Physical Fitness in People After Burn Injury: A Systematic Review

Moderation Effects of Daily Behavior on Associations Between Symptoms and Social Participation Outcomes After Burn Injury: A 6-Month Digital Phenotyping Study

OBJECTIVE

To examine the moderation effects of daily behavior on the associations between symptoms and social participation outcomes after burn injury.

DESIGN

A 6-month prospective cohort study.

SETTING

Community.

PARTICIPANTS

Twenty-four adult burn survivors.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Symptoms and social participation outcomes were assessed weekly using smartphone surveys, including symptoms of pain (Patient-Reported Outcomes Measurement Information System [PROMIS] Pain Intensity and Pain Interference), anxiety (PROMIS Anxiety), and depression (Patient Health Questionnaire), as well as outcomes of social interactions and social activities (Life Impact Burn Recovery Evaluation [LIBRE] Social Interactions and Social Activities). Daily behaviors were automatically recorded by a smartphone application and smartphone logs, including physical activity (steps, travel miles, and activity minutes), sleep (sleep hours), and social contact (number of phone calls and message contacts).

RESULTS

Multilevel models controlling for demographic and burn injury variables examined the associations between symptoms and social participation outcomes and the moderation effects of daily behaviors. Lower (worse) LIBRE Social Interactions and LIBRE Social Activities scores were significantly associated with higher (worse) PROMIS Pain Intensity, PROMIS Pain Interference, PROMIS Anxiety, and Patient Health Questionnaire-8 scores (P<.05). Additionally, daily steps and activity minutes were associated with LIBRE Social Interactions and LIBRE Social Activities (P<.05), and significantly moderated the association between PROMIS Anxiety and LIBRE Social Activities (P<.001).

CONCLUSIONS

Social participation outcomes are associated with pain, anxiety, and depression symptoms after burn injury, and are buffered by daily physical activity. Future intervention studies should examine physical activity promotion to improve social recovery after burns.

Inpatient Rehabilitation Following Burn Injury

Inpatient rehabilitation confers excellent benefit to burn survivors and should be considered as a potential destination during discharge planning. Consulting physiatrists identify and manage complications within the inpatient rehabilitation setting. Interventions can be taken to address medical sequelae of injury, including pain, itch, neuropathy, psychological coping and mood, and nutritional needs. Physiatrists also oversee and direct a rehabilitation program focusing on scar management, contracture prevention, dysphagia treatment, and evaluation and treatment of cognitive impairments. Aerobic and resistive exercise are key components of an inpatient rehabilitation program to reduce the systemic impact of a burn injury and improve quality of life.

Web-based E-survey in identifying current physiotherapy practices in paediatric burns

INTRODUCTION

Physiotherapy practices in pediatric burns involves relaxation techniques and exercise training for attaining physical fitness, improving quality of life and, thereby to prevent primary and secondary complications. Physical activity and exercise act as a meaningful and purposeful tool for attaining physical fitness after burn injury.

AIM

The aim of this e-survey is to identify the current practices of physiotherapy interventions in pediatric burn rehabilitation among physiotherapy students and professionals.

METHODS

The e-survey was created with validated questionnaire using a Google Forms to gather the information related to current physiotherapy practices in pediatric burns. After the sample size estimation, survey link were sent to identified 144 physiotherapy students and professionals using social networking sites which includes, WhatsApp, Facebook and Instagram for this cross-sectional e-survey. The frequency and percentage of survey responses were analyzed.

RESULTS

Among 144 identified participants, 62 participants completed the survey, resulting in the response rate of (43.0%). The findings of this study revealed that> 50% of physiotherapy students, and professionals, are performing pain and scar assessment, along with their regular physiotherapy management in children with burns. In addition to these, they also practice physiotherapy for burn conditions in pediatric intensive care units (PICU), pediatric wards, and clinical outpatient department (OPD) settings.

CONCLUSION

Physiotherapy students and professionals have sufficient knowledge regarding pediatric burns complications, and also, they are well aware regarding recent physiotherapy practices in pediatric burn care management.

Rehabilitation of Burn Victims: Improving Quality of Life in Victims With Face and Neck Burn Through an Augmented Reality Coupled Pamphlet

The present study aimed to investigate the effect of implementing rehabilitation programs using an augmented reality (AR) coupled pamphlet on the quality of life (QOL) of patients with face/neck burns. This randomized clinical trial was conducted on 60 patients (intervention = 30, control = 30) admitted to the burn center of Imam Reza Hospital, Mashhad, Iran. Patients in the intervention group performed their rehabilitation program using AR coupled pamphlet during 6 weeks, while control patients used simple pamphlet. The Burn-Specific Health Scale for Face and Neck (BSHS-FN) was completed at the beginning, and 2 and 6 weeks after the intervention. The results for 2 weeks after intervention measures in model 1 ANCOVA showed significant raise of measures only for Hand function (P = .035). However, for the total QOL score and other domains the differences were not significant (All P > .05). Adjusting for confounders, model 2 ANCOVA showed similar results for 2 weeks after intervention. However, in both models, the results indicated significant intervention effect for 6 weeks after intervention in QOL score and all domains (All P < .05), so that the amount of increase in measures were significantly higher in the intervention group. According to the findings, implementing rehabilitation program for patients with face and neck burns using AR coupled pamphlet can improve their QOL.

Molecular mechanisms of post-burn muscle wasting and the therapeutic potential of physical exercise

After a severe burn injury, a systemic stress response activates metabolic and inflammatory derangements that, among other, leads to muscle mass loss (muscle wasting). These negative effects on skeletal muscle continue for several months or years and are aggravated by short-term and long-term disuse. The dynamic balance between muscle protein synthesis and muscle protein breakdown (proteolysis) is regulated by complex signalling pathways that leads to an overall negative protein balance in skeletal muscle after a burn injury. Research concerning these molecular mechanisms is still scarce and inconclusive, understanding of which, if any, molecular mechanisms contribute to muscle wasting is of fundamental importance in designing of therapeutic interventions for burn patients as well. This review not only summarizes our present knowledge of the molecular mechanisms that underpin muscle protein balance but also summarizes the effects of exercise on muscle wasting post-burn as promising strategy to counteract the detrimental effects on skeletal muscle. Future research focusing on the pathways causing post-burn muscle wasting and the different effects of exercise on them is needed to confirm this hypothesis and to lay the foundation of therapeutic strategies.

Grip strength in children after non-severe burn injury

PURPOSE

To characterise grip strength in children with non-severe burn injury, and further understanding of how demographic and clinical variables impact musculoskeletal recovery.

METHODS

A retrospective, cross-sectional audit of routinely collected clinical data was performed. Standardised protocols were used to measure height, weight and grip strength. Demographic and clinical information was collected from patient medical records. Grip strength comparisons were made against normative data using paired t-tests. General linear regressions with backwards elimination were performed to assess impact of clinical, demographic and physical variables on grip strength.

RESULTS

Children who were right hand (RH) dominant had reduced RH (18.9 ± 9.9 kg, p = 0.001) and left hand (LH)(17.6 ± 9.3 kg, p = 0.027) grip strength compared to age, sex and hand-dominance matched norms (RH, 20.0 ± 10.0 kg; LH, 18.4 ± 9.5 kg). Children who were assessed closer to the time of their injury, and those who were burnt at a young age were more likely to score grip strength values below the norm (p < 0.001 for all analyses). In particular, females appeared to be at a higher risk of low grip strength scores if burnt at a young age (p < 0.001).

CONCLUSIONS

Children with non-severe burn injury struggle to recover musculoskeletal strength, with those who were assessed closer to the time of injury or burnt at a young age especially at risk of impaired grip strength performance. Grip strength does not appear to be influenced by any other clinical variables or burn injury characteristics.

Evaluation of Kinesiophobia in Survivors of Major Burn Injury

Kinesiophobia, the fear of movement and re-injury, has not been described in burn injury survivors. Physical activity is a key component of burn rehabilitation programs. Yet, not all burn survivors exercise at the recommended level. This is an exploratory study examining the association of the demographics and injury characteristics of burn survivors with a fear of movement. The subjective fear of movement was measured using the Tampa Scale for Kinesiophobia (TSK). The TSK score was compared between several demographics and injury characteristics by performing the independent sample t-test. Sixty-six percent of subjects in our study (n=35), reported high levels of kinesiophobia (score 37 or above). The mean scores of the TSK were greater in males (40.7), non-White (43.0), Hispanic/Latino (41.1), age greater than 50 years (42.3), and total body surface area (TBSA) burn of >15% compared to females (36.9), White (38.5), non-Hispanic/Latino (39.3), age 50 years or less (38.1), and TBSA 15% or less (39.4) respectively. However, with the exception of time post injury, none of the mean differences were statistically significant. Subjects who had sustained a burn injury more than 12 months ago showed higher levels of kinesiophobia than the subjects who were injured within 12 months with a mean difference of 7.35 (p=.01). Thus, this study highlights the importance of (i) continued, long-term follow up for burn survivors, and (ii) appropriate educational and treatment interventions to address any underlying existing, new, or emerging medical issues that may contribute to the fear or avoidance of movement.

Graded aerobic exercise (GAEx): An effective exercise regimen to improve cardio-respiratory fitness and physical and psychosocial functioning in children with burn sequelae of the chest

PURPOSE

The cardio-respiratory function is compromised in children recovering from burns, particularly, those who sustain a burn injury across the chest, which leads to further prejudicial effects on physical and psychosocial health. This study endeavored to explore the efficacy of 12 weeks of graded aerobic exercise (GAEx) on the cardiorespiratory capacity and physical and psychosocial functioning in children with burn sequelae of the chest.

METHODS

Thirty-six burn-injured children aged 10-18 years (%TBSA: 24.2 ± 4.9, and 38.8 ± 12.9 months since injury) were randomly assigned to GAEx group (n = 18; undergone a 12-week intensity- and time-graded aerobic exercise program plus standard rehabilitation) or control group (n = 18; received the standard rehabilitation only). The cardio-respiratory fitness [marked by the peak oxygen uptake (VO_2peak), minute ventilation (V_E), ventilatory equivalent of inhaled oxygen (VEq/VO₂), oxygen pulse (O₂P), respiratory exchange ratio (RER), maximum heart rate (HR_max), and the heart rate recovery at one minute (HRR₁)] and physical and psychosocial functioning were assessed pre- and post-intervention.

RESULTS

Children in the GAEx group showed significant increases in VO_2peak (P = 0.013), V_E (P = 0.026), O₂P (P = 0.034), HR_max (P = 0.035), and HRR₁ (P = 0.04) and declines in VEq/VO₂ (P = 0.009) and RER (P = 0.011) as compared to the control group. Additionally, the GAEx group reported higher physical (P = 0.029) and psychosocial (P = 0.012) functioning.

CONCLUSION

Twelve weeks of GAEx has salutary effects on cardio-respiratory capacity and physical and psychosocial functioning in children with burn sequelae of the chest. These findings suggest that adding GAEx as a complementary therapy to the long-term rehabilitation protocol for this patient population is worthwhile.

Optimization of pulmonary function, functional capacity, and quality of life in adolescents with thoracic burns after a 2-month arm cycling exercise programme: A randomized controlled study

BACKGROUND

Burns to the thorax are at high risk for long-term pulmonary complications due to chest muscle contractures and chronic inflammation in both adolescents and young adults. Few studies have investigated the effects of arm cycling exercise in those individuals. For that reason, this study examined pulmonary function, functional capacity, and quality of life (QOL) in adolescents with thoracic burns subsequent to 2-month arm cycling exercise programme.

METHODS

A single-blinded, two-month randomized prospective controlled study was carried out between July 2019 and March 2020 on thirty adolescents with chest burns aged 11-17 years. They were randomized into two equal groups (n = 15), traditional physiotherapy programme (control group), and arm cycling exercise plus traditonal physiotherapy (arm cycling exercise group) for 2 consecutive months. Forced vital capacity (FVC), forced expiratory volume in one second (FEV1), six-minute walk test (6MWT), and Pediatric Quality of Life Inventory (PedsQL) were measured in both groups at baseline and after 2-month after intervention.

RESULTS

No statistical significance was detected at baseline between control and arm cycling exercise groups (FVC, p = 0.903, FEV1, p = 0.835, 6MWT, p = 0.817, and PedsQL, p = 0.612). 2 months after intervention showed statistical improvements in the arm cycling exercise group in all measures (FVC, p = 0.001, FEV1, p < 0.0001, 6MWT, p = 0.001, and PedsQL, p = 0.001) however, the control group showed statistical improvements in FVC, p = 0.044 and FEV1, p = 0.024 with non-statistically significant changes in 6MWT, p = 0.145 and PedsQL, p = 0.067. The arm cycling exercise group showed greater improvements than control group in the outcome measures (FVC, p = 0.034, FEV1, p < 0.017, 6MWT, p = 0.037, and PedsQL, p = 0.021).

CONCLUSIONS

This prospective study clearly demonstrated positive and beneficial influences of two-month arm cycling exercise in the optimization of pulmonary functions, functional performance, and QOL in adolescents suffering from chest burns and thereby eliminating post-burn complications.

Edward F. Adolph Distinguished Lecture. It's more than skin deep: thermoregulatory and cardiovascular consequences of severe burn injuries in humans

Each year, within the United States, tens of thousands of individuals are hospitalized for burn-related injuries. The treatment of deep burns often involves skin grafts to accelerate healing and reduce the risk of infection. The grafting procedure results in a physical disruption between the injured and subsequently debrided host site and the skin graft placed on top of that site. Both neural and vascular connections must occur between the host site and the graft for neural modulation of skin blood flow to take place. Furthermore, evaporative cooling from such burn injured areas is effectively absent, leading to greatly impaired thermoregulatory responses in individuals with large portions of their body surface area burned. Hospitalization following a burn injury can last weeks to months, with cardiovascular and metabolic consequences of such injuries having the potential to adversely affect the burn survivor for years postdischarge. With that background, the objectives of this article are to discuss 1) our current understanding of the physiology and associated consequences of skin grafting, 2) the effects of skin grafts on efferent thermoregulatory responses and the associated consequences pertaining to whole body thermoregulation, 3) approaches that may reduce the risk of excessive hyperthermia in burn survivors, 4) the long-term cardiovascular consequences of burn injuries, and 5) the extent to which burn survivors can "normalize" otherwise compromised cardiovascular responses. Our primary objective is to guide the reader toward an understanding that severe burn injuries result in significant physiological consequences that can persist for years after the injury.

The efficacy of resistance training in addition to usual care for adults with acute burn injury: A randomised controlled trial

Resistance training immediately after a burn injury has not been investigated previously. This randomised, controlled trial assessed the impact of resistance training on quality of life plus a number of physical, functional and safety outcomes in adults with a burn injury. Patients were randomly assigned to receive, in addition to standard physiotherapy, four weeks of high intensity resistance training (RTG) or sham resistance training (CG) three days per week, commenced within 72h of the burn injury. Outcome data was collected at six weeks, three and six months after burn injury. Quality of life at 6 months was the primary endpoint. Data analysis was an available cases analysis with no data imputed. Regression analyses were used for all longitudinal outcome data and between-group comparisons were used for descriptive analyses. Forty-eight patients were randomised resistance training (RTG) (n=23) or control group (CG) (n=25). The RTG demonstrated improved outcomes for the functional domain of the Burn Specific Health Scale-Brief (p=0.017) and the Quick Disability of Arm Shoulder and Hand (p<0.001). Between group differences were seen for C-reactive protein and retinol binding protein (p=0.001). Total quality of life scores, lower limb disability, muscle strength and volume were not seen to be different between groups (p>0.05). Resistance training in addition to usual rehabilitation therapy showed evidence of improving functional outcomes, particularly in upper limb burn injuries. Additionally, resistance training commenced acutely after a burn injury was not seen to be harmful to patients.

Physiotherapeutic and dietetic parameters in burns patients modelling a multidisciplinary approach to burns practice: A bi-disciplinary illustration of interrelated factors

OBJECTIVE

Early mobilisation and early enteral feeding after burn injury are two of the most important treatment therapies for optimal recovery. These factors form a part of a team approach, but research has historically focused on one discipline at a time and its effects in isolation; integrated inter-disciplinary influences are not typically studied. This observational study combines strategies and outcomes from the disciplines of nutrition and physiotherapy in an attempt to part-way exemplify the team approach.

METHODS

Patients were recruited through the Burns Unit records and divided into two groups: Group 1 constituted burn patients who were mobilised before surgery and Group 2 constituted burn patients who were mobilised after surgery.

RESULTS

Patients mobilised after surgery had significantly greater burn surface area, significantly fewer days to wait for surgery (3.4 vs 6.9 days, p < 0.01), significantly more days to mobilise after burn injury (13 vs 2.3 days, p < 0.05), and significantly more time to achieve independent mobilization (42 vs 19.5 days, p < 0.05); they had a significantly longer stay in intensive care (10.8 vs 4.1 days, p < 0.05), and a longer hospital stay (p < 0.05). These patients also had significantly greater episodes of diarrhoea (11.6 vs 4.1 episodes, p < 0.05), significantly lower albumin levels and more days on antibiotics compared with the group of patients who were mobilised before surgery (p < 0.05). Patients mobilised after surgery waited longer to be enterally fed (89 days vs 62.5 days), and although this was not statistically significant, it may be clinically significant. There were significant correlations between independent mobilisation and diarrhoea, independent mobilisation and albumin, length of stay and diarrhoea (p < 0.05). Regression analysis showed hours taken to commence enteral feeding and days in ICU predicted diarrhoea (p < 0.05).

CONCLUSIONS

This study illustrates the combined approach of two disciplines and their interrelated factors. Mobilisation appears to interrelate with nutrition factors, and this includes diarrhoea (which is likely a manifestation of gut effects due to the nature and timing of substrate delivery). A few factors were revealed in this interrelation that have not been documented previously in burns, namely the associations between mobilisation, diarrhoea, and serum albumin. Team members need to ensure inclusion of key recommendations from other disciplines when a particular, crucial factor from one discipline cannot be applied. Results in this study need to be interpreted with caution due to the small sample size, the use of statistical applications with sample size, and the retrospective nature of the study. A larger, more rigorous prospective research study is required to confirm these results.

The use of exercise in burns rehabilitation: A worldwide survey of practice

INTRODUCTION

Exercise-based interventions have been used to enhance the recovery of burn patients affected by hypermetabolism, muscle wasting and contractures. Although the benefits of exercise in burn population have been previously reported, the extent of exercise prescription in burn patients worldwide remains unknown. Therefore, the purpose of this study is to identify the extent and characteristics of exercise use in specialised and non-specialised burn centres worldwide.

METHODS

A web-based survey was developed in English and translated into Spanish and Chinese languages. Distribution of the surveys was made via email using personal contacts of the authors and through six scientific societies related to burn care in 2018. Data were analysed using descriptive statistics and comparisons between frequency distribution on variables of interest using the Chi-Square test and contingency tables.

RESULTS

One hundred and fifty-six surveys were completed (103 from the English version, 20 from the Chinese version, and 33 from the Spanish version). The response rate varied from 36.2% (English version) to 9.3% (Chinese version). Fifty eight percent of the surveyed clinicians worked in cities of 1 million inhabitants or more, and 92.3% worked in hospital-based burn centres. Exercise was used by 64.1% of the participants at the intensive care unit level, 75% in burn wards prior to complete wound healing, and 80.1% in rehabilitation units after wound healing. The type of exercise offered, parameters assessed, and characteristics of exercise programs varied notably among burn centres and clinicians consulted.

CONCLUSION

The majority of the surveyed clinicians used exercise for rehabilitation of patients following burn injuries. Further investigation is required to elucidate the access to exercise interventions prescribed by health professionals in remote areas, in less developed countries, and the extent of home-based exercise performed by patients.

Progressive exercise training improves maximal aerobic capacity in individuals with well-healed burn injuries

Long-term rehabilitative strategies are important for individuals with well-healed burn injuries. Such information is particularly critical because patients are routinely surviving severe burn injuries given medical advances in the acute care setting. The purpose of this study was to test the hypothesis that a 6-mo community-based exercise training program will increase maximal aerobic capacity (V̇o_2max) in subjects with prior burn injuries, with the extent of that increase influenced by the severity of the burn injury (i.e., percent body surface area burned). Maximal aerobic capacity (indirect calorimetry) and skeletal muscle oxidative enzyme activity (biopsy of the vastus lateralis muscle) were measured pre- and postexercise training in noninjured control subjects (n = 11) and in individuals with well-healed burn injuries (n = 13, moderate body surface area burned; n = 20, high body surface area burned). Exercise training increased V̇o_2max in all groups (control: 15 ± 5%; moderate body surface area: 11 ± 3%; high body surface area: 11 ± 2%; P < 0.05), though the magnitude of this improvement did not differ between groups (P = 0.7). Exercise training also increased the activity of the skeletal muscle oxidative enzymes citrate synthase (P < 0.05) and cytochrome c oxidase (P < 0.05), an effect that did not differ between groups (P = 0.2). These data suggest that 6 mo of progressive exercise training improves V̇o_2max in individuals with burn injuries and that the magnitude of body surface area burned does not lessen this adaptive response.

Estimated versus achieved maximal oxygen consumption in severely burned children maximal oxygen consumption in burned children

PURPOSE

In burned children, exercise training increases maximal oxygen consumption (VO2 max) and can be combined with the nonspecific beta-blocker propranolol to decrease cardiac work. VO2 max is estimated if indirect calorimetry is not available. We compared measured and estimated VO2 max in severely burned children treated with or without propranolol to determine the suitability of commonly used formulas in these populations.

METHODS

Patients received propranolol or placebo (control) during acute hospitalization. VO2 max was measured during a modified Bruce treadmill test at discharge and compared to values obtained using the Cooper, Bruce, American College of Sports Medicine, and Porro formulas. Pearson correlations and Bland-Altman analyses were used to compare measured and estimated values.

RESULTS

Ninety-nine children (propranolol n=46,control n=53) admitted at our facility between 2003 and 2016 were analyzed. Age at burn (propranolol 12±4years, control 12±3years,p=0.893) and total body surface area burned (propranolol 44±15%,control 49±14%,p=0.090) were comparable between groups. Measured VO2 max was higher in the propranolol group (25.5±6.0mL/min/kg vs. 22.0±4.7mL/min/kg,p=0.002) and was generally lower than estimated values. Age, sex, inhalation injury, body mass index, exercise time, and maximal speed were predictive of measured VO2 max in the control group. Age, sex, and maximal speed were predictive in the propranolol group. Backward selection yielded the formula [7.63+ 2.16×sex(females=0,males=1)+0.41×age(years)+0.15×maximal speed(m/min)] (R2=0.6525).

CONCLUSIONS

Propranolol seems to have beneficial effects on cardiorespiratory capacity in burned children. However, estimated VO2 max with common formulas were too high. The VO2 max formula reported here is suitable for propranolol-treated children and the Porro formula for non-propranolol-treated children.

Effects of structured home-based exercise program on depression status and quality of life in burn patients

BACKGROUND

Burns can cause life-threatening injuries and severe limitations. This study aimed to evaluate the effects of the structured home-based exercise program on depression status and quality of life in burn patients.

MATERIALS AND METHODS

This study was carried out in the Wound and Burn Treatment Department of University of Health Sciences, Dr. Lütfi Kırdar Kartal Education and Research Hospital, Istanbul. Thirty burn patients voluntarily participated in this study. Patients' demographic data such as burn area and grade, percentage, type, number of grafts, and duration of hospitalization were recorded. The quality of life was evaluated using the Short Form-36 (SF-36), and depression status was evaluated using Beck Depression Inventory (BDI). The home-based exercise program was defined by the clinical physiotherapist on the day when the patient was discharged. The home-based exercise program was applied for 3 weeks. Evaluations were performed at discharge and repeated after 3 weeks at the end of the exercise program.

RESULTS

Of the 30 patients who completed the study (age range, 21-61 years; mean, 34.9±12.99 years), 96.7% (n=29) were male and 3.3% (n=1) were female. A statistically significant difference was observed between BDI and SF-36 scores before and after the home-based exercise program (p<0.05). BDI scores decreased after the home-based exercise program, whereas SF-36 scores increased.

CONCLUSION

Our study concludes that burn patients who underwent the structured home-based exercise programs attained acceleration of their physical, social, and psychological integrity. Thus, establishing a structured home-based exercise program according to the burn type and clinical course should be continued.

Exercise training for improving outcomes post-burns: a systematic review and meta-analysis

OBJECTIVES

To determine the effectiveness of different modalities of exercise and to evaluate the safety of exercise-based interventions post-burns.

DATA SOURCES

Six databases were searched from inception to October 2017 using "burn," "exercise" and synonyms as keywords. Relevant authors, key journals and reference lists of included studies were hand-searched.

REVIEW METHODS

Articles reporting on exercise interventions in patients post-burn and considering physical, physiological or psychological outcomes were considered. Two authors independently screened 2253 records and selected 19 articles for inclusion. The quality of the evidence was assessed at the study level and at the outcome level.

RESULTS

Unbiased effect size estimators (pooled Hedges' g) with 95% confidence intervals (CIs) were calculated if there were two or more trials with homogeneous outcomes. There were no significant differences post-exercise training in VO2_peak ( g = 0.99; 95% CI: -0.4 to 2.4: P = 0.18), resting energy expenditure ( g = -0.51; 95% CI: -1.99 to 0.97: P = 0.5) and muscle strength ( g = 0.51; 95% CI: -0.03 to 1.05: P = 0.07) between groups. Evidence suggested exercise had a beneficial effect on body composition ( g = 0.59; 95% CI: 0.05 to 1.14: P = 0.03), need of surgical release of contractures (risk ratio = 0.34; 95% CI: 0.2 to 0.7; P = 0.004) and health-related quality of life. However, a lack of evidence existed regarding the safety of exercise training post-burns.

CONCLUSION

Limited evidence suggests that exercise has a beneficial effect on physical and physiological outcomes in patients post-burn. Further trials using high-quality methodology are required, with focus on reporting of adverse events, health-related quality of life and psychological outcomes.

A systematic review protocol on the effectiveness of therapeutic exercises utilised by physiotherapists to improve function in patients with burns

BACKGROUND

Therapeutic exercises play a crucial role in the management of burn injuries. The broad objective of this review is to systematically evaluate the effectiveness, safety and applicability to low-income countries of therapeutic exercises utilised by physiotherapists to improve function in patients with burns. Population = adults and children/adolescents with burns of any aspect of their bodies. Interventions = any aerobic and/or strength exercises delivered as part of a rehabilitation programme by anyone (e.g. physiotherapists, occupational therapists, nurses, doctors, community workers and patients themselves). Comparators = any comparator. Outcomes = any measure of outcome (e.g. quality of life, pain, muscle strength, range of movement, fear or quality of movement). Settings = any setting in any country.

METHODS/DESIGN

A systematic review will be conducted by two blinded independent reviewers who will search articles on PubMed, CiNAHL, Cochrane library, Medline, Pedro, OTseeker, EMBASE, PsychINFO and EBSCOhost using predefined criteria. Studies of human participants of any age suffering from burns will be eligible, and there will be no restrictions on total body surface area. Only randomised controlled trials will be considered for this review, and the methodological quality of studies meeting the selection criteria will be evaluated using the Cochrane Collaboration tool for assessing risk of bias. The PRISMA reporting standards will be used to write the review. A narrative analysis of the findings will be done, but if pooling is possible, meta-analysis will be considered.

DISCUSSION

Burns may have a long-lasting impact on both psychological and physical functioning and thus it is important to identify and evaluate the effects of current and past aerobic and strength exercises on patients with burns. By identifying the characteristics of effective exercise programmes, guidelines can be suggested for developing intervention programmes aimed at improving the function of patients with burns. The safety and precautions of exercise regimes and the optimal frequency, duration, time and intensity will also be examined to inform further intervention.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CDR42016048370 .

Resistance training for rehabilitation after burn injury: A systematic literature review & meta-analysis

BACKGROUND/AIM

Resistance training is beneficial for rehabilitation in many clinical conditions, though this has not been systematically reviewed in burns. The objective was to determine the effectiveness of resistance training on muscle strength, lean mass, function, quality of life and pain, in children and adults after burn injury.

METHODS

Medline & EMBASE, PubMed, CINAHL and CENTRAL were searched from inception to October 2016. Studies were identified that implemented resistance training in rehabilitation. Data were combined and included in meta-analyses for muscle strength and lean mass. Otherwise, narrative analysis was completed. The quality of evidence for each outcome was summarised and rated using the GRADE framework.

RESULTS

Eleven studies matched our inclusion criteria. Primary analysis did not demonstrate significant improvements for increasing muscle strength (SMD 0.74, 95% CI -0.02 to 1.50, p=0.06). Sensitivity analysis to correct an apparent anomaly in published data suggested a positive effect (SMD 0.37, 95% CI 0.08-0.65, p=0.01). Psychological quality of life demonstrated benefit from training (MD=25.3, 95% CI 3.94-49.7). All studies were rated as having high risk of bias. The quality of the evidence was rated as low or very low.

CONCLUSION

Further research with robust methodology is recommended to assess the potential benefit suggested in this review.

Poor methodological quality and reporting standards of systematic reviews in burn care management

The methodological and reporting quality of burn-specific systematic reviews has not been established. The aim of this study was to evaluate the methodological quality of systematic reviews in burn care management. Computerised searches were performed in Ovid MEDLINE, Ovid EMBASE and The Cochrane Library through to February 2016 for systematic reviews relevant to burn care using medical subject and free-text terms such as 'burn', 'systematic review' or 'meta-analysis'. Additional studies were identified by hand-searching five discipline-specific journals. Two authors independently screened papers, extracted and evaluated methodological quality using the 11-item A Measurement Tool to Assess Systematic Reviews (AMSTAR) tool and reporting quality using the 27-item Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Characteristics of systematic reviews associated with methodological and reporting quality were identified. Descriptive statistics and linear regression identified features associated with improved methodological quality. A total of 60 systematic reviews met the inclusion criteria. Six of the 11 AMSTAR items reporting on 'a priori' design, duplicate study selection, grey literature, included/excluded studies, publication bias and conflict of interest were reported in less than 50% of the systematic reviews. Of the 27 items listed for PRISMA, 13 items reporting on introduction, methods, results and the discussion were addressed in less than 50% of systematic reviews. Multivariable analyses showed that systematic reviews associated with higher methodological or reporting quality incorporated a meta-analysis (AMSTAR regression coefficient 2.1; 95% CI: 1.1, 3.1; PRISMA regression coefficient 6·3; 95% CI: 3·8, 8·7) were published in the Cochrane library (AMSTAR regression coefficient 2·9; 95% CI: 1·6, 4·2; PRISMA regression coefficient 6·1; 95% CI: 3·1, 9·2) and included a randomised control trial (AMSTAR regression coefficient 1·4; 95%CI: 0·4, 2·4; PRISMA regression coefficient 3·4; 95% CI: 0·9, 5·8). The methodological and reporting quality of systematic reviews in burn care requires further improvement with stricter adherence by authors to the PRISMA checklist and AMSTAR tool.

Relief of knee flexion contracture and gait improvement following adaptive training for an assist device in a transtibial amputee: A case study

BACKGROUND

Management of a knee contracture is important for regaining gait ability in transtibial amputees. However, there has been little study of prosthesis training for enhancing mobility and improving range of motion in cases of restricted knee extension.

OBJECTIVE

This study aimed to evaluate the effects of adaptive training for an assist device (ATAD) for a transtibial amputee with a knee flexion contracture (KFC). A male transtibial amputee with KFC performed 4 months of ATAD with a multidisciplinary team. During the ATAD, the passive range of motion (PROM) in the knee, amputee mobility predictor (AMP) assessment, center of pressure (COP) on a force plate-equipped treadmill, gait features determined by three-dimensional motion analysis, and Short-Form 36 Item Health Survey (SF-36) scores were evaluated.

RESULTS

Following ATAD, PROM showed immediate improvement (135.6 ± 2.4° at baseline, 142.5 ± 1.7° at Step 1, 152.1 ± 1.8° at Step 2, 165.8 ± 1.9° at Step 3, and 166.0 ± 1.4° at Step 4); this was followed by an enhanced COP. Gradually, gait features also improved. Additionally, the AMP score (5 at baseline to 29 at Step 4) and K-level (K0 at baseline to K3 at Step 4) increased after ATAD. Along with these improvements, the SF-36 score also improved.

CONCLUSIONS

ATAD could be beneficial for transtibial amputees by relieving knee contractures and improving gait.

Effect of vitamin D supplementation and isokinetic training on muscle strength, explosive strength, lean body mass and gait in severely burned children: A randomized controlled trial

OBJECTIVE

To determine the effects of vitamin D (VD) supplementation and isokinetic training on muscle strength, explosive strength (counter movement jump) (ES), lean body mass (LBM) and gait parameters in severe pediatric burn.

METHODS

Forty-eight burned children with circumferential lower extremity burns covering 40-55% of the total body surface area (TBSA), aged 10-16 years (Mean±SD 13.01±1.75), were randomized into the standard of care (n=16), isokinetic (n=17) and VD (n=15) groups. Unburned children (n=20) served as matched controls. All burned children received 12 weeks of routine physical therapy program (RPTP). In addition, the isokinetic group received isokinetic training for the quadriceps dominant limb 3 times per week at angular velocity 150°/s, and the VD group received the isokinetic training plus an oral daily dose of vitamin D₃ 1000 IU (Cholecalciferol). The primary measures, assessed at baseline and 12 weeks, included quadriceps strength by isokinetic dynamometer, ES, LBM by dual-energy X-ray absorptiometry (DEXA) and gait parameters by GAITRite system.

RESULTS

The VD and isokinetic groups showed significant improvement in quadriceps strength, ES, LBM and gait parameters compared with the standard of care, and VD group show significant improvement in the VD level as compared with the other groups. The outcome measures (and percent of improvement where applicable) for the VD, isokinetic and standard of care are as follows: quadriceps strength, 85.25±0.93Nm (85%), 64.25±0.93 (36%) and 51.88±1.31Nm (12%); stride length, 94.00±2.69 (7%), 110.60±2.87 (25%) and 139.56±2.57 (60%); step length, 67.26±2.45 (72%), 55.25±2.49 (43%) and 43.76±1.34 (18%); velocity, 133.94±1.65 (82%), 99.94±1.65 (35%) and 80.11±1.91 (9%); and cadence, 140.63±1.36 (68%), 132.63±1.36 (58%) and 90.35±1.32 (9%), VD level 43.33±7.48 (75%), 24.77±7.38 (5%) and 25.63±8.39 (4%) respectively.

CONCLUSIONS

VD supplementation combined with exercise training significantly increased muscle strength, ES, LBM, gait and VD level in severely burned children.

The metabolic stress response to burn trauma: current understanding and therapies

Major burns provoke a profound stress response, which is unrivalled in terms of its magnitude and duration. Evidence suggests that the pathophysiological stress response to severe burn trauma persists for several years after injury. Thus, there is a pressing need for novel strategies that mitigate this response and restore normal metabolic function in patients with burns. This is the first in a Series of three papers about the care of people with burns. In this paper, we review the current knowledge of the stress response to burn trauma, with a focus on hypermetabolism, muscle wasting, and stress-induced diabetes. We highlight recent developments and important knowledge gaps that need to be pursued to develop novel therapeutic strategies to improve outcomes in burn survivors.

Effectiveness of resistance strength training in children and adolescents with ≥30% total body surface area: A systematic review

Purpose

Children and adolescents with burn injuries are at risk of living with social, educational, physical and psychological impairments. The systematic review aimed to ascertain the effectiveness of resistance strength training on muscle strength and lean body mass (LBM) in children and adolescents with burn injuries.

Method

Five databases were searched. Randomised controlled trials with an intervention defined as a supervised, individualised resistance exercise programme were sought. The outcomes included muscle strength and/or LBM. The PEDro scale was used to describe the methodological quality. Comparable data were combined using RevMan^©.

Results

Seven papers were included in the review with an average methodological appraisal score of 5.7/11. Comparable data were combined for muscle strength and LBM. The meta-analysis revealed no significant clinical difference between the exercise and standard care groups after 3 months of strength training for both muscle strength (p = 0.43) and LBM (p = 0.60).

Conclusions

There is no conclusive evidence to support the benefit of strength training for children and adolescents with burns injuries in terms of muscle strength and LBM. However, it appears that isokinetic training might benefit children and adolescents with burns, but more studies investigating the effect of isokinetic training are required.

Effects of whole-body vibration exercise on bone mineral content and density in thermally injured children

BACKGROUND

Loss of bone mass, muscle mass, and strength leads to significant disability in severely burned children. We assessed the effects of exercise combined with whole-body vibration (WBV) on bone mass, lean mass (LM), and muscle strength in children recovering from burns.

METHODS

Nineteen burned children (≥30% total body surface area [TBSA] burns) were randomly assigned to a 6-week exercise regimen either alone (EX; n=10) or in combination with a 6-week WBV training regimen (EX+WBV; n=9). WBV was performed concurrent to the exercise regimen for 5days/week on a vibrating platform. Dual-energy X-ray absorptiometry quantified bone mineral content (BMC), bone mineral density (BMD), and LM; knee extension strength was assessed using isokinetic dynamometry before and after training. Alpha was set at p<0.05.

RESULTS

Both groups were similar in age, height, weight, TBSA burned, and length of hospitalization. Whole-body LM increased in the EX group (p=0.041) and trended toward an increase in the EX+WBV group (p=0.055). On the other hand, there were decreases in leg BMC for both groups (EX, p=0.011; EX+WBV, p=0.047), and in leg BMD for only the EX group (EX, p<0.001; EX+WBV, p=0.26). Truncal BMC decreased in only the EX group (EX, p=0.009; EX+WBV, p=0.61), while BMD decreased in both groups (EX, p<0.001; EX+WBV group, p<0.001). Leg strength increased over time in the EX group (p<0.001) and the EX+WBV group (p<0.001; between-group p=0.31).

CONCLUSIONS

Exercise in combination with WBV may help attenuate regional bone loss in children recovering from burns. Studies are needed to determine the optimal magnitude, frequency, and duration of the vibration protocol, with attention to minimizing any potential interference with wound healing and graft closure.

Recovery trajectories after burn injury in young adults: does burn size matter?

The impact of burn size on mortality is well known, but the association of burn size with the trajectories of long-term functional outcomes remains poorly studied. This prospective multi-center study included burned adults ages 19 to 30 years who completed the Young Adult Burn Outcome Questionnaire at initial baseline contact, 2 weeks, and at 6 and 12 months after initial questionnaire administration. Non-burned adults of comparable ages also completed the questionnaire as a reference group. The association between functional recovery and TBSA burned was analyzed longitudinally using generalized linear models with the generalized estimation equation technique. Functional status was characterized in 15 domains: physical function, fine motor function, pain, itch, social function limited by physical function, perceived appearance, social function limited by appearance, sexual function, emotion, family function, family concern, satisfaction with symptom relief, satisfaction with role, work reintegration, and religion. Scores were standardized to a mean of 50 and a SD of 10 based on non-burned controls. There were 153 burned and 112 non-burned subjects with a total of 620 questionnaires. TBSA burned was 11 ± 14% (mean ± SD); 31% had face involvement and 57% had hand involvement. The lag time from burn injury to questionnaire administration was on average 7 ± 7.7 months, with a maximum of 36 months. Lower recovery levels were associated with increasing burn size for physical function, pain, itch, work reintegration, emotion, satisfaction with symptom relief, satisfaction with role, family function, and family concern (P value ranged from .04-<.0001). No significant differences in recovery levels were found with increasing burn size for fine motor function, social function limited by physical function, sexual function, and religion; these areas tracked toward the age-matched non-burned group regardless of burn size. Perceived appearance and social function limited by appearance remained below the non-burn levels throughout the 3-year period regardless of burn size. Three-year recovery trajectories of survivors with larger burn size showed improvements in most areas, but these improvements lagged behind those with smaller burns. Poor perceived appearance was persistent and prevalent regardless of burn size and was found to limit social function in these young adult burn survivors. Expectations for multidimensional recovery from burns in young adults can be benchmarked based on burn size with important implications for patient monitoring and intervening in clinical care.

The role of exercise in the rehabilitation of patients with severe burns

Severe burn trauma results in persistent skeletal muscle catabolism and prolonged immobilization. We hypothesize that structured rehabilitative exercise is a safe and efficacious strategy to restore lean body mass and physical function in burn victims. Here, we review the evidence for the utility of rehabilitative exercise training in restoring physiological function in burn survivors.

Review of burn research for the year 2011

The year 2011 was another robust year for burn research. Over 1100 articles were published on a wide range of burn injury and treatment topics. In this review, we highlight some of the interesting and potentially influential research in the following areas: critical care, infection, inhalation injury, epidemiology, wound characterization and treatment, nutrition and metabolism, pain management, burn reconstruction, psychology, and rehabilitation. As in years past, burn injury research reflects the multidisciplinary and holistic care that is needed to treat this challenging injury condition.

How disabling are pediatric burns? Functional independence in Dutch pediatric patients with burns

Although the attention for functional outcomes after burn injury has grown over the past decades, little is known about functional independence in performing activities of daily living in children after burn injury. Therefore, in this prospective cohort study functional independence was measured by burn care professionals with the WeeFIM(®) instrument in 119 pediatric patients with burns (age: 6 months-16 years; 58.8% boys) in the Netherlands. In order to identify whether functional independence was affected, participants' total scores on the WeeFIM(®) instrument were compared to American norm values. Of the participants assessed at 2 weeks post burn (n = 117), 3 months post burn (n = 68) and/or 6 months post burn (n = 38), 22, 9 and 9 participants showed affected performance, respectively. Improvements in WeeFIM(®) total scores for the total study population between 2 weeks and 6 months post burn were significant (Wilcoxon T = 2.5; p<.001, effect size = -0.59). Individual improvements were found to be significant for 30.3% of the assessed participants between 2 weeks and 3 months post burn, and for 12.1% between 3 and 6 months post burn. This study is unique in providing data on functional independence for this large and special population. However, a proportion of participants were lost to follow-up and the use of the WeeFIM(®) instrument in this specific population and setting has its limitations. To conclude, burn injury impacts functional independence in children, yet the vast majority of Dutch pediatric patients with burns returns to functional independence typical for age within 6 months post burn.

Design of a cross-sectional study on physical fitness and physical activity in children and adolescents after burn injury

Background

Burn injuries have a major impact on the patient’s physical and psychological functioning. The consequences can, especially in pediatric burns, persist long after the injury. A decrease in physical fitness seems logical as people survive burn injuries after an often extensive period of decreased activity and an increased demand of proteins leading to catabolism, especially of muscle mass. However, knowledge on the possibly affected levels of physical fitness in children and adolescents after burn injury is limited and pertains only to children with major burns. The current multidimensional study aims to determine the level of physical fitness, the level of physical activity, health-related quality of life and perceived fatigue in children after a burn injury. Furthermore, interrelations between those levels will be explored, as well as associations with burn characteristics.

Methods/design

Children and adolescents in the age range of 6 up to and including 18 years are invited to participate in this cross-sectional descriptive study if they have been admitted to one of the three Dutch burn centers between 6 months and 5 years ago with a burn injury involving at least 10% of the total body surface area and/or were hospitalized ≥ 6 weeks. Physical fitness assessments will take place in a mobile exercise lab. Quantitative measures of cardiorespiratory endurance, muscular strength, body composition and flexibility will be obtained. Outcomes will be compared with Dutch reference values. Physical activity, health-related quality of life and fatigue will be assessed using accelerometry and age-specific questionnaires.

Discussion

The findings of the current study will contribute to a better understanding of the long-term consequences of burn injury in children and adolescents after burns. The results can guide rehabilitation to facilitate a timely and optimal physical recovery.

Trial registration

The study is registered in the National Academic Research and Collaborations Information System of the Netherlands (OND1348800).