Burn Rehabilitation

The lived experience of relationships after major burn injury

AIMS AND OBJECTIVES

To explore and describe the meaning of relationships after major burn injury.

BACKGROUND

A major burn injury may represent a threat to preburn appearance and level of functioning. Social resources and interaction are considered important for minimising the negative impacts on life after burn through all phases of care and rehabilitation. Yet, the subjective experiences of relating to others after burns have not been extensively explored.

DESIGN

The study was performed by using a phenomenological approach.

METHODS

A purposive sample (n = 14) of patients who had experienced major burns were interviewed in average 14 (5-35) months postinjury. The interviews were analysed by the phenomenological method of Giorgi.

RESULTS

The essence of the experience of relationships was constituted by other people re-anchoring the burn-injured persons to preburn life, being confirming of the new self, as well as being sensitive, competent and safeguarding with respect to actual and potential problems and harms. New bodily limitations demanded assistive others. Moreover, a worry about the overall burden on close family was typical. The supportive actions from others were mostly described as positive, but could also be experienced as challenging, and sometimes even unwanted and interfering with the struggle for regained freedom.

CONCLUSIONS

Across variation, an increased awareness of the meaning of mutual interdependence was typical. Supportive relationships with family, friends and health professionals were important for the return to society, preburn activities and a meaningful life.

RELEVANCE TO CLINICAL PRACTICE

A perspective that values the significance of social support from family, friends, health professionals and others who are important for the burn-injured person, and that does not underestimate challenges that may be involved, is recommended during all phases of burn care. Health professionals should also acknowledge the importance of relationships when developing structured educational programmes and organising peer support.

Guidelines for vocational evaluation following burns: integrated review of relevant process and factors

PURPOSE

A systematic literature review was undertaken to gather evidence to develop a guideline for vocational evaluation following burn injuries (BI). This review aimed to identify the key processes evaluators should follow and the key factors they should consider when completing such evaluations.

METHODS

Steps outlined in Cochrane Handbook of Systematic Review were followed including: development of review question; search strategies and selection criteria; quality appraisal; data extraction; analysis & synthesis; drawing conclusions. Four databases (Pubmed, Medline, CINHAL, PsycINFO) and 14 websites were searched for relevant articles and studies (quantitative, qualitative), reviews and guidelines. Two reviewers independently completed reviews, performed quality assessments and extracted data into evidence tables. Using the ICF model and directed content analysis, key processes and factors were analyzed and synthesized across the evidence.

RESULTS

A total of 138 articles were identified using the key words (e.g. burns, work). Studies, reviews and guidelines were retrieved if they focused on adults and discussed the processes relevant to vocational evaluation and/or factors associated with successful return to work (RTW) following a BI. Items were excluded if they did not address adults who had suffered a burn, the process of work or RTW, or challenges related to work after a BI. Using the above criteria 76 items were retrieved for full review. Fifty-six items remained after the quality appraisal. Results were integrated to develop the Evidence-based Framework for Vocational Evaluation Following Burn Injury.

CONCLUSIONS

This framework outlines 7 key processes relevant to vocational evaluation following burn injuries.

Influencing factors of the quality of life in Chinese burn patients: Investigation with adapted Chinese version of the BSHS-B

OBJECTIVE

The study aims to evaluate the quality of life (QOL) in burn patients in China and find out principal influencing factors, so as to provide evidence for interventions.

METHODS

A total of 271 burn patients in three major burn units in China were asked to fill in the adapted Chinese version (ACV) of the Burn Specific Health Scale-Brief (ACV BSHS-B) in order to seek out the principal influencing factors in combination with a self-designed demographic and disease condition questionnaire. Multivariable linear regression was used to analyse the principal influencing factors.

RESULTS

The findings showed that there were seven principal influencing factors for the overall ACV BSHS-B score. They were: percent total body surface area (TBSA) burned (with the standardised regression coefficient being -0.594), burn area of lower limber (0.241), itch level (-0.227), pain level (-0.220), gender (0.217), mechanical ventilation (0.216) and hand deformity (-0.141).

CONCLUSION

QOL decreased in burn patients to different degrees depending on the intensity of burns. With a better understanding of influencing factors of burn patients' QOL, the medical and nursing staff can take specific countermeasures to help patients gain a higher QOL.

12-month generic health status and psychological distress outcomes following an Australian natural disaster experience: 2009 Black Saturday Wildfires

OBJECTIVE

To describe the generic health status, health-related quality of life and psychological distress over a 12-month period of burns patients affected by the 2009 Black Saturday Wildfires.

DESIGN SETTING AND PARTICIPANTS

Cohort study with retrospective assessment of pre-injury status and prospective assessment of physical and psychosocial functioning in the Black Saturday Wildfires burns patients across time. Generic health status and burn specific quality of life using the 36-item Short Form Health Survey (SF-36) and Burn Specific Health Scale (BSHS) were collected at three, six and twelve months post-burn injury. In addition, similar time points were used to measure level of psychological distress and the presence of pain using the Kessler-10 questionnaire (K-10) and the McGill Pain Questionnaire.

RESULTS

At 12 months post-injury, patients reported a mean 16.4 (standard error, SE: 3.2) reduction in physical health and a 5.3 (SE 2.5) reduction in mental health scores of the SF-36 as compared to their pre-injury scores, with significant decreases observed in the "bodily pain", "physical functioning", "role physical" and "vitality" subscales. High levels of psychological distress and persistent pain were experienced, with no significant changes during the study period to the overall burns specific quality of life.

CONCLUSIONS

Even 12 months post-burn injury, patients affected by the 2009 Victorian Wildfires still experienced a significant reduction in generic health, increased psychological distress and persistent pain. The need for early and ongoing identification of physical and psychosocial impairments during hospital admission and upon discharge could be helpful to establish systematic interdisciplinary goals for long-term rehabilitation after severe burn injury.

Burn management in sub-Saharan Africa: opportunities for implementation of dedicated training and development of specialty centers

BACKGROUND

In low- and middle-income countries burn injuries remain responsible for a large burden of death and disability. Given an annual worldwide incidence of almost 11 million new individuals affected per year, major burn injuries have a higher annual incidence than HIV and tuberculosis combined.

METHODS

A survey instrument was adapted for use as an international assessment tool and then used to measure the availability of personnel, materials, equipment, medicines, and facility resources in nine Rwandan hospitals, including three referral centers.

RESULTS

Forty-four percent of surveyed hospitals had a dedicated acute-care burn ward, while two-thirds had intensive care options. Relevant wound-care supplies were widely available, but gaps in the availability of critical pieces of equipment such as monitors, ventilators, infusion pumps, electrocautery, and dermatomes were discovered in many of the surveyed institutions, including referral hospitals. Early excision and grafting were not performed in any of the hospitals and there were no physicians with specialty training in burn care.

CONCLUSIONS

Whereas all surveyed hospitals were theoretically equipped to handle the initial resuscitation of burn patients, none of the hospitals were capable of delivering comprehensive care due to gaps in equipment, personnel, protocols, and training. Accordingly, steps to improve capacity to care for those with thermal injury should include training of physicians specialized in critical care and trauma surgery, as well as plastic and reconstructive surgery. Consideration should be given to creation of national referral centers specializing in burn care.

Management of Hypertrophic Burn Scar: A Comparison between the Efficacy of Exercise-Physiotherapy and Pressure Garment-Silicone on Hypertrophic Scar

Purpose

Our study aims to investigate the effectiveness of other treatment methods for burn related scarring and to determine the possibility of their routine administration in similar clinical settings.

Methods

Through a prospective study, 66 patients were enrolled to receive either the conventional pressure garment therapy (PGT) and Silicone (control group) or exercise and physiotherapy (case group). Patients were visited regularly to be examined for the status of their scars’ regression, limbs’ dysfunction, and joint motion. Then, these two groups were compared to determine the efficacy of exercise and physiotherapy as an alternative to the conventional treatment with PGT.

Results

After about 20 months follow-up, decreased articular range of motion (ROM) was: 16 (51.5%) cases compared to 5 (15%) of controls had mild, 11 (35.5%) of the cases compared to 13 (39.5%) of the controls had moderate; and 4 (13%) of the cases compared to 15 (45.5%) of the controls had severe decreased ROM which revealed statistically significant difference (P<0.01). At the same time, Vancouver Scar Scale score was: 15 (48%) of the cases and 6 (18%) of the controls had mild Scar Scale, 12 (39%) of the cases and 14 (42.5%) of the controls had moderate score and 4 (3%) of the cases and 13 (39.5%) of the controls had severe score which revealed a statistically significant difference (P<0.05).

Conclusion

Our study showed that physical therapy andexercise are more effective than PGT, in management of burn hypertrophic scar, hence could be an alternative in cases that conventional therapy cannot be used for any reason.

Burn-specific health 2 years to 7 years after burn injury

BACKGROUND

Knowledge concerning the pattern of recovery and predictors of burn-specific health years after burn injury is limited, and these factors were therefore assessed with a disease-specific instrument, the Burn Specific Health Scale-Brief.

METHODS

Consecutive adult burn patients were prospectively included during hospitalization and assessed at 3, 6, and 12 months as well as at 2 years to 7 years (4.6 years on average) after burn. Data concerning injury characteristics, sociodemographic variables, psychiatric disorders, and burn-specific health were obtained.

RESULTS

Burn-specific health improved over time, from 6 months to the final assessment after burn. At 2 years to 7 years after burn, most problems were reported in the subscales heat sensitivity, body image, and work. The regression analyses revealed that length of stay, any preburn psychiatric disorder, major depression, and posttraumatic stress disorder 12 months after burn were predictors of long-term burn-specific health in the affect and relations domain, whereas time since injury, length of stay, and major depression 12 months after burn predicted outcome in the skin involvement domain. Predictors for the subscale work were length of stay, working at the time of injury, and posttraumatic stress disorder at 12 months.

CONCLUSION

This study underscores that significant improvement in postburn health can be expected even later than 2 years after injury. Furthermore, the results imply that both preburn factors and factors identified 1 year after burn have impact on burn-specific health after several years.

LEVEL OF EVIDENCE

Level III.

Attempted suicide by self-immolation is a powerful predictive variable for survival of burn injuries

Up to 9% of all burn victims in western countries are reported to have been caused by self-immolation with suicidal intent and usually involve extensive injuries. The authors sought to identify differences between suicide burn victims as opposed to those who sustained their injuries accidentally with regard to injury severity and mortality and determine the possible impact of suicide as a prognostic variable in the context of a scoring system such as the Abbreviated Burns Severity Index (ABSI). The data of all burns patients treated at the Specialist Burns Intensive Care Unit, University Hospital Zürich, between 1968 and 2008 were analyzed retrospectively. Of the 2813 patients included in the study, 191 were identified as attempted suicides, most commonly involving the use of accelerants. Thirty percent of all suicide victims had preexisting psychiatric diagnoses. Suicide victims presented with significantly more extensive burns (53.7%, ±0.98 SEM vs 21.4 %, ±0.36 SEM, P < .0001), had higher total ABSI scores (8.4, ±0.23 SEM vs 6.6, ±0.05 SEM, P < .0001), and had higher mortality rates (42.9% [83/191] vs 16.3% [426/2622]) than accident victims. Furthermore, logistic regression revealed suicide to be a significant predictor of mortality as inhalation injury (odds ratio 2.2, 95% confidence interval 1.4-3.5, P < .0003 and odds ratio 2.4, 95% confidence interval 1.4-4.0, P < .0009, respectively). The odds of dying from an attempted suicide are twice as high compared with those of accident patients in the same ABSI category, making suicide a powerful predictor of mortality. The authors therefore suggest including it as a fixed variable in scoring systems for estimating a patient's mortality after burn injuries such as the widely used ABSI.

Health-related quality of life of hospitalized patients with burns-comparison with general population and a 2-year follow-up

OBJECTIVE

Health-related quality of life (HRQoL) has gained increasing interest as an important indicator of adaptation after a burn injury. Our objective was to compare HRQoL of medium severity hospitalized burn victims with no need for intensive care treatment with that of the general population.

METHODS

The 15D HRQoL questionnaire at discharge, and 6, 12 and 24 months thereafter.

RESULTS

44 patients filled in the baseline questionnaire between June 2007 and December 2009. At discharge the mean (SD) HRQoL score (on a scale of 0-1) of the patients was worse in comparison with that of the general population (0.839 (0.125) vs. 0.936 (0.071)), p<0.001. The most striking differences (p<0.001) were seen on the dimensions of sleeping, usual activities, discomfort and symptoms, and sexual activity. At the 2-year follow-up the mean HRQoL score had increased from 0.835 (0.121) to 0.856 (0.149), but the difference was not statistically significant. Of the dimensions, moving and usual activities improved statistically significantly.

CONCLUSIONS

HRQoL of patients hospitalized for treatment of burns is, at discharge, compromised compared with that of the general population. During follow-up HRQoL showed slight improvement but remained at a clearly lower level.

Ein Gruppenbehandlungsprogramm zur Bewältigung von schweren Brandverletzungen

Theoretischer Hintergrund: Schwere Verbrennungen verursachen häufig bleibende körperliche Einschränkungen und Entstellungen. Viele Betroffene fühlen sich beim Bewältigungsprozess der Unfallfolgen überfordert. Das deutschlandweit erste verhaltenstherapeutische Gruppenbehandlungsprogramm speziell für Brandverletzte wurde entwickelt, um Betroffene bei der Bewältigung der längerfristigen Folgen des Unfalls und der Rückkehr in den Alltag zu unterstützen. Fragestellung: Ziel der Arbeit ist die Beschreibung des Programms und der Implementierung sowie die Darstellung der Ergebnisse zur Zufriedenheit der Teilnehmer (n = 86). Methode: Mit Hilfe eines Evaluationsbogens bewerteten die Gruppenteilnehmer, wie hilfreich und interessant sie die einzelnen Sitzungen fanden. Antworten auf die Frage: „Was könnte an der Sitzung verbessert werden?” wurden qualitativ ausgewertet. Ergebnisse: Die Zufriedenheit der Patienten mit dem Gruppenprogramm war hoch. 89,3 % beurteilten es als „gut oder sehr gut” und 80,4 % der Teilnehmer empfanden es als „sehr hilfreich oder hilfreich”. Als besonders wichtig wurde in den Rückmeldungen der Austausch mit anderen Betroffenen hervorgehoben. Schlussfolgerung: Das neu entwickelte Gruppenbehandlungsprogramm für Brandverletzte wurde von den Betroffenen gut angenommen und als hilfreich für die Bewältigung der Unfallfolgen beurteilt.

Burn survivors' perceptions of rehabilitation

BACKGROUND

The perspectives of burn survivors offer a powerful tool in assessing the efficacy of burn therapy interventions and methods. Despite this potential wealth of data, comprehensive analysis of burn survivor feedback remains largely uninvestigated and underdocumented. The aim of this study was to evaluate specific burn therapy interventions based on the opinions of a sample of the burn community.

METHODS

The survey was distributed to a convenience sample drawn from burn survivors attending the Phoenix Society's 21st Annual World Burn Congress in New York City, New York. Items of inquiry focused on therapeutic intervention and reintegration. The 164 surveys (a 44% response rate) returned included burn survivors from a variety of demographic segments and with burn injuries of disparate size, location, and severity. Interventions of interest included splinting and positioning, pressure garments, therapeutic exercise, group therapy, and nontraditional therapy. Respondents also rated the contribution of acute burn rehabilitation toward reintegration into familial, societal, and professional roles.

RESULTS

The vast majority of respondents felt that the rehabilitative interventions they experienced positively affected their long-term physical and psychosocial outcomes. In the areas of improving movement and scarring and expediting reintegration and usefulness, the majority of applicable interventions generated "strongly agree" or "agree" as the most popular responses.

CONCLUSIONS

These findings support the efficacy of many practices employed by burn rehabilitation specialists and offer a glimpse into the inherent benefits found in assessment of burn survivors' perspectives.

Posttraumatic stress symptoms after exposure to two fire disasters: comparative study

This study investigated traumatic stress symptoms in severely burned survivors of two fire disasters and two comparison groups of patients with "non-disaster" burn injuries, as well as risk factors associated with acute and chronic stress symptoms. Patients were admitted to one out of eight burn centers in The Netherlands or Belgium. The Impact of Event Scale (IES) was administered to 61 and 33 survivors respectively of two fire disasters and 54 and 57 patients with "non-disaster" burn etiologies at 2 weeks, 3, 6, 12 and 24 months after the event. We used latent growth modeling (LGM) analyses to investigate the stress trajectories and predictors in the two disaster and two comparison groups. The results showed that initial traumatic stress reactions in disaster survivors with severe burns are more intense and prolonged during several months relative to survivors of "non-disaster" burn injuries. Excluding the industrial fire group, all participants' symptoms on average decreased over the two year period. Burn severity, peritraumatic anxiety and dissociation predicted the long-term negative outcomes only in the industrial fire group. In conclusion, fire disaster survivors appear to experience higher levels of traumatic stress symptoms on the short term, but the long-term outcome appears dependent on factors different from the first response. Likely, the younger age, and several beneficial post-disaster factors such as psychosocial aftercare and social support, along with swift judicial procedures, contributed to the positive outcome in one disaster cohort.

Efficacy of inpatient burn rehabilitation: a prospective pilot study examining range of motion, hand function and balance

PURPOSE

To examine the effect of inpatient rehabilitation therapy on range of motion, hand function and balance in the burn population.

METHODS

This study utilizes a prospective longitudinal design. Inclusion criteria are adults admitted to a regional inpatient rehabilitation hospital with a primary diagnosis of burn injury. Demographic and medical data are collected. Primary outcomes include range of motion at four joints (shoulder, elbow, hip, knee), hand function (Jebsen Taylor Hand Test) and balance (Berg Balance Scale). Outcomes are measured at admission and discharge. Students't-test is used to determine significant differences in outcomes from admission to discharge.

RESULTS

Eleven subjects meet inclusion criteria. The mean age is 50 years, rehabilitation length of stay is 35 days and total body surface area burned is 41%. Subjects demonstrate significant improvements in range of motion, hand function and balance from admission to discharge (p<0.05).

CONCLUSIONS

Specific functional measures, range of motion, hand function and balance, demonstrate significant improvement during inpatient rehabilitation. Future work is needed to investigate other functional benefits of rehabilitation and to compare the impact of inpatient rehabilitation to other therapeutic interventions.

Clinical competencies for burn rehabilitation therapists

Nationally agreed-upon standards for competence are needed for burn physical and occupational rehabilitation therapists (BRTs) to define what constitutes safe and competent burn rehabilitation practice. Currently, consensus regarding the knowledge and skill components needed for the training and evaluation of BRT job performance is lacking. The Rehabilitation Committee of the American Burn Association used a staged, multimethod approach and input from more than 25 experts in the burn rehabilitation community to develop competency standards for BRTs. The result was the "Burn Rehabilitation Therapist Competency Tool" (BRTCT) that defines competency domains required of BRTs to provide physical and occupational therapy to patients with burn injury during their initial acute hospitalization and rehabilitation. This article describes the staged development and validation of the BRTCT. The component parts of the tool itself are presented, and the recommendations for assessment of competence are discussed. The BRTCT provides a common framework and language for expectations of performance in burn rehabilitation. Development of the BRTCT is a critical step in the ongoing process of promoting professional development and consistent practice standards in burn rehabilitation.

Burn Specific Health up to 24 months after the Burn-A prospective validation of the simplified model of the Burn Specific Health Scale-Brief

BACKGROUND

Outcome after burn injury is a multidimensional concept, but few multidimensional, injury-specific outcome measures have been psychometrically evaluated. A recent cross-sectional study using the Burn Specific Health Scale-Brief (BSHS-B) found three psychometrically sound health domains: function, skin involvement, and affect and relations. The aim of this study was to reexamine the psychometric properties of the BSHS-B using a prospective study design.

METHODS

Ninety-four consecutive adult patients with burns were included and asked to fill in questionnaires, the BSHS-B, the Hospital Anxiety and Depression Scale, and the short-form 36 (SF-36), at 6 months, 12 months, and 24 months postburn.

RESULTS

The factor structure was replicated and the three domains, function, skin involvement, and affect and relations, had excellent internal consistency. Over time the scores of function and skin involvement increased, indicating health improvement, whereas the domain affect and relations did not change over time. At 6 months and 12 months postburn, all domains were associated with burn severity. The function domain was highly associated with the SF-36 subscales physical functioning and role-physical, the affect and relations domain was highly associated with the Hospital Anxiety and Depression Scale and the SF-36 subscales denoting psychological health, and the domain skin involvement was highly associated with subscales indicating role-concerns, social functioning, vitality, and mental health.

CONCLUSION

The psychometric properties of the BSHS-B domains were excellent and they had intelligible concurrent associations with other measures. Thus, the simplified model of the BSHS-B is a reliable, valid, and useful tool in describing postburn health over time.

A review on static splinting therapy to prevent burn scar contracture: do clinical and experimental data warrant its clinical application?

BACKGROUND

Static splinting therapy is widely considered an essential part in burn rehabilitation to prevent scar contractures in the early phase of wound healing. However, scar contractures are still a common complication. In this article we review the information concerning the incidence of scar contracture, the effectiveness of static splinting therapy in preventing scar contractures, and specifically focus on the - possible - working mechanism of static-splinting, i.e. mechanical load, at the cellular and molecular level of the healing burn wound.

METHOD

A literature search was done including Pubmed, Cochrane library, CINAHL and PEDRO.

RESULTS

Incidence of scar contracture in patients with burns varied from 5% to 40%. No strong evidence for the effectiveness of static splinting therapy in preventing scar contracture was found, whereas in vitro and animal studies demonstrated that mechanical tension will stimulate the myofibroblast activity, resulting in the synthesis of new extracellular matrix and the maintenance of their contractile activity.

CONCLUSION

The effect of mechanical tension on the wound healing process suggests that static splinting therapy may counteract its own purpose. This review stresses the need for randomised controlled clinical trials to establish if static splinting to prevent contractures is a well-considered intervention or just wishful thinking.

Local and systemic treatments for acute edema after burn injury: a systematic review of the literature

Burn injury is a complex trauma that results in local and generalized edema. Edema fluid limits the exchange of vital nutrients in healing the burn wound and will compromise vulnerable tissues. Although the importance of edema control in tissue salvage is recognized, treatments targeted at edema control have not been critically reviewed. Thus, the objective was to assess the evidence for the effectiveness of local and systemic treatments for edema management immediately after burn injury. Searches for randomized controlled trials were conducted of online databases, research and thesis registers, and grey literature repositories. Handsearches included journals, bibliographies, and proceedings. Authors were contacted to clarify and submit extra study details. Eight studies were included. Management of acute major burn resuscitation including colloid increases lung edema (mean difference [MD], 0.04 ml/ml alv vol; 95% confidence interval [CI], 0.03-0.04; P < .00001) and mortality (risk ratio, 3.67; 95% CI, 1.16-11.58; P = .03). Continuous administration of vitamin C in acute burn resuscitation reduces local wound edema (MD, -3.50 ml/g; 95% CI, -4.63 to -2.37; P < .00001) and systemic fluid retention (MD, -8.60 kg; 95% CI, -13.47 to -3.73; P = .0005). Local acute hand burn edema is reduced (MD, -29.00 ml; 95% CI, -53.14 to -4.86; P = .02), and active hand motion increased (MD, 10.00°; 95% CI, 4.58-15.42; P = .0003), using electrical stimulation with usual physiotherapy. Each review outcome was based on a small single-facility study. Thus, future research in intervention for acute burn edema must focus on multicentre trials and validation of outcome measures in the burn population.

Select practices in management and rehabilitation of burns: a survey report

The purpose of this study is to document the organization and current practices in physical rehabilitation across burn centers. An online survey developed for the specific purposes of this study sought information regarding a) logistics of the burn center; b) inpatient and outpatient treatment of patients with burn injury; and c) specific protocols in the treatment of a few complications secondary to burn injuries. Of the 159 responses received, 115 were received from the United States, 20 from Australia, 16 from Canada, and 7 from New Zealand. The overall sample included responses from 76 physical therapists (PTs) and 78 occupational therapists. Seventy-three of those surveyed considered themselves primarily a burn therapist. Nurses (86%) were reported as primarily responsible for wound care of inpatients, followed by wound care technicians (24%). Ninety-seven percent of the therapists reported following their own treatment plans. The trunk and areas of head and neck were treated by both PTs and occupational therapists, whereas the lower extremities continue to be treated predominantly by PTs. Some common practices regarding treatment of a few complications secondary to burn injuries such as splinting to prevent contractures, treatment of exposed or ruptured extensor tendons, exposed Achilles tendons, heterotopic ossification, postoperative ambulation, conditioning, scar massage, and use of compression garments are described. Opportunities exist for 1) developing a common document for practice guidelines in physical rehabilitation of burns; and 2) conducting collaborative studies to evaluate treatment interventions and outcomes.

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.

Mental disorders after burn injury: a prospective study

OBJECTIVE

To prospectively investigate variations in prevalences of mental disorders after burn, and correlation between burn severity and mental disorders among hospitalized burn patients.

METHOD

A cohort of 107 consecutive acute adult burn patients was examined with structured diagnostic interview (SCID-I) at baseline, and 92 patients (86%) at 6 months after injury. Prevalences of mental disorders for the whole 6-month follow-up period, plus 1-month point prevalences in acute care and in a second 6-month interview were assessed, and the two point prevalences were compared. Burn severity was estimate by %TBSA.

RESULTS

During the 6-month follow-up 55% (51/92) of burn patients had at least one mental disorder, including 12% (11/92) with post-traumatic stress disorder (PTSD). In a multinomial regression, %TBSA exposure independently and strongly predicted risk for mental disorders, especially for anxiety disorders and delirium. The overall point prevalence of mental disorders decreased significantly (p=0.036) from acute care (45%) to 6 months (33%).

CONCLUSIONS

After burn, more than half of the patients suffer from some type of mental disorder, but the prevalence declines over time after the acute phase. The disorders are not limited to depression and PTSD. A strong relationship likely exists between burn severity and some post-burn mental disorders.

Return to work after burn injury: burn-injured individuals' perception of barriers and facilitators

The aim of this study was to explore burn-injured individuals' perception of factors seen as facilitators or barriers in the process of returning to work after a severe burn injury. Semistructured interviews were prospectively conducted with 39 former burn injury patients, admitted to the Uppsala Burn Center between March 2000 and March 2007. The participants were employed or studying at the time of injury and were interviewed on average 4.6 years after the burn. The interview data were analyzed with qualitative content analysis. Factors acknowledged by the participants as facilitators and barriers to return to work (RTW) were identified and sorted into five categories: the Individual, Social Life, Health Care and Rehabilitation, the Workplace, and Social Welfare Agencies. Facilitators were perceived to a great extent as individual characteristics, such as own ability to take action, setting up goals in rehabilitation, having willpower, being persistent, and learning to live with impairments. The possibility of getting modified work tasks or a change of workplace, when having physical or psychological impairments, was also seen as facilitating factors. Some barriers experienced as delaying RTW were difficulties when ceasing pain medication, limited knowledge of wound care at primary health care facilities, lack of individualized rehabilitation plans, and lack of psychological support during rehabilitation. Former burn injury patients emphasized psychological resources and capabilities as facilitators in the RTW process. The need in rehabilitation for a coordinator and for assessment of work capacity, and not solely a focus on impairments, is discussed.

Mechanical receptor-related mechanisms in scar management: a review and hypothesis

BACKGROUND

The physiopathogenesis of proliferative scarring in human skin is not well understood. Furthermore, knowledge of the precise mechanisms of action for physical treatment modalities is limited. Compression garments, occlusive/adhesive skin taping, and silicone gel sheets are applied to form an occlusion on the scar surface, reduce tension, and/or increase pressure on the scar itself. The mechanisms by which the external or superficial actions of these treatments cause remission of a protruding scar may be related to mechanoreceptor (nociceptor and cellular mechanoreceptor) responses.

METHODS

Basic research studies about mechanoreceptor-related (nociceptors and cellular mechanoreceptors, separately) events are reviewed and discussed based on proliferative scarring background. Scar management-related studies were corrected from the standpoint of mechanotransduction mechanisms. The methodologic quality of the clinical trials and basic studies was evaluated and reviewed.

RESULTS

It was suggested that many of the physical scar management methods, including compression therapy, silicone therapy, adhesive tape, and occlusive dressing therapy, are related to mechanotransduction mechanisms.

CONCLUSIONS

A unifying perspective of basic research findings and clinical observations may be obtained by considering the mechanoreceptor-related events in scar management. Moreover, a precise understanding of the roles that cellular mechanoreceptors and mechanosensitive nociceptors play in proliferative scarring may lead to the development of innovative treatment strategies and new pharmacologic therapies targeting cellular mechanoreceptors and mechanosensitive nociceptors in fibroproliferative diseases.

A randomized, controlled trial of immersive virtual reality analgesia, during physical therapy for pediatric burns

This randomized, controlled, within-subjects (crossover design) study examined the effects of immersive virtual reality as an adjunctive analgesic technique for hospitalized pediatric burn inpatients undergoing painful physical therapy. Fifty-four subjects (6-19 years old) performed range-of-motion exercises under a therapist's direction for 1-5 days. During each session, subjects spent equivalent time in both the virtual reality and the control conditions (treatment order randomized and counterbalanced). Graphic rating scale scores assessing the sensory, affective, and cognitive components of pain were obtained for each treatment condition. Secondary outcomes assessed subjects' perception of the virtual reality experience and maximum range-of-motion. Results showed that on study day one, subjects reported significant decreases (27-44%) in pain ratings during virtual reality. They also reported improved affect ("fun") during virtual reality. The analgesia and affect improvements were maintained with repeated virtual reality use over multiple therapy sessions. Maximum range-of-motion was not different between treatment conditions, but was significantly greater after the second treatment condition (regardless of treatment order). These results suggest that immersive virtual reality is an effective nonpharmacologic, adjunctive pain reduction technique in the pediatric burn population undergoing painful rehabilitation therapy. The magnitude of the analgesic effect is clinically meaningful and is maintained with repeated use.