Rehabilitation of the burned patient: James Laing Memorial Essay for 1993

Predictors of post-traumatic growth in young adult burn survivors

Although burns most often result in negative psychological consequences, some studies have identified self-reported, positive psychological growth after such injuries. Post-traumatic growth is a positive psychological change in which an individual develops stronger functioning, beliefs, and values following a trauma. To date, no quantitative analysis has been done of post-traumatic growth in young adult burn survivors. The present study aims: (1) to delineate the overall level of post-traumatic growth among Korean young adult burn survivors, and (2) to investigate the factors that influence the post-traumatic growth. To accomplish this, data for 221 burn survivors in a burn hospital and self-help groups were analyzed. Young adult burn survivors were found to have experienced post-traumatic growth, although to a lesser degree than previous research would suggest (36.86 ± 31.16). Results of the hierarchical multiple regression analysis indicated that change in a family relationship after the burn experience, treatment situation, and level of interpersonal relationship skills, were statistically significant in young adult burn survivors' post-traumatic growth. Results support good interpersonal relationship skills and positive family relationships appear to facilitate the positive growth after burn experience. Clinical implications are presented in the discussion.

Hypertrophie Scars and Keloids: An Overview of the Aetiology and Management

Hypertrophic scars and keloids are a common surgical problem. There is increasing knowledge of the pathology of this condition but the exact pathogenesis is yet unknown. Treatment remains difficult and is associated with high recurrence rates in certain forms. The psychological implications for the patient are enormous and have still to be fully defined. This article is a review of the current aetiology, pathology and management of hypertrophic scars and keloids. Various treatment options are discussed and psychological aspects have been emphasised.

Examining the Correlation between Objective Injury Parameters, Personality Traits, and Adjustment Measures among Burn Victims

BACKGROUND

Burn victims experience immense physical and mental hardship during their process of rehabilitation and regaining functionality. We examined different objective burn-related factors as well as psychological ones, in the form of personality traits that may affect the rehabilitation process and its outcome.

OBJECTIVE

To assess the influence and correlation of specific personality traits and objective injury-related parameters on the adjustment of burn victims post-injury.

METHODS

Sixty-two male patients admitted to our burn unit due to burn injuries were compared with 36 healthy male individuals by use of questionnaires to assess each group's psychological adjustment parameters. Multivariate and hierarchical regression analysis was conducted to identify differences between the groups.

RESULTS

A significant negative correlation was found between the objective burn injury severity (e.g., total body surface area and burn depth) and the adjustment of burn victims (p < 0.05, p < 0.001, Table 3). Moreover, patients more severely injured tend to be more neurotic (p < 0.001), and less extroverted and agreeable (p < 0.01, Table 4).

CONCLUSION

Extroverted burn victims tend to adjust better to their post-injury life while the neurotic patients tend to have difficulties adjusting. This finding may suggest new tools for early identification of maladjustment-prone patients and therefore provide them with better psychological support in a more dedicated manner.

Functional independence in teenage patients with burns

The purpose of this study was to assess the functional independence of teenagers undergoing a process of rehabilitation. A cross-sectional study was carried out on a sample of 63 teenagers, aged 12 to 20, who had suffered burns and were going through a process of rehabilitation, with the application of the Functional Independence Measurement (FIM). The data was analysed using descriptive statistics and also a test for comparison of means (Student's t-test), as well as Cronbach's reliability test. There was proof of a high degree of independence in FIM. Analysis of the location of the burn and also the performance of work and/or study activities showed these not to interfere with functional independence. The results indicate the reliability of the instruments applied, making it possible to conduct an assessment of the functional independence of the teenagers during the rehabilitation process.

Polish adaptation and validation of burn specific health scale - brief

BACKGROUND

The Burn Specific Health Scale - Brief is a well-described, specific tool to assess health condition (quality of life) of burnt patients. This project was aimed at creating a Polish adaptation and validation of the Burn Specific Health Scale - Brief.

METHOD

Adaptation of the tool was performed in two stages. The first stage involved translation, back translation, evaluation by a panel of judges and a pre-test of the tool. The second stage consisted of surveying 202 burned patients. Those data were used to conduct a psychometric analysis. Reliability was checked by determining the Cronbach's α internal consistency coefficient and conducting the test-retest procedure (ICC). Content validity was evaluated by a panel of judges. Criterion validity was determined using SF-36. Construct validity was determined using known-groups validation.

RESULTS

Reliability of the tool, determined using the internal consistency coefficient (Cronbach's α=0.94) and the test-retest procedure (ICC=0.89), proved to be high. Criterion validity, determined using the relationship of results of comparable BSHS-B and SF-36 subscales, obtained a satisfactory level with a correlation of r=0.55-0.89 (p<0.01). Analysis of inter-group differences showed that patients who stayed at a hospital for more than 10 days (p=0.002), patients after surgical intervention (p=0.018), patients with a burn larger than 19% of the TBSA (p=0.01) and patients with 3rd degree burns (p=0.001) have much poorer results than the rest of the subjects.

DISCUSSION

The Polish version of BSHS-B is a reliable and valid tool for assessing quality of life of burned patients. It may be used to plan the burn treatment process and evaluate its outcomes.

Assessment of health status of adolescent burn victims undergoing rehabilitation: a cross-sectional field study

Teenagers may experience physiological and psychological changes when they suffer from a severe burn. The aim of this study was to assess the state of health of teenagers who were undergoing a rehabilitation process following a severe burn. A cross-sectional field study was carried out with 63 teenagers and young adults who had suffered burns. The tests applied were social, demographic, and clinical instruments. The specific tests included the Burn Specific Health Scale-Revised, Beck Depression Inventory, Rosenberg's Self-Esteem Scale, and Functional Independence Measurement. The results were analyzed by using descriptive statistics, multivariate analysis of variance, variance analysis, and Cronbach's reliability analysis. The social and demographic analysis of the population has shown a prevalence of female (60.3%), single subjects (93.7%), and ages between 12 and 20 years (mean age of 15.95 years). The mean total body surface area burn was 23.84%, with accidents as the main causative factor (92.10%). More than half (52.4%) reported functional and aesthetic effects after the burn, with 81% concerned about the visible scar. Cronbach's reliability analysis has shown statistically confident results for all the instruments as applied. The multivariate analysis showed a correlation between the work domain and marital status, whereas there was no evidence to show a correlation between sex, age, physical or aesthetic sequelae or visibility of burns, and depression, self-esteem, functional independence, or current state of health. The results obtained prove the reliability of the instruments applied, making it possible to assess the state of teenagers and young adults health during the rehabilitation process.

Itching following burns: epidemiology and predictors

BACKGROUND

Itching (pruritus) following burns is a well-known clinical problem. However, there are no long-term prospective studies that document the course and the extent of the problem. Studies on risk factors are anecdotal.

OBJECTIVES

To study self-reported itching in a multicentre cohort among adults with burns at 3, 12 and 24 months postburn. Further, to examine psychological and injury characteristics in relation to itching at these three points in time.

METHODS

Itching was assessed as part of a self-report scar complaint list in a prospective longitudinal cohort study. Injury characteristics, demographics and self-reported post-traumatic stress symptoms were examined as possible risk factors in three linear regression models.

RESULTS

A total of 510 persons participated. The reported prevalence rates of mild to severe itching were as high as 87%, 70% and 67% at the three respective points in time. Significant predictors of itching at all three points in time were deep dermal injury and early post-traumatic stress symptoms. Along with these, total burned surface area and female gender were predictors at 3 months postburn.

CONCLUSIONS

Itching remains a significant problem over a 2-year period. Individuals having undergone surgical procedures and experiencing early post-traumatic distress are more likely to suffer from long-term and persistent itching. Implications regarding practice and research are discussed.

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.

Impaired Generic Health Status But Perception of Good Quality of Life in Survivors of Burn Injury

BACKGROUND

Although it is recognized that burn survivors face a variety of challenges related to physical, psychologic and social late-effects of their injury, the impact of thermal injury on the lives of patients is not fully understood. To learn more about burn patient needs and to obtain information relevant to the design of clinical programs for treatment and aftercare, self-reports on how burn patients perceive their health and quality of life may be of significant value.

METHODS

The generic health status (evaluated by SF-36) and overall quality of life (evaluated by the Quality of Life Scale [QOLS]) of 95 adult burn patients (total body surface area burned = 18.5 +/- 14.2% [mean +/- SD]; 82.1% men) were assessed 47.0 +/- 23.8 months postburn and compared with population norms.

RESULTS

The burn patient generic health status was significantly poorer than expected from general population scores, with reduced scores in the Physical Function (p < 0.001), Role Physical (p < 0.01), General Health (p < 0.001), Social Function (p < 0.001), and Role Emotional (p < 0.001) domains of the SF-36. Despite their reduced health status, overall quality of life was perceived as good, with QOLS scores similar to those of the general population. Patients living alone, unemployed, having nonburn physical illness, psychologic disorders, chronic pain, or having sustained full thickness injuries were found to be at particular risk.

CONCLUSIONS

Forty-seven months postinjury, burn patients still experienced a significant reduction of generic health, reporting limitations related to both physical and psychosocial SF-36 domains. On the other hand, the patients as a group reported overall quality of life similar to that of the norm population, suggesting that they were able to feel satisfaction with their new situation of life. Identification of several risk factors for reduced generic health status and overall quality of life support the need for specialized multidisciplinary aftercare for burn patients.

Psychopathology and psychological problems in patients with burn scars: epidemiology and management

Burn injury is often a devastating event with long-term physical and psychosocial effects. Burn scars after deep dermal injury are cosmetically disfiguring and force the scarred person to deal with an alteration in body appearance. In addition, the traumatic nature of the burn accident and the painful treatment may induce psychopathological responses. Depression and post-traumatic stress disorder (PTSD), which are prevalent in 13-23% and 13-45% of cases, respectively, have been the most common areas of research in burn patients. Risk factors related to depression are pre-burn depression and female gender in combination with facial disfigurement. Risk factors related to PTSD are pre-burn depression, type and severity of baseline symptoms, anxiety related to pain, and visibility of burn injury. Neuropsychological problems are also described, mostly associated with electrical injuries. Social problems include difficulties in sexual life and social interactions. Quality of life initially seems to be lower in burn patients compared with the general population. Problems in the mental area are more troublesome than physical problems. Over a period of many years, quality of life was reported to be rather good. Mediating variables such as low social support, emotion and avoidant coping styles, and personality traits such as neuroticism and low extraversion, negatively affect adjustment after burn injury. Few studies of psychological treatments in burn patients are available. From general trauma literature, it is concluded that cognitive (behavioral) and pharmacological (selective serotonin reuptake inhibitors) interventions have a positive effect on depression. With respect to PTSD, exposure therapy and eye movement reprocessing and desensitization are successful. Psychological debriefing aiming to prevent chronic post-trauma reactions has not, thus far, shown a positive effect in burn patients. Treatment of problems in the social area includes cognitive-behavioral therapy, social skills training, and community interventions. Sexual health promotion and counseling may decrease problems in sexual life.In conclusion, psychopathology and psychological problems are identified in a significant minority of burn patients. Symptoms of mood and anxiety disorders (of which PTSD is one) should be the subject of screening in the post-burn phase and treated if indicated. A profile of the patient at risk, based on pre-injury factors such as pre-morbid psychiatric disorder and personality characteristics, peri-traumatic factors and post-burn factors, is presented. Finally, objective characteristics of disfigurement appear to play a minor role, although other factors, such as proneness to shame, body image problems, and lack of self-esteem, may be of significance.

The use of pressure garments on hypertrophic scars

Hypertrophic scars are unsightly and can cause much distress to the sufferer. Pressure garments have been the preferred conservative management option for these scars for the last three decades. This paper reviews the history, underpinning theory and use of compression therapy in the management of hypertrophic scars particularly following burn injury. It is particularly aimed at clinicians who do not come into contact with this type of scarring frequently and are not familiar with its treatment. Other methods for managing hypertrophic scarring are also described briefly. Overall, there is a fair body of evidence to support the use of pressure garments, but it is not definitive research and further work is needed. However, the selection of any treatment must follow negotiation and agreement with the patient who will be required to continue treating their scars at home.

Long-term psychosocial adjustment after burn injury

The paper examines the relevant professional literature in order to explore how adjustment after burn injury may be enhanced. For this purpose, the unique characteristics of burn injury, and particularly the psychological meaning of the skin injury, are examined. An attempt is made to understand why some researchers find that a majority of this population suffers psychological disturbance, while others show that it is a 'normal' population, with no premorbid psychopathology. The ways of enhancing the psychological adjustment of burn victims, beginning with the acute phase of hospitalization and until long-term adjustment in the community, are discussed. These include, mainly, integrative team work to create a 'cover' as a skin substitute around the patient, social support, different techniques of psychotherapy when necessary, and job placement. In an attempt to learn what happens to burn patients a year after injury and later, we reviewed studies of their situation in terms of work, the family (including sexual functioning) and social interaction. In light of all this, the possibility of predicting long-term psychological adjustment among burn victims and the variables that may be relevant to this, such as, size of the burn or, rather, the individual's personality traits, are discussed.

Do burn patients need burn specific multidisciplinary outpatient aftercare: research results

In a cross-sectional study of patients 12-24 months after a burn injury, the need for a multidisciplinary burn specific outpatient clinic was examined in relation to aftercare consumption, physical and psychological problems. Four hundred and twenty nine patients were assessed by means of three self-report questionnaires: IES, SCL(PTSD-SL) and BSHS-SV-S. Results indicated that the current aftercare providers are almost exclusively medical doctors and that a quarter of the patients are dissatisfied with received aftercare. However, dissatisfaction about current aftercare was not the only criterion to determine whether patients wanted burn-specific aftercare. The severity of psychological and physical problems predicted interest in a multi-disciplinary outpatient clinic. Self-reported psychological and physical problems were found to be related to one another. Univariate logistic regression outcomes suggested that patients with serious psychological and physical problems are more likely to express interest in a burn-specific outpatient clinic, but that, in a multivariate regression analysis, physical problems and psychological problems measured on the SCL(PTSD-SLEEP) do not contribute to the prediction of the interest in a burn-specific outpatient clinic anymore once symptoms of PTSD are taken care of. Results suggest that psychological aftercare for burn patients needs to be improved. Possible steps to improve aftercare to meet patients' needs are discussed.

Posttraumatic stress and maladjustment among adult burn survivors 1 to 2 years postburn. Part II: the interview data

The purpose of this study was to assess the reaction to burn trauma, the hospitalisation characteristics and psychosocial adjustment in 174 burn victims who agreed to participate in a structured interview. It was postulated that once patients sustain a burn, the level of loneliness feelings and feelings of shame is a function of the visibility of the scars. Contrary to expectation, the visibility of the burn scars was not a predictor of pathological feelings of shame. By contrast, social introversion was a factor significantly associated with the development of burn related pathological feelings of shame.

Health status after recovery from burn injury

Outcome studies after burn injury have become increasingly important as overall mortality from injury has decreased. The present study, concerning physical and psychosocial aspects, is the second part of our larger survey of outcome after burn. The basis of our study instrument was the Abbreviated Burn Specific Health Scale. A postal survey was conducted among 315 patients aged 15-65 years, treated at Töölö Hospital Burns Unit between 11 November 1988 and 31 December 1994. The study series analysed consisted of 124 patients, whose mean total body surface area (TBSA) burned was 13.0%, mean full-thickness (FT) burns 6.2%, mean age 37 years and mean time of hospital treatment 16 days. Statistical analyses were performed with non-parametric tests and a probability level of 0.05 as the limit of statistical significance. Physical function was affected by the severity of the burn and by hand burns. Body image was influenced by FT burns but not by hand or facial injuries. Sexual life was affected by FT burns larger than 20%. Patients older than 25 years, those with TBSA greater than 30%, FT greater than 20% or time of hospitalization over one month were concerned about their general health. The effect of burns on patients' physical and psychosocial life was, however, slight, even with respect to severe injuries.

The role of pre-expanded free flaps in revision of burn scarring

The authors present two patients affected by scars resulting from burning of over 60 per cent of the total body area, in which the pre-expansion of a free flap has been used to increase the tissue surface useful for transfer from the only area of residual healthy skin (left forearm, left parascapular region). In both cases it was possible to transfer abundant healthy tissue into the desired areas, obtaining a rapid release of the region, which made possible an early physical rehabilitation of the patient starting after the second postoperative week. One of the main problems encountered, when facing surgical rehabilitation for the seriously burned patient, is the poor availability of skin donor areas suitable for reconstructive flaps. The pre-expansion of free flaps provides an advantage in that it allows the few integral residual areas to be used, improving vascularization and therefore increasing the available surface. Furthermore, as pre-expansion reduces tension on the margins, it allows for the easier closing of the donor area, with a minor risk of complications and a better scar outcome.

Return to employment after burn

The increase in the survival rate of burned patients has stressed the need to study their rehabilitation. The purpose of our study was to characterize the factors influencing such patients' return to work. We conducted a mail survey among 316 patients aged 15-65 years, treated at Töölö Hospital Burns Unit between 11 November 1988 and 31 December 1994. Of 175 participants, 130 (74 per cent) were men and 45 (26 per cent) women. The mean TBSA was 14.0 per cent, mean FT 6.4 per cent and the mean time of hospital treatment (TOT) 17.5 days. Statistical significance was calculated by Mann-Whitney U test, Kruskall-Wallis one-way analysis of variance and Chi-square test as appropriate, with a probability level of 0.05. In the study, 54 per cent of patients whose burn area was 1-10 per cent, returned to work within 2 months. No difference was found between patients who had hand burns and those who had burn injuries in other parts of the body. Patients who did not return to work were significantly older (mean age 45 years) than those who did (mean ages varying from 33 to 36 years; P < 0.05). Total body surface area burned (TBSA), FT, TOT, age and employment status at the time of injury were the factors predicting the resumption of working ability after burn injury.