Psychosocial adjustments 5 years after burn injury

Effects of a hospital based Wellness and Exercise program on quality of life of children with severe burns

OBJECTIVE

To examine the effect of a 12-week Wellness and Exercise (W&E) program on the quality of life of pediatric burn survivors with burns of ≥40% total body surface area. We hypothesized this comprehensive regimen would improve physical and psychosocial outcomes.

METHODS

Children were recruited for participation upon their discharge from the ICU. They were not taking anabolic/cardiovascular agents. Seventeen children participated in the W&E group and 14 children in the Standard of Care (SOC) group. Quality of life was assessed with the Child Health Questionnaire (CHQ) at discharge and 3 months. Children completed the CHQ-CF 87 and caregivers completed the CHQ-PF 28.

RESULTS

The mean age of children in the W&E group was 14.07±3.5 years and mean TBSA was 58±11.8%. The mean age of children in the SOC group was 13.9±3.1 years and mean TBSA was 49±7.8%. ANOVA did not reveal statistically significant differences between the groups. Matched paired t-tests revealed that parents with children in the W&E group reported significant improvements with their children's physical functioning, role/social physical functioning, mental health, overall physical and psychosocial functioning after exercise.

CONCLUSIONS

These results are clinically relevant in that a comprehensive W&E program may be beneficial in promoting physical and psychosocial outcomes.

Biopsychosocial factors that interfere in the rehabilitation of burn victims: integrative literature review

This study aimed to identify the biopsychosocial factors that influence the rehabilitation of burn victims, through an integrative literature review, from January 1987 to January 2007. Articles were searched in databases Scielo, Pubmed and Lilacs, resulting in 982 articles, of which 45 were selected, after the analysis and categorization processes. Most studies were descriptive and qualitative. The most frequently associated factors to the rehabilitation process were: mental health state before the accident, coping strategies and family support, besides the severity of the burn and the total body surface area burned. The quality of the selected studies, most classified as evidence level VI, shows the scarce production of strong evidences in this knowledge area, which needs more investment, considering the important implications of the sequelae of burns in the social reintegration of these people.

Reliability and validity of the Impact of Event Scale (IES): version for Brazilian burn victims

AIMS

The aims of this study were to assess the internal reliability (internal consistency), construct validity, sensitivity and ceiling and floor effects of the Brazilian-Portuguese version of the Impact of Event Scale (IES).

DESIGN

Methodological research design.

METHOD

The Brazilian-Portuguese version of the IES was applied to a group of 91 burned patients at three times: the first week after the burn injury (time one), between the fourth and the sixth months (time two) and between the ninth and the 12th months (time three). The internal consistency, construct validity (convergent and dimensionality), sensitivity and ceiling and floor effects were tested.

RESULTS

Cronbach's alpha coefficients showed high internal consistency for the total scale (0·87) and for the domains intrusive thoughts (0·87) and avoidance responses (0·76). During the hospitalisation (time one), the scale showed low and positive correlations with pain measures immediately before (r=0·22; p<0·05) and immediately after baths and dressings (r=0·21; p<0·05). After the discharge, we found strong and negative correlations with self-esteem (r=-0·52; p<0·01), strong and positive with depression (r=0·63; p<0·01) and low and negative with the Bodily pain (r=-0·24; p<0·05), Social functioning (r=-0·34; p<0·01) and Mental health (r=-0·27; p<0·05) domains of the SF-36 at time two. Regarding the sensitivity, no statistically significant differences were observed between mean scale scores according to burned body surface (p=0·21). The floor effect was observed in most of the IES items.

CONCLUSION

The adapted version of the scale showed to be reliable and valid to assess postburn reactions on the impact of the event in the group of patients under analysis.

RELEVANCE TO CLINICAL PRACTICE

The Impact of Event Scale can be used in research and clinical practice to assess nursing interventions aimed at decreasing stress during rehabilitation.

Psychiatric aspects of burn

Burn injuries and their subsequent treatment cause one of the most excruciating forms of pain imaginable. The psychological aspects of burn injury have been researched in different parts of the world, producing different outcomes. Studies have shown that greater levels of acute pain are associated with negative long-term psychological effects such as acute stress disorder, depression, suicidal ideation, and post-traumatic stress disorder for as long as 2 years after the initial burn injury. The concept of allostatic load is presented as a potential explanation for the relationship between acute pain and subsequent psychological outcomes. A biopsychosocial model is also presented as a means of obtaining better inpatient pain management and helping to mediate this relationship.

Treatments for common psychiatric conditions among adults during acute, rehabilitation, and reintegration phases

Common and pernicious adult psychiatric disorders consequent to burn injury include post-traumatic stress disorder (PTSD), major depressive disorder (MDD), and new-onset substance abuse disorder. Diagnosing and treating these disorders is complicated by the complex psychosocial issues associated with burns including grief, pain, role impairment, disfigurement, dysfunction, stigma, as well as financial and legal issues. Additionally, pre-morbid psychiatric and neurological illnesses are risk factors for burns, adding to the challenge of diagnosis and treatment. This article will focus on the diagnosis and treatment of PTSD and MDD consequent to burn trauma, as these are the major psychiatric outcomes, addressing the attendant psychosocial problems as threads in this post-trauma tapestry.

Pain, depression, and physical functioning following burn injury

OBJECTIVE

Little is known about how pain and depression after burn injury may influence long-term outcomes such as physical functioning. This prospective study examined associations between pain, depression, and physical functioning in a sample of burn injury survivors.

DESIGN AND PARTICIPANTS

Questionnaires assessing pain, depression, and physical functioning were completed by 64 (52% of original sample) adult burn survivors shortly after discharge from burn care and at 1- and 2-year follow-ups.

RESULTS

Pain and physical functioning improved over the 2 years of the study, whereas depression levels were stable. Pain and depression were associated with poorer physical functioning over time, but associations varied according to the time span under consideration. Also, the association between pain and physical functioning was strongest among persons with higher depression scores.

CONCLUSIONS

Pain and depression may contribute independently to compromises in physical functioning. The co-occurrence of pain and depression represents even greater risk for reduced physical functioning over time among burn survivors.

Pediatric facial burns

Despite major advances in the area of burn management, burn injury continues to be a leading cause of pediatric mortality and morbidity. Facial burns in particular are devastating to the affected child and result in numerous physical and psychosocial sequelae. Although many of the principles of adult burn management can be applied to a pediatric patient with facial burns, the surgeon must be cognizant of several important differences. Facial burns and subsequent scar formation can drastically affect the growth potential of a child's face. Structures such as the nose and teeth may become deformed due to abnormal external forces caused by contractures. Serious complications such as occlusion amblyopia and microstomia must be anticipated and urgently addressed to avert permanent consequences, whereas other reconstructive procedures can be delayed until scar maturation occurs. Furthermore, because young children are actively developing the concept of self, severe facial burns can alter a child's sense of identity and place the child at high risk for future emotional and psychologic disturbances. Surgical reconstruction of burn wounds should proceed only after thorough planning and may involve a variety of skin graft, flap, and tissue expansion techniques. The most favorable outcome is achieved when facial resurfacing is performed with respect to the aesthetic units of the face. Children with facial burns remain a considerable challenge to their caregivers, and these patients require long-term care by a multidisciplinary team of physicians and therapists to optimize functional, cosmetic, and psychosocial outcomes.

The social milieu of burn injury and recovery: using "social capital" as a framework for evaluating sex differences

This retrospective review describes differences in social and demographic factors of women and men hospitalized for acute burns. These differences are examined using the framework of social capital to assess burn injury outcomes. Our TRACS-ABA registry was used to identify adult women admitted for the treatment of acute burns from 1998 to 2002. Each woman was matched by age (+/-5 years), %TBSA (+/-5%), and inhalation injury to a man hospitalized during the same period. Patient medical records were reviewed for sociodemographic data, burn etiology, hospital course, and discharge information. One hundred forty-five adult women hospitalized for burn injury during the study period were successfully matched by age, burn size, and inhalation injury to 145 men. The mean age of study patients was 46.4 +/- 18 years. The mean %TBSA burned was 13.0 +/- 18, and 15.5% had inhalation injury. There were no sex-related differences in any clinical outcomes evaluated. A surprising finding was that women were admitted to the hospital significantly later than men after injury (3.7 vs 1.2 days; P < .05). Days from admit to injury negatively correlated with %TBSA in women, but not in men. Women also differed from men in a number of sociodemographic factors. Social and demographic differences exist between men and women admitted for treatment of acute burn injury. These differences influence admission after burn injury. Additional efforts are needed to better measure and evaluate the role of social capital in burn injury epidemiology, management, and outcomes.

The risk factors of psychosocial problems for burn patients

Many burn patients experience psychosocial problems such as personality change, post-traumatic stress disorder, family trouble, and financial burden. The purpose of this study was to identify the risk factors of these psychosocial problems that prevented burn patients from developing appropriate adjustments after burn. Six hundred eighty-six adult burn inpatients were interviewed. Most of them suffered from burns less than 10% of total body surface area. They were asked to fill in a questionnaire for this study, which was a psychosocial problem checklist of 17 items. Descriptive analysis, factor analysis, Chi-square test, and multiple logistic regression analysis were used to analyze the results. Lack of family support and living expense burden were the two significant risk factors for psychosocial problems including, burn treatment problems, rehabilitation problems, and welfare information problems on both acute and chronic burn patients. Medical expense burden was the risk factor among chronic burn patients. These findings suggested that active interventions by the burn team including mental health professionals (psychologist, psychiatrist or social worker) might reduce psychosocial problems of burn patients and encourage social rehabilitation.

Use of the Beck Depression Inventory for assessing depression in patients hospitalized with severe burn Disentangling symptoms of depression from injury and treatment factors

The objective of this study was to assess whether scores on the Beck Depression Inventory (BDI) are biased by injury severity among hospitalized survivors of burn (N=262). A confirmatory factor analysis (CFA) model was developed with a general depression factor that loaded on all items and somatic and cognitive factors that were orthogonal to the general factor and to each other. The model fit the data well and substantially better than an alternative three-factor model with correlated factors. Percent total body surface area burned (TBSA) was significantly associated with the general depression factor (p=.04), but also with the orthogonal somatic factor (p<.001), suggesting biased measurement due to overlap between somatic symptoms of depression and the severity of the burn injury. Analysis of item communalities, however, suggested that only approximately 2% of total predicted item variance was associated with bias related to injury severity. It was concluded that, despite a small amount of bias, the BDI is a reasonably accurate clinical tool even in the context of severe burn. Appropriate adjustments for bias, however, should be made in research with the BDI among patients with acute burn.

Symptoms of depression predict change in physical health after burn injury

This study investigated the prevalence of symptoms of depression in patients hospitalized with severe burns and the association of symptoms of depression in the hospital with physical health 2 months after discharge, controlling for pre-burn physical health as measured by the SF-36 physical composite score. Survivors of acute burns were evaluated during the hospitalization (N=262) and at 1 week (N=165) and 2 months (N=100) after discharge. The prevalence of at least mild to moderate symptoms of depression (Beck Depression Inventory > or = 10) ranged from 23% to 26%. In-hospital symptoms of depression predicted change in physical health from pre-burn to 2 months post-discharge (p=.02), controlling for patient demographics, burn severity, and symptoms of PTSD. These results suggest that patients should be screened for depression, both in-hospital and during rehabilitation after discharge.

Depression in burn reconstruction patients: symptom prevalence and association with body image dissatisfaction and physical function

OBJECTIVE

This study investigated the prevalence and the clinical correlates of symptoms of depression among burn reconstruction patients.

METHOD

A sample of 224 burn reconstruction patients completed the Beck Depression Inventory (BDI), the SF-36 Health Survey and the Satisfaction with Appearance Scale.

RESULTS

The prevalence of at least mild to moderate symptoms of depression (BDI > or =10) was 46%. Female patients were disproportionately represented in this burn reconstruction population (46%) compared to all survivors from the burn center (29%; P<.001) and compared to a national sample of burn survivors (27%; P<.001). Compared to males, female patients presented for consultation much longer after a burn injury (P<.001), tended to have smaller burns (P=.06) and were less likely to have facial burns (P=.08). Depressive symptoms were largely predicted by body image dissatisfaction (beta=.58; P<.001), with additional variance predicted by physical function (beta=-.13; P=.07). The effect of patient and burn injury variables on depressive symptoms was mediated by body image dissatisfaction and physical function.

CONCLUSION

The high prevalence of significant symptoms of depression in burn reconstruction patients and their relationship with body image suggest the importance of the routine psychological screening of patients seeking reconstruction services.

Quality of Life After Burn Injury: The Impact of Joint Contracture

We sought to investigate quality of life, and to specifically assess how joint contracture affects it, in patients with burn injuries. The study is involved 22 adults with burn injuries. Patients were divided into two groups according to the presence (n = 11) or absence (n = 11) of any joint contracture. Patient age, sex, date of burn injury, burn type, location, and extent of burn (TBSA) were recorded for each case. Each individual underwent a thorough musculoskeletal system examination, with special focus on range of motion of the joints. Quality of life was evaluated using the Short Form 36 (SF-36). Eight (36.4%) of the patients were women, and 14 (63.6%) were men, and their mean age (+/- SE) was 24.7 +/- 4.68 years. The mean interval from injury to the study assessment was 21.45 +/- 14.69 months. Eleven patients (50%) had at least one joint contracture. The patients with one or more contractures had significantly lower scores for the SF-36 subscales of physical functioning, physical role limitations, bodily pain, and vitality (P = .05, P = .01, P = .04, and P = .02, respectively). In the 22 patients overall, TBSA was negatively correlated with the scores for the SF-36 subscales vitality and emotional role limitations (r = -.586 and r = -.805, respectively). Joint contracture does impact burn patients' quality of life, especially with respect to physical functioning, physical role limitations, bodily pain, and vitality. In addition, the amount of BSA burned is correlated with psychosocial problems and poorer quality of life, regardless of whether joint contractures develop.

Depression in survivors of burn injury: a systematic review

BACKGROUND

The objective of this study was to systematically review the prevalence, persistence, and risk factors for depression postburn injury.

METHODS

A search of the MEDLINE, CINAHL, and PsycINFO databases was conducted in June 2006 to identify studies that used a standardized interview or validated questionnaire to assess depression. The search was augmented by hand searching of selected journals and references of identified articles and reviews.

RESULTS

Major depression was identified in 4% to 10% of adult patients using structured interviews in hospital and in the year following discharge. The prevalence of significant depressive symptoms in studies that used the depression subscale of the Hospital Anxiety and Depression Scale post discharge was 4% to 13%, whereas studies that used the Beck Depression Inventory generally produced substantially higher rates: between 13% and 26% for "moderate to severe" symptoms and between 22% and 54% for at least "mild" symptoms.

CONCLUSIONS

The general low quality of studies reviewed suggests the need for future studies using larger sample sizes to adequately assess prevalence rates and risk factors. No existing studies have addressed the persistence of depression in burn survivors; there are no treatment studies; and there are no recent studies of children.

Long-term risk factors for impaired burn-specific health and unemployment in patients with thermal injury

The success of acute burn therapy has led to an increased demand for high-quality rehabilitation. When optimizing burn care programs, knowledge of long-term risk factors associated with impaired health and unemployment of the patient may be significant. The health and work status of 95 patients (82.1% males; mean age 43.7 (S.D.: 14.5) years; mean total body surface burn 18.5 (S.D.: 14.2) % were assessed 47.0 (S.D.: 23.8) months after injury, using the Norwegian version of the abbreviated burn-specific health scale (BSHS-N) and a questionnaire asking for socio-demographic and medical characteristics. A regression model demonstrated that the BSHS-N total score was significantly reduced by chronic pain (P<0.001), psychological illness (P<0.001), and living alone (P=0.030), as well as full-thickness facial (P=0.011) and foot (P=0.013) burns. Unemployment was significantly associated with housing and economic problems (P=0.001), chronic pain (P=0.001), the extent of full-thickness injury (P=0.005), the presence of deformities (P=0.037), the number of operations (P=0.001) and the length of hospital stay (P=0.016). Thus, socio-demographic factors, non-burn-related morbidity and the injury itself significantly impaired long-term physical and psychosocial health and work status.

The classification and treatment algorithm for post-burn cervical contractures reconstructed with free flaps

Neck contractures after burn produce restrictions in motion and unacceptable aesthetic outcomes. Proper planning and tissue selection is essential to minimize donor site morbidity while optimizing outcomes. A classification system and treatment algorithm aids in achieving this goal. Between December 1999 and January 2003, 40 burn patients underwent release and reconstruction with free perforator flaps. Neck extensibility and zone of injury were evaluated. Choice of reconstruction was based on available tissue, restriction degree and zones involved. Cervical territories were classified according to movement restrictions and amount of improvement. Reconstructive territories were classified as central above (CA), central below (CB), central above and below (CAB) and lateral (L). Single, split, double and preexpanded free flaps were used for the reconstructions. Maximal gain in motion was noted at 4 weeks and maintained for the average 11 months follow-up. Types of reconstructive territories showed significant effects on range of motion while etiology and time between injury and reconstruction showed no impact on the functional outcome. Classification of neck territories aids in improving outcomes while minimizing donor morbidity. The central above territory, when reconstructed with free flaps, yielded the most rewarding improvement. A classification and treatment algorithm aids in achieving significant improvements in range of neck motion while taking into consideration the donor sites.

Psychosocial outcomes derived from an acid burned population in Bangladesh, and comparison with Western norms

Assault by acid burns typically results in severe disfigurement, yet the psychosocial impact of this injury is so far unreported. This study provides the first empirical data using standardised assessment scales, from 44 acid burns survivors in Bangladesh. Compared with published norms, individuals show high levels of psychological distress including social anxiety and avoidance, anxiety and depression. Consistent with the published literature, there is no relationship between severity of injury and level of psychological distress. One interesting feature of this population is the relative preservation of perceived self-concept, and this is discussed with relation to the supportive and therapeutic environment of the clinic where this group were studied. We also note an interesting sub-group who were attacked by members of their own family and for whom psychological morbidity seems particularly pronounced.

Functional outcome after burns: a review

We conducted a Medline search (1966-11/2003) on empirical studies into the consequences of burns. The International Classification of Functioning, disabilities and health (ICF) was used to classify dimensions of functional outcome. We included 50 studies, reporting a wide spectrum of ICF-dimensions. The current state of knowledge on the functional outcome after burns was hard to summarise, due to the wide variety in study designs and outcome assessment methods. Some indications on the major functional problems after burns were gained. Problems in mental function were described in subgroups of patients, both in children/adolescents and adults. Restrictions in range of motion were observed in about one-fifth of burn patients, even 5 years after injury. Problems with appearance were reported often (up to 43%), even in patients with minor burns (14%). Problems with work were reported in 21-50% of the adult patients, with permanent incapacity for work in 1-5%. None of the publications gave sufficient information to fully estimate the functional consequences of burns. We recommend the development of a standard core set for measurement and reporting of functional outcome after burns.

High risk for accidental death in previously burn-injured adults

This study investigated the long-term mortality in 1182 burn patients admitted at a single burn centre in 1984-2003. One thousand and forty-nine patients were discharged alive, of which 999 (95.2% of all discharged) were available for follow-up (mean observation time: 9.6+/-5.5 (S.D.) years). One hundred and twenty-two patients had died after discharge but before follow-up. For 111 patients, the official information recorded from their death certificates revealed that 83 patients (mainly in the higher age groups) had died due to a variety of natural causes. Twenty-three patients (M:F=18:5) (age: 37.7+/-11.3 years), previously hospitalised for burns, had later suffered accidental or violent deaths, including suicide (5), assault (2), and deaths related to substance and/or alcohol abuse (12). Additionally, five other deaths were recorded as sudden death, with no additional specific information as to the cause of death. This study shows that the rates of accidental or violent death in previously burned adult patients (around 40 deaths per 1000 years at risk) may be an order of magnitude higher than that in the average Norwegian population.

Burden of Burn: A Norm-Based Inquiry into the Influence of Burn Size and Distress on Recovery of Physical and Psychosocial Function

This prospective, longitudinal study examined the influence of baseline physical and psychological burden on serial assessments of health-related quality of life among adults with major burns from three regional burn centers (n = 162). Physical burden groups were defined by % TBSA burned: <10%, 10% to 30%, or >30%. Psychological burden groups were defined by in-hospital distress using the Brief Symptom Inventory Global Severity Index T-score with scores of < 63 or > or = 63. Analyses compared groups across level of burden and with published normative data. Assessments reflected health and function (Short Form 36) during the month before burn, at discharge, and at 6 and 12 months after burn. Physical functioning was significantly more impaired and the rate of physical recovery slower among those with either large physical burden or large psychological burden. Notably, psychosocial functioning also was more impaired and the rate of psychosocial recovery slower among those with greater psychological burden. These results suggest that, in addition to aggressive wound closure, interventions that reduce in-hospital distress may accelerate both physical and psychosocial recovery.