. [DOI: 10.1016/j.burnso.2021.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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14
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Parry I. Mouth stretching devices. Burns Open 2021. [DOI: 10.1016/j.burnso.2021.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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15
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Parry I. Adhesive crescent strips to manage eyelid ectropion during sleep. Burns Open 2021. [DOI: 10.1016/j.burnso.2021.08.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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16
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Parry I. Strategies for facial exercises with children. Burns Open 2021. [DOI: 10.1016/j.burnso.2021.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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17
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Khor D, Liao J, Fleishhacker Z, Schneider JC, Parry I, Kowalske K, Richard R, Wibbenmeyer L. Update on the practice of splinting during acute burn admission from the ACT study. J Burn Care Res 2021; 43:640-645. [PMID: 34490885 DOI: 10.1093/jbcr/irab161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Burn scar contracture (BSC) is a common pathological outcome following burn injuries, leading to limitations in range of motion (ROM) of affected joints and impairment in function. Despite a paucity of research addressing its efficacy, static splinting of affected joints is a common preventative practice. A survey of therapists performed 25 years ago showed a widely divergent practice of splinting during the acute burn injury. We undertook this study to determine the current practice of splinting during the index admission for burn injuries. METHODS This is a review of a subset of patients enrolled in the Burn Patient Acuity Demographics, Scar Contractures and Rehabilitation Treatment Related to Patient Outcome Study (ACT) database. ACT was an observational multicenter study conducted from 2010-2013. The most commonly splinted joints (elbow, wrist, knee and ankle) and their 7 motions were included. Variables included patients' demographics, burn variables, rehabilitation treatment and hospital course details. Univariate and multivariate analysis of factors related to splinting was performed. P< 0.05 was significant. RESULTS Thirty percent of the study population (75 patients) underwent splinting during their hospitalization. Splinting was associated with larger burns and increased injury severity on the patient level and increased involvement with burns requiring grafting in the associated cutaneous functional unit (CFU) on the joint level. The requirement for skin grafting in both analyses remained independently related to splinting, with requirement for grafting in the associated CFU increasing the odds of splinting 6 times (OR =6.0, 95% CI=3.8-9.3, p<0.001). On average splinting was initiated about a third into the hospital length of stay (LOS, 35 ± 21% of LOS) and splints were worn for 50% (50 ± 26%) of the LOS. Joints were splinted for an average 15.1 ± 4.8 hours a day. The wrist was most frequently splinted joint being splinted with one third of wrists splinted ( 30.7%) while the knee was the least frequently splinted joint with 8.2% splinted. However, when splinted, the knee was splinted the most hours per day (17.6 ± 4.8 hours) and the ankle the least (14.4 ± 4.6 hours). Almost one third had splinting continued to discharge (20, 27%). CONCLUSIONS The current practice of splinting, especially the initiation, hours of wear and duration of splinting following acute burn injury remains variable. Splinting is independently related to grafting, grafting in the joint CFU, larger CFU involvement and is more likely to occur around the time of surgery. A future study looking at splinting application and its outcomes is warranted.
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Affiliation(s)
- Desmond Khor
- Department of Surgery, University of Iowa Hospitals and Clinics
| | - Junlin Liao
- Department of Surgery, University of Iowa Hospitals and Clinics
| | | | - Jeffrey C Schneider
- Spaulding Rehabilitation Hospital, Spaulding Research Institute, Department of Physical Medicine and Rehabilitation, Harvard Medical School
| | - Ingrid Parry
- Department of Occupational and Physical Therapy, Shriners Hospital for Children, Northern California, University of California, Davis
| | - Karen Kowalske
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern
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18
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Yelvington M, Godleski M, Lee AF, Goverman J, Parry I, Herndon DN, Suman OE, Kowalske K, Holavanahalli R, Gibran NS, Esselman PC, Ryan CM, Schneider JC. Contracture Severity at Hospital Discharge in Children: A Burn Model System Database Study. J Burn Care Res 2021; 42:425-433. [PMID: 33247583 DOI: 10.1093/jbcr/iraa169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Contractures can complicate burn recovery. There are limited studies examining the prevalence of contractures following burns in pediatrics. This study investigates contracture outcomes by location, injury, severity, length of stay, and developmental stage. Data were obtained from the Burn Model System between 1994 and 2003. All patients younger than the age of 18 with at least one joint contracture at hospital discharge were included. Sixteen areas of impaired movement from the shoulder, elbow, wrist, hand, hip, knee, and ankle joints were examined. Analysis of variance was used to assess the association between contracture severity, burn size, and length of stay. Age groupings were evaluated for developmental patterns. A P value of less than .05 was considered statistically significant. Data from 225 patients yielded 1597 contractures (758 in the hand) with a mean of 7.1 contractures (median 4) per patient. Mean contracture severity ranged from 17% (elbow extension) to 41% (ankle plantarflexion) loss of movement. Statistically significant associations were found between active range of motion loss and burn size, length of stay, and age groupings. The data illustrate quantitative assessment of burn contractures in pediatric patients at discharge in a multicenter database. Size of injury correlates with range of motion loss for many joint motions, reflecting the anticipated morbidity of contracture for pediatric burn survivors. These results serve as a potential reference for range of motion outcomes in the pediatric burn population, which could serve as a comparison for local practices, quality improvement measures, and future research.
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Affiliation(s)
| | | | - Austin F Lee
- Massachusetts General Hospital, Boston.,University of Massachusetts Medical School, Worcester
| | - Jeremy Goverman
- Massachusetts General Hospital, Harvard Medical School, Boston
| | - Ingrid Parry
- Shriners Hospital for Children, Northern California/UC Davis Medical Center, Sacramento
| | - David N Herndon
- University of Texas Medical Branch, Shriners Hospitals for Children, Galveston
| | - Oscar E Suman
- University of Texas Southwestern Medical Center, Dallas
| | | | | | | | | | - Colleen M Ryan
- Massachusetts General Hospital, Shriners Hospitals for Children, Boston
| | - Jeffrey C Schneider
- Spaulding Rehabilitation Hospital, Spaulding Research Institute and Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
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19
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Valladares-Poveda S, Avendaño-Leal O, Castillo-Hidalgo H, Murillo E, Palma C, Parry I. A comparison of two scar massage protocols in pediatric burn survivors. Burns 2020; 46:1867-1874. [PMID: 32532477 DOI: 10.1016/j.burns.2020.05.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/15/2020] [Accepted: 05/14/2020] [Indexed: 11/29/2022]
Abstract
The current evidence to support the use of massage for scar management is conflicting in the literature. The purpose of this study was to compare two scar massage protocols administered with pediatric burn survivors to determine if a more structured and standardized approach to scar massage could improve outcome. A retrospective review of the medical records of 100 children who received massage during the time period when two different protocols were implemented was conducted and data that was collected as part of the clinical exam regarding scar height, vascularity, pliability, itch and pain were extracted. Comparisons were made within subject for scar changes from baseline to follow up and between subjects receiving Protocol A and those receiving Protocol B for the same scar characteristics. Versions of the Vancouver Scar Scale were used to assess scars, while visual analogue scale, Itch Man Scale and Wong-Baker Faces Pain Scale were used to assess itch and pain. Results demonstrated improvements in itch and vascularity over time with both scar massage protocols. However, when comparing patients who received Protocol A to those who received Protocol B, there was no difference found in scar height, vascularity, pliability, itch or pain. Using commonly applied subjective scar assessment tools, we did not find clinically meaningful changes in scar characteristics with the implementation of a structured scar massage program compared to a general approach to massage. Further research is needed to better define the impact of massage on the recovery experience for burn survivors.
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Affiliation(s)
| | - Oneyda Avendaño-Leal
- APROQUEN, Department of Physiotherapy and Occupational Therapy, Managua, Nicaragua
| | | | - Evelyn Murillo
- APROQUEN, Department of Physiotherapy and Occupational Therapy, Managua, Nicaragua
| | - Carmen Palma
- APROQUEN, Department of Physiotherapy and Occupational Therapy, Managua, Nicaragua
| | - Ingrid Parry
- Shriners Hospital for Children, Northern California, Department of Physical and Occupational Therapy, 2425 Stockton Blvd., Sacramento, CA 95817, United States.
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20
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Abstract
There is a clinical trend toward "early mobilization" of patients with burn injury, however mobility is not well defined in burn care. Burn injuries result in various extents of injury, body areas affected, and types of skin graft surgeries needed-all of which may influence the type, timing, safety, and outcome of mobilization activities. This study surveyed burn clinicians to determine current mobility practices and the influence of skin graft surgery on clinical decisions to mobilize patients. A 32-question survey was electronically distributed to burn clinicians and included questions about postoperative range of motion (ROM) and out of bed (OOB) mobility practices for various skin graft types and locations. For all types of grafts on all body locations, the average time after skin graft surgery that patients resumed ROM activities was postoperative day (POD) 3.87 (±2.04) while OOB mobility resumed on POD 2.54 (±1.38). There was significantly greater variability for OOB mobility compared to ROM (coefficient of variation [CV] 0.71 ± 0.8 vs 0.5 ± 0.05). Time to postoperative ROM was significantly different depending on the type of skin graft placed with sheet skin grafts resuming ROM the earliest. Time to OOB mobility after surgery was significantly different for different body locations with grafts placed above the waist resuming OOB mobility earliest. This study provides a summary of current mobility practices and serves as a foundation for future studies investigating the optimal timing and practical application of mobility protocols that may influence safety and outcome of burn survivors.
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Affiliation(s)
- Ingrid Parry
- Shriners Hospital for Children, Northern California, Sacramento
| | - Soman Sen
- Shriners Hospital for Children, Northern California, Sacramento
| | - Tina Palmieri
- Shriners Hospital for Children, Northern California, Sacramento
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21
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Cambiaso-Daniel J, Parry I, Rivas E, Kemp-Offenberg J, Sen S, Rizzo JA, Serghiou MA, Kowalske K, Wolf SE, Herndon DN, Suman OE. Strength and Cardiorespiratory Exercise Rehabilitation for Severely Burned Patients During Intensive Care Units: A Survey of Practice. J Burn Care Res 2020; 39:897-901. [PMID: 29579311 DOI: 10.1093/jbcr/iry002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Minimizing the deconditioning of burn injury through early rehabilitation programs (RP) in the intensive care unit (ICU) is of importance for improving the recovery time. The aim of this study was to assess current standard of care (SOC) for early ICU exercise programs in major burn centers. We designed a survey investigating exercise RP on the ICU for burn patients with >30% total burned surface area. The survey was composed of 23 questions and submitted electronically via SurveyMonkey® to six major (pediatric and adult) burn centers in Texas and California. All centers responded and reported exercise as part of their RP on the ICU. The characteristics of exercises implemented were not uniform. All centers reported to perform resistive and aerobic exercises but only 83% reported isotonic and isometric exercises. Determination of intensity of exercise varied with 50% of centers using patient tolerance and 17% using vital signs. Frequency of isotonic, isometric, aerobic, and resistive exercise was reported as daily by 80%, 80%, 83%, and 50% of centers, respectively. Duration for all types of exercises was extremely variable. Mobilization was used as a form of exercise by 100% of burn centers. Our results demonstrate that although early RP seem to be integral during burn survivor's ICU stay, no SOC exists. Moreover, early RP are inconsistently administered and large variations exist in frequency, intensity, duration, and type of exercise. Thus, future prospective studies investigating the various components of exercise interventions are needed to establish a SOC and determine how and if early exercise benefits the burn survivor.
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Affiliation(s)
- Janos Cambiaso-Daniel
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, Texas.,Department of Surgery, Division of Plastic, Aesthetic and Reconstructive Surgery, Medical University of Graz, Austria
| | - Ingrid Parry
- Shriners Hospitals for Children, Northern California, Sacramento, California
| | - Eric Rivas
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, Texas.,Department of Kinesiology and Sport Management, Texas Tech University, Lubbock, Texas
| | - Jennifer Kemp-Offenberg
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, Texas
| | - Soman Sen
- Department of Kinesiology and Sport Management, Texas Tech University, Lubbock, Texas.,Department of Surgery, Division for Burn Surgery, University of California, Davis, California
| | - Julie A Rizzo
- The United States Army Institute of Surgical Research, San Antonio, Texas.,Uniformed Services University of Health Sciences, Bethesda MD
| | | | - Karen Kowalske
- University of Texas Southwest Medical Center, Dallas, Texas
| | - Steven E Wolf
- University of Texas Southwest Medical Center, Dallas, Texas
| | - David N Herndon
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, Texas
| | - Oscar E Suman
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, Texas
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22
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Benavides L, Shie V, Yee B, Yelvington M, Simko LC, Wolfe AE, McMullen K, Epp J, Parry I, Shon R, Holavanahalli R, Herndon D, Rosenberg M, Rosenberg L, Meyer W, Gibran N, Wiechman S, Ryan CM, Schneider JC. An Examination of Follow-up Services Received by Vulnerable Burn Populations: A Burn Model System National Database Study. J Burn Care Res 2020; 41:377-383. [PMID: 31710682 DOI: 10.1093/jbcr/irz185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
While disparities in healthcare outcomes and services for vulnerable populations have been documented, the extent to which vulnerable burn populations demonstrate disparities in long-term care is relatively underexplored. This study's goal was to assess for differences in long-term occupational or physical therapy (OT/PT) and psychological service use after burn injury in vulnerable populations. Data from the Burn Model System National Database (2006-2015) were analyzed. The vulnerable group included participants in one or more of these categories: 65 years of age or older, nonwhite, no insurance or Medicaid insurance, preinjury receipt of psychological therapy or counseling, preinjury alcohol and/or drug misuse, or with a preexisting disability. Primary outcomes investigated were receipt of OT/PT and psychological services. Secondary outcomes included nine OT/PT subcategories. Outcomes were examined at 6, 12, and 24 months postinjury. One thousand one hundred thirty-six burn survivors (692 vulnerable; 444 nonvulnerable) were included. The vulnerable group was mostly female, unemployed at time of injury, and with smaller burns. Both groups received similar OT/PT and psychological services at all time points. Adjusted regression analyses found that while the groups received similar amounts services, some vulnerable subgroups received significantly more services. Participants 65 years of age or older, who received psychological therapy or counseling prior to injury, and with a preexisting disability received more OT/PT and psychological or peer support services at follow-up. Overall, vulnerable and nonvulnerable groups received comparable OT/PT and psychological services. The importance of long-term care among vulnerable subgroups of the burn population is highlighted by this study. Future work is needed to determine adequate levels of follow-up services.
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Affiliation(s)
- Lynne Benavides
- Rhode Island Burn Center, Rhode Island Hospital, Providence, Rhode Island
| | - Vivian Shie
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, Massachusetts
| | - Brennan Yee
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, Massachusetts
| | - Miranda Yelvington
- Department of Rehabilitation, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Laura C Simko
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, Massachusetts
| | - Audrey E Wolfe
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, Massachusetts
| | | | - Janelle Epp
- Burnett Burn Center, University of Kansas Health System, Kansas City, Kansas
| | - Ingrid Parry
- University of California Davis and Shriners Hospitals for Children - Northern California; Sacramento, California
| | | | - Radha Holavanahalli
- Department of Physical Medicine and Rehabilitation, UT Southwestern Medical Center, Dallas, Texas
| | - David Herndon
- University of Texas Medical Branch, Shriners Hospitals for Children - Galveston, Texas
| | - Marta Rosenberg
- University of Texas Medical Branch, Shriners Hospitals for Children - Galveston, Galveston, Texas
| | - Laura Rosenberg
- University of Texas Medical Branch, Shriners Hospitals for Children - Galveston, Texas
| | - Walter Meyer
- University of Texas Medical Branch, Shriners Hospitals for Children - Galveston, Texas
| | - Nicole Gibran
- University of Texas Medical Branch, Shriners Hospitals for Children - Galveston, Galveston, Texas
| | - Shelley Wiechman
- University of Texas Medical Branch, Shriners Hospitals for Children - Galveston, Galveston, Texas
| | - Colleen M Ryan
- Department of Surgery, Massachusetts General Hospital, Shriners Hospitals for Children - Boston, Massachusetts
| | - Jeffrey C Schneider
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, Massachusetts
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23
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Lensing J, Wibbenmeyer L, Liao J, Parry I, Kowalske K, Reg R, Schneider JC. Demographic and Burn Injury-Specific Variables Associated with Limited Joint Mobility at Discharge in a Multicenter Study. J Burn Care Res 2020; 41:363-370. [DOI: 10.1093/jbcr/irz174] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Abstract
Burn scar contractures. Existing research on contractures is limited by incomplete analysis of potential contributing variables and differing protocols. This study expands the exploration of contributing variables to include surgery and rehabilitation treatment-related factors. Additionally, this study quantifies direct patient therapy time and patient exposure to rehabilitation prevention therapies. Data from subjects enrolled in the prospective Burn Patient Acuity Demographics, Scar Contractures and Rehabilitation Treatment Related to Patient Outcome Study (ACT) were analyzed to determine variables related to a limited range of motion (limROM) in seven joints and 18 motions (forearm supination) at discharge. Chi-squared and Student’s t-test were used accordingly. Multivariate analysis was performed at the patient and joint motion level to control for confounders. Of the 300-member study group, 259 (86.3%) patients had limROM at discharge. Variables independently related to the development of moderate-to-severe limROM on the patient level were larger TBSA, having skin grafted and prolonged bed rest. Variables independently related to moderate–severe limROM on the joint motion level were the percentage of cutaneous functional unit (CFU) burned (P = .044), increase in the length of stay, weight gain, poor compliance with rehabilitation therapy and lower extremity joint burns. Rates of limROM are increased in patients who had larger burns, required surgery, had a greater percentage of the associated CFU burned, and had lower extremity burns. Attention to adequate pain control to ensure rehabilitation tolerance and early ambulation may also decrease limROM at discharge and quicker return to pre-burn activities and employment.
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Affiliation(s)
- Jonathan Lensing
- Department of Surgery, Acute Surgery Division, University of Iowa, Iowa City, IA, USA
| | - Lucy Wibbenmeyer
- Department of Surgery, Acute Surgery Division, University of Iowa, Iowa City, IA, USA
| | - Junlin Liao
- Department of Surgery, Acute Surgery Division, University of Iowa, Iowa City, IA, USA
| | - Ingrid Parry
- Department of Surgery, Acute Surgery Division, University of Iowa, Iowa City, IA, USA
| | - Karen Kowalske
- Department of Surgery, Acute Surgery Division, University of Iowa, Iowa City, IA, USA
| | - Richard Reg
- Department of Surgery, Acute Surgery Division, University of Iowa, Iowa City, IA, USA
| | - Jeffrey C Schneider
- Department of Surgery, Acute Surgery Division, University of Iowa, Iowa City, IA, USA
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Parry I, Richard R, Aden JK, Yelvington M, Ware L, Dewey W, Jacobson K, Caffrey J, Sen S. Goniometric Measurement of Burn Scar Contracture: A Paradigm Shift Challenging the Standard. J Burn Care Res 2019; 40:377-385. [DOI: 10.1093/jbcr/irz038] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
ABSTRACT
Standard goniometry is the most commonly used method of assessing the range of motion (ROM) in patients with burn scar contracture. However, standard goniometry was founded on arthrokinematic principles and doesn’t consider the cutaneous biomechanical influence between adjacent joint positions and skin pliability to accommodate motion. Therefore, the use of standard goniometry to measure burn scar contracture is called into question. This prospective, multicenter, comparative study investigated the difference between standard goniometry, based on arthrokinematics and a revised goniometry protocol, based on principles of cutaneokinematics and functional positions to measure ROM outcome in burn survivors. Data were collected for 174 joints from 66 subjects at seven burn centers totaling 1044 measurements for comparison. ROM findings using the revised protocol demonstrated significantly more limitation in motion 38.8 ± 15.2% than the standard protocol 32.1 ± 13.4% (p < .0001). Individual analyses of the motions likewise showed significantly more limitation with revised goniometry compared with standard goniometry for 9/11 joint motions. Pearson’s correlation showed a significant positive correlation between the percentage of cutaneous functional units scarred and ROM outcome for the revised protocol (R2 = .05, p = .0008) and the Δ between the revised and standard protocols (R2 = .04, p = .0025) but no correlation was found with the standard goniometric protocol (R2 = .015, p = .065). The results of this study support the hypothesis that standard goniometry underestimates the ROM impairment for individuals whose motion is limited by burn scars. Having measurement methods that consider the unique characteristics of skin impairment and the impact on functional positions is an important priority for both clinical reporting and future research in burn rehabilitation.
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Affiliation(s)
- Ingrid Parry
- Department of Surgery, University of California, Davis, Sacramento
| | - Reg Richard
- US Army Institute of Surgical Research, San Antonio Texas (Retired)
| | - James K Aden
- Department of Graduate Medical Education, Brooks Army Medical Center, San Antonio, Texas
| | | | - Linda Ware
- Rehabilitation Services Department, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - William Dewey
- Department of the Army, U.S. Army Institute of Surgical Research, San Antonio, Texas
| | - Keith Jacobson
- Rehabilitation Therapy Services Department, North Carolina Jaycee Burn Center at UNC Healthcare,Chapel Hill
| | - Julie Caffrey
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Soman Sen
- Department of Surgery, University of California, Davis, Sacramento
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Mulcahey MJ, Thielen CC, Sadowsky C, Silvestri JL, Martin R, White L, Cagney JA, Vogel LC, Schottler J, Davidson L, Parry I, Taylor HB, Higgins K, Feltz ML, Sinko R, Bultman J, Mazurkiewicz J, Gaughan J. Despite limitations in content range, the SCIM-III is reproducible and a valid indicator of physical function in youths with spinal cord injury and dysfunction. Spinal Cord 2017; 56:332-340. [PMID: 29269778 DOI: 10.1038/s41393-017-0036-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 10/30/2017] [Accepted: 10/31/2017] [Indexed: 11/10/2022]
Abstract
STUDY DESIGN Multi-center, repeated measures OBJECTIVES: Evaluate psychometric properties of the SCIM-III in children. SETTING Seven facilities in North America METHODS: One-hundred and twenty-seven youths, mean age of 10.8 years and chronic spinal cord injury/dysfunction completed two administrations of the Spinal Cord Independence Measure-III (SCIM-III). Mean, standard deviation, range values were calculated for SCIM-III total and subscales for the entire sample, four age groups and injury characteristics. Test-retest reliability, concurrent validity, and floor and ceiling effects were examined. RESULTS Total SCIM-III and self-care (SC) subscale scores for the youngest age group were lower than those for the three older age groups. There were statistically significant differences in SC subscale scores between neurological level (NL) C5-T1 and T2 -T12; C5-T1 and L1-S4/5; and T2-T12 and L1-S4/5 and in in-room, and indoor/outdoor mobility subscale scores between C1-C4 and T2-T12; C1-C4 and L1-S4/5; C5-T1 and T2-T12; C5-T1 and L1-S4/5; and T2-T12 and L1-S4/5. All scores between motor complete and motor incomplete differed. Test-retest reliability was good (ICC values = > 0.84) and there was moderate to strong correlation between SCIM-III and the FIM® Instrument (r = 0.77-0.92). Ceiling effects were present in the SC subscale for the oldest age group (24%) and for NL L1-S4/5 (35.5%) and in in-room mobility subscale for 6-12 (45.7%), 13-15 (30.43%) and 16-17 (60%) ages, paraplegia (42.4%), tetraplegia (37.1%), incomplete injuries (50%), and T2-T12 (38%) and L1-S4/5 (100%) NL. CONCLUSION Despite limitations in content range, the SCIM-III is reproducible, and a valid indicator of physical functioning in youth with SCI/D 6 years of age and older. SPONSORSHIP The study was funded by the Craig H. Neilsen Foundation, Spinal Cord Injury Research on the Translation Spectrum, Senior Research Award Grant #282592 (Mulcahey, PI).
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Affiliation(s)
- M J Mulcahey
- Thomas Jefferson University, Philadelphia, PA, USA. .,Shriners Hospitals for Children, Philadelphia, PA, USA.
| | | | | | | | - Rebecca Martin
- Kennedy Krieger Rehabilitation Institute, Baltimore, MD, USA
| | - Lauren White
- Kennedy Krieger Rehabilitation Institute, Baltimore, MD, USA
| | - Julie A Cagney
- Kennedy Krieger Rehabilitation Institute, Baltimore, MD, USA
| | | | | | | | - Ingrid Parry
- Shriners Hospitals for Children, Sacramento, CA, USA
| | | | | | | | | | - Jackie Bultman
- Mary Free Bed Rehabilitation Hospital, Grand Rapids, MI, USA
| | | | - John Gaughan
- Thomas Jefferson University, Philadelphia, PA, USA
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Marconi A, Di Marcantonio P, D'Odorico V, Cristiani S, Maiolino R, Oliva E, Origlia L, Riva M, Valenziano L, Zerbi FM, Abreu M, Adibekyan V, Allende Prieto C, Amado PJ, Benz W, Boisse I, Bonfils X, Bouchy F, Buchhave L, Buscher D, Cabral A, Canto Martins BL, Chiavassa A, Coelho J, Christensen LB, Delgado-Mena E, de Medeiros JR, Di Varano I, Figueira P, Fisher M, Fynbo JPU, Glasse ACH, Haehnelt M, Haniff C, Hansen CJ, Hatzes A, Huke P, Korn AJ, Leão IC, Liske J, Lovis C, Maslowski P, Matute I, McCracken RA, Martins CJAP, Monteiro MJPFG, Morris S, Morris T, Nicklas H, Niedzielski A, Nunes NJ, Palle E, Parr-Burman PM, Parro V, Parry I, Pepe F, Piskunov N, Queloz D, Quirrenbach A, Rebolo Lopez R, Reiners A, Reid DT, Santos N, Seifert W, Sousa S, Stempels HC, Strassmeier K, Sun X, Udry S, Vanzi L, Vestergaard M, Weber M, Zackrisson E. EELT-HIRES the high-resolution spectrograph for the E-ELT. ACTA ACUST UNITED AC 2016. [DOI: 10.1117/12.2231653] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | | | - V. D'Odorico
- INAF - Osservatorio Astronomico di Trieste (Italy)
| | - S. Cristiani
- INAF - Osservatorio Astronomico di Trieste (Italy)
| | | | - E. Oliva
- INAF - Osservatorio Astrofisico di Arcetri (Italy)
| | - L. Origlia
- INAF - Osservatorio Astronomico di Bologna (Italy)
| | - M. Riva
- INAF - Osservatorio Astronomico di Brera (Italy)
| | | | | | | | | | | | - P. J. Amado
- Instituto de Astrofísica de Andalucía (Spain)
| | | | - I. Boisse
- Lab. d'Astrophysique de Marseille (France)
| | - X. Bonfils
- Observatoire de Science de l'Univ. de Grenoble (France)
| | | | | | | | | | | | - A. Chiavassa
- Lab. Lagrange, Univ. Côte d'Azur, Observatoire de la Côte d'Azur (France)
| | | | | | | | | | - I. Di Varano
- Leibniz-Institut für Astrophysik Potsdam (Germany)
| | | | | | | | | | | | | | | | - A. Hatzes
- Thüringer Landessternwarte Tautenburg (Germany)
| | - P. Huke
- Univ. of Göttingen (Germany)
| | | | - I. C. Leão
- Federal Univ. of Rio Grande do Norte (Brazil)
| | | | | | | | | | | | | | | | | | | | | | | | | | - E. Palle
- Instituto de Astrofísica de Canarias (Spain)
| | | | - V. Parro
- Instituto Mauá de Tecnologia (Brazil)
| | - I. Parry
- Univ. of Cambridge (United Kingdom)
| | - F. Pepe
- Univ. de Genève (Switzerland)
| | | | | | | | | | | | | | | | | | | | | | | | - X. Sun
- Univ. of Cambridge (United Kingdom)
| | - S. Udry
- Univ. de Genève (Switzerland)
| | - L. Vanzi
- Pontificia Univ. Católica de Chile (Chile)
| | | | - M. Weber
- Leibniz-Institut für Astrophysik Potsdam (Germany)
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Serghiou M, Niszczak J, Parry I, Richard R. Clinical practice recommendations for positioning of the burn patient. Burns 2016; 42:267-75. [DOI: 10.1016/j.burns.2015.10.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 10/01/2015] [Indexed: 10/22/2022]
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Parry I, Carbullido C, Kawada J, Bagley A, Sen S, Greenhalgh D, Palmieri T. Keeping up with video game technology: objective analysis of Xbox Kinect™ and PlayStation 3 Move™ for use in burn rehabilitation. Burns 2013; 40:852-9. [PMID: 24296065 DOI: 10.1016/j.burns.2013.11.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Revised: 10/31/2013] [Accepted: 11/07/2013] [Indexed: 10/26/2022]
Abstract
Commercially available interactive video games are commonly used in rehabilitation to aide in physical recovery from a variety of conditions and injuries, including burns. Most video games were not originally designed for rehabilitation purposes and although some games have shown therapeutic potential in burn rehabilitation, the physical demands of more recently released video games, such as Microsoft Xbox Kinect™ (Kinect) and Sony PlayStation 3 Move™ (PS Move), have not been objectively evaluated. Video game technology is constantly evolving and demonstrating different immersive qualities and interactive demands that may or may not have therapeutic potential for patients recovering from burns. This study analyzed the upper extremity motion demands of Kinect and PS Move using three-dimensional motion analysis to determine their applicability in burn rehabilitation. Thirty normal children played each video game while real-time movement of their upper extremities was measured to determine maximal excursion and amount of elevation time. Maximal shoulder flexion, shoulder abduction and elbow flexion range of motion were significantly greater while playing Kinect than the PS Move (p≤0.01). Elevation time of the arms above 120° was also significantly longer with Kinect (p<0.05). The physical demands for shoulder and elbow range of motion while playing the Kinect, and to a lesser extent PS Move, are comparable to functional motion needed for daily tasks such as eating with a utensil and hair combing. Therefore, these more recently released commercially available video games show therapeutic potential in burn rehabilitation. Objectively quantifying the physical demands of video games commonly used in rehabilitation aides clinicians in the integration of them into practice and lays the framework for further research on their efficacy.
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Affiliation(s)
- Ingrid Parry
- Shriners Hospital for Children, Northern California, 1832 Suffolk Way, Carmichael, CA 95608, United States.
| | | | - Jason Kawada
- Shriners Hospital for Children, Northern California, United States
| | - Anita Bagley
- Shriners Hospital for Children, Northern California, United States
| | - Soman Sen
- Shriners Hospital for Children, Northern California, University of California, Davis, United States
| | - David Greenhalgh
- Shriners Hospital for Children, Northern California, University of California, Davis, United States
| | - Tina Palmieri
- Shriners Hospital for Children, Northern California, University of California, Davis, United States
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Parry I, Hanley C, Niszczak J, Sen S, Palmieri T, Greenhalgh D. Harnessing the Transparent Face Orthosis for facial scar management: A comparison of methods. Burns 2013; 39:950-6. [DOI: 10.1016/j.burns.2012.11.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Revised: 11/12/2012] [Accepted: 11/13/2012] [Indexed: 11/29/2022]
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Hurlin Foley K, Doyle B, Paradise P, Parry I, Palmieri T, Greenhalgh DG. Use of an improved Watusi collar to manage pediatric neck burn contractures. J Burn Care Rehabil 2002; 23:221-6. [PMID: 12032375 DOI: 10.1097/00004630-200205000-00014] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Burns to the neck present a serious challenge to the pediatric burn team. Even when full neck range of motion is maintained, scarring may lead to banding and a loss of the neck's natural contour. Conventional thermoplastic neck conformers have been used to maintain neck position and provide pressure to maturing scars, but they are rigid and limit functional mobility. This is of particular concern in the pediatric population where limiting neck mobility can disrupt the development of sensory and motor patterns that are essential to normal developmental progression. The Multi-Ring Watusi collar is a flexible neck orthosis that allows mobility and provides circumferential pressure to the neck. We modified this collar to improve its comfort, cosmetic appearance and ease in donning/doffing. The improved Watusi collar is a flexible splint that supports neck position, provides circumferential pressure, and allows for functional neck mobility.
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Affiliation(s)
- K Hurlin Foley
- Shriners Hospital for Children-Northern California, 2425 Stockton Blvd., Sacramento, CA 95817, USA
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