Injury-related fear-avoidance, neuroticism and burn-specific health

Early predictors of health-related quality of life outcomes at 12 months post-burn: ABLE study

There remains a paucity of evidence on the early predictors of long-term Health-Related Quality of Life (HRQoL) outcomes post-burn in hospitalised adults. The overall aim of this study was to identify the factors (personal, environmental, burn injury and burn treatment factors) that may predict long-term HRQoL outcomes among adult survivors of hospitalised burn injuries at 12 months post-burn. A total of 274 participants, aged 18 years or over, admitted to a single state-wide burn centre with a burn injury were recruited. Injury and burn treatment information were collected from medical records or the hospital database and surveys collected demographic and social data. HRQoL outcome data were collected at 3-, 6- and 12-months using the 12-Item Short Form Survey (SF-12 v1) and Burns Specific Health Scale-Brief (BSHS-B). Personal, environmental, burn injury and burn treatment factors were also recorded at baseline. Analyses were performed using linear and logistic regression. Among 274 participants, 71.5 % (N=196) remained enrolled in the study at 12 months post-burn. The majority of participants reported HRQoL outcomes comparable with population norms and statistically significant improvements in generic (SF-12 v1) and condition-specific (BSHS-B) outcomes over time. However, for participants with poor HRQoL outcomes at 12-months post-burn, Univariable predictors included longer hospital length of stay, unemployment at the time of injury, a diagnosed pre-injury mental health condition, inadequate pre-burn social support, intentional injury, recreational drug use pre-injury and female gender. The early multivariable predictors of insufficient HRQoL outcomes were female gender, a previously diagnosed mental health condition, unemployment, inadequate social support, intentional injury, and prolonged hospital length of stay. These results suggest potential factors that could be used to screen and burns patients for psychosocial intervention and long-term follow up.

Validation of the Burn Survivor Fear-Avoidance Questionnaire and Its Association With Pain Intensity, Catastrophizing, and Disability

According to the Fear-avoidance (FA) model, FA beliefs can lead to disability due to avoidance of activities expected to result in pain or further injury. Extensive research on the relationship of FA, pain, catastrophizing, and disability has been generated with patients suffering from chronic neck and back pain, but little research has been conducted with burn survivors. To address this need, the Burn Survivor FA Questionnaire (BSFAQ) was developed (Langlois J, Vincent-Toskin, S, Duchesne, P et al. Fear-avoidance beliefs and behaviors of burn survivors: A mixed-methods approach. Burns 2021;47:175-89.) but has not been validated. Thus, the primary objective of this study was to investigate the construct validity of the BSFAQ among burn survivors. The secondary objective was to examine the relationship between FA and 1) pain intensity and 2) catastrophizing at baseline, 3 months and 6 months postburn, and 3) disability among burn survivors at 6 months postburn. A prospective mixed-methods approach was used to examine the construct validity by comparing the quantitative scores of the BSFAQ to independently performed qualitative interviews of burn survivors (n = 31) that explored their lived experiences, to determine if the BSFAQ discriminated those who had, from those who did not have FA beliefs. Data for the secondary objective, scores of burn survivors (n = 51) pain intensity (numeric rating scale), catastrophizing (pain catastrophizing scale), and disability (Burn Specific Health Scale-brief), were collected through a retrospective chart review. For the primary objective, Wilcoxon rank sum test results showed a statistically significant difference (P = .015) between the BSFAQ scores of participants who were identified from the qualitative interviews as fear avoidant compared to those who were identified as non fear avoidant, with a receiver operating characteristic curve indicating that the BSFAQ correctly predicted FA 82.4% of the time. For the secondary objective, Spearman correlation test results showed a moderate correlation between FA and 1) pain at baseline (r = .466, P = .002), 2) catastrophizing thoughts over time (r = .557, P = .000; r = .470, P = .00; r = .559, P = .002 respectively at each time point), and 3) disability at 6 months postburn (r = -.643, P = .000). These results support that the BSFAQ is able to discriminate which burn survivors are experiencing FA beliefs. It is also consistent with the FA model since burn survivors who express FA are more likely to report higher levels of pain early during their recovery that correlates with persistently elevated catastrophizing thoughts and ultimately results in higher self-reported disability. The BSFAQ demonstrates construct validity and is able to correctly predict fear-avoidant burn survivors; however, additional research is required to further examine the BSFAQ's clinimetric properties.

Fear avoidance beliefs and behaviors of burn survivors: A mixed methods approach

The Fear-Avoidance Model was developed with patients who had sustained neck and back injuries and describes a cascade of events after pain that is perceived as threatening, which may lead to avoidance of valued and meaningful life activities. The literature examining burn survivors suggests they may experience fear-avoidance, however, their lived experience has yet to be thoroughly explored and the evaluation tool that has been used is four items extracted from the Tampa Scale of Kinesiophobia that were modified for burn survivors, but never formally validated with this population. Therefore, the aim of this study was to explore, through a mixed methods approach, the lived experience of burn survivors with respect to fear-avoidance and determine whether the reduced four question Tampa Scale of Kinesiophobia (4TSK) reflects and accurately measures their experience. Burn survivors (n = 17) who had undergone surgical debridement and grafting were recruited. They completed the reduced 4TSK and participated in an in-depth interview to explore their lived experience regarding fear-avoidance and their opinions on the relevance of the questions. The interviews were analyzed using a thematic-analysis approach. Five major themes that represented the lived experience of fear-avoidance in burn survivors were identified: perceived vulnerability to re-injury, others as fear influencers, difficulties & hardships during recovery, engagement in activity, and active thoughts. Based upon the interviews researchers identified 9 potential fear-avoidant participants, which differed from the screening results from the reduced 4TSK (n = 12). Overall, this study demonstrated the potential uniqueness of the burn survivor population and provided insight into their lived experience of fear of movement or activities.

Comparison of upper limb burn injury versus simulated pathology in terms of gait and footprint parameters

BACKGROUND

Little is known about whether a simulated upper limb condition reflects a real (burn-injury) upper limb pathology in terms of gait/footprint parameters.

RESEARCH QUESTION

The main aim of this study was to investigate the differences in these parameters between two conditions (real-simulation).

METHODS

The study included burn patients (n = 30) and a control group of 30 healthy subjects. Gait and footprint parameters were evaluated using the GAITRite electronic walkway. Kinesiophobia and pain were assessed with the Tampa Kinesiophobia Scale and Visual Analog Scale, respectively. Gait evaluation of the control group was performed randomly in two conditions:1. Normal arm swing (control group) 2.Elbow flexed at 90° with a bandage (simulated group).

RESULTS

Step and stride length in the burn group were significantly shorter than in the other groups (p < 0.05). Stance phase was significantly higher while swing phase, velocity and cadence were lower in the burn group (p < 0.05). Peak time in the midfoot for both sides were significantly higher in the burn group (p < 0.05). Peak time in the hindfoot for the affected side was significantly lower while peak time in the hindfoot for the intact side was significantly higher in the burn group compared to the simulated group (p < 0.05). There were significant correlations between pain, kinesiophobia and velocity, and cadence in the burn group (p < 0.05).

SIGNIFICANCE

Compared to the other groups, patients with burn injury have different gait/footprint parameters due to increased pain and kinesiophobia. To determine the effects of upper limb injury and arm swing on gait parameters, a real pathology should be considered rather than a simulated pathology.

The Fear-Avoidance Components Scale (FACS): Responsiveness to Functional Restoration Treatment in a Chronic Musculoskeletal Pain Disorder (CMPD) Population

OBJECTIVES

To assess the clinical validity and factor structure of the Fear-Avoidance Components Scale (FACS), a new fear-avoidance measure.

MATERIALS AND METHODS

In this study, 426 chronic musculoskeletal pain disorder patients were admitted to a Functional Restoration Program (FRP). They were categorized into 5 FACS severity levels, from subclinical to extreme, at admission, and again at discharge. Associations with objective lifting performance and other patient-reported psychosocial measures were determined at admission and discharge, and objective work outcomes for this predominantly disabled cohort, were assessed 1 year later.

RESULTS

Those patients in the severe and extreme FACS severity groups at admission were more likely to "drop out" of treatment than those in the lower severity groups (P=0.05). At both admission and discharge, the FACS severity groups were highly and inversely correlated with objective lifting performance and patient-reported fear-avoidance-related psychosocial variables, including kinesiophobia, pain intensity, depressive symptoms, perceived disability, perceived injustice, and insomnia (Ps<0.001). All variables showed improvement at FRP discharge. Patients in the extreme FACS severity group at discharge were less likely to return to, or retain, work 1 year later (P≤0.02). A factor analysis identified a 2-factor solution.

DISCUSSION

Strong associations were found among FACS scores and other patient-reported psychosocial and objective lifting performance variables at both admission and discharge. High discharge-FACS scores were associated with worse work outcomes 1 year after discharge. The FACS seems to be a valid and clinically useful measure for predicting attendance, physical performance, distress, and relevant work outcomes in FRP treatment of chronic musculoskeletal pain disorder patients.

Predictors of health-related quality of life after burn injuries: a systematic review

Background

Identifying predictors of health-related quality of life (HRQL) following burns is essential for optimization of rehabilitation for burn survivors. This study aimed to systematically review predictors of HRQL in burn patients.

Methods

Medline, Embase, Web of Science, Cochrane, CINAHL, and Google Scholar were reviewed from inception to October 2016 for studies that investigated at least one predictor of HRQL after burns. The Quality in Prognostic Studies tool was used to assess risk of bias of included studies.

Results

Thirty-two studies were included. Severity of burns, postburn depression, post-traumatic stress symptoms, avoidance coping, less emotional or social support, higher levels of neuroticism, and unemployment postburn were found to predict a poorer HRQL after burns in multivariable analyses. In addition, weaker predictors included female gender, pain, and a postburn substance use disorder. Risk of bias was generally low in outcome measurement and high in study attrition and study confounding.

Conclusions

HRQL after burns is affected by the severity of burns and the psychological response to the trauma. Both constructs provide unique information and knowledge that are necessary for optimized rehabilitation. Therefore, both physical and psychological problems require attention months to years after the burn trauma.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-2071-4) contains supplementary material, which is available to authorized users.

Health related quality of life in adults after burn injuries: A systematic review

OBJECTIVES

Measurement of health-related quality of life (HRQL) is essential to qualify the subjective burden of burns in survivors. We performed a systematic review of HRQL studies in adult burn patients to evaluate study design, instruments used, methodological quality, and recovery patterns.

METHODS

A systematic review was performed. Relevant databases were searched from the earliest record until October 2016. Studies examining HRQL in adults after burn injuries were included. Risk of bias was scored using the Quality in Prognostic Studies tool.

RESULTS

Twenty different HRQL instruments were used among the 94 included studies. The Burn Specific Health Scale-Brief (BSHS-B) (46%), the Short Form-36 (SF-36) (42%) and the EuroQol questionnaire (EQ-5D) (9%) were most often applied. Most domains, both mentally and physically orientated, were affected shortly after burns but improved over time. The lowest scores were reported for the domains 'work' and 'heat sensitivity' (BSHS-B), 'bodily pain', 'physical role limitations' (SF-36), and 'pain/discomfort' (EQ-5D) in the short-term and for 'work' and 'heat sensitivity', 'emotional functioning' (SF-36), 'physical functioning' and 'pain/discomfort' in the long-term. Risk of bias was generally low in outcome measurement and high in study attrition.

CONCLUSION

Consensus on preferred validated methodologies of HRQL measurement in burn patients would facilitate comparability across studies, resulting in improved insights in recovery patterns and better estimates of HRQL after burns. We recommend to develop a guideline on the measurement of HRQL in burns. Five domains representing a variety of topics had low scores in the long-term and require special attention in the aftermath of burns.

Sexual Function Following Burn Injuries: Literature Review

Sexual function is a profound facet of the human personality. Burns due their sudden and devastating nature can have longstanding effects on intimate function by virtue of physical sequelae as well as alterations in body image and perceived desirability. A considerable number of patients encounter problems with intimate function in burns rehabilitation; nevertheless, the topic appears to be poorly addressed in specialist centers worldwide. Review of the literature suggests that a number of parameters can affect the quality of sexual life following burn injuries including age at the time of injury, location, and severity of the burn as well as coping mechanisms employed by the individual survivor. Addressing issues of intimacy relies on awareness, education, and a holistic approach on behalf of the multidisciplinary team members and, to this effect, recommendations are made on managing sexual function concerns in burns rehabilitation.

Injury-related fear-avoidance and symptoms of posttraumatic stress in parents of children with burns

Parents of children with burns experience a range of psychological reactions and symptoms, and parents' health is known to impact children's health. So far, there is little research into potential mechanisms that maintain parents' symptoms. The aim was to investigate parental injury-related fear-avoidance, and its associations with injury severity and health measures. Parents (n=107) of children aged 0.4-18 years that sustained burns 0.1-9.0 years previously completed questionnaires on fear-avoidance, posttraumatic stress, and health of the child. Analyses showed that the average level of fear-avoidance was low and positively associated with measures of injury severity and parents' symptoms of posttraumatic stress, and negatively associated with parents' ratings of their child's health. In two separate multiple regressions with parents' symptoms of PTSD and the child's health as dependent variables, fear-avoidance made the largest contribution in both models while injury severity was non-significant. Results were not related to comorbid conditions of the child, scarring, or parent-related socio-demographic variables. In summary, injury-related fear-avoidance is more likely among parents whose children sustain more severe burns. In turn, fear-avoidance contributes significantly to parents' symptoms of PTSD and to poorer health ratings regarding the child, irrespective of injury severity or child comorbidity.

Perceived support in parents of children with burns

OBJECTIVE

Children sustaining burns that require treatment in a burn center have a need for multiprofessional aftercare services over a prolonged time. So far, there is little research into satisfaction with care and support after pediatric burns. The aim was to investigate parents' perception of support after pediatric burn and associations with parent, child and injury characteristics.

METHOD

Parents (n=101) of children aged 0.4-17.8 years completed questionnaires on support, parent's psychological symptoms and health of the child. Time since injury was 0.1-9.0 years.

RESULTS

Perceived lack of psychosocial, medical, societal or family support was reported by 21% of the parents. Lack of support was not associated with injury or sociodemographic characteristics, but it was significantly associated with parents' symptoms of general anxiety, depression and injury-related fear avoidance, as well as parents' ratings of their child's general health and heat sensitivity.

CONCLUSION

Perceived support did not differ on account of burn severity or sociodemographic status. However, care providers should be more attentive to and supportive of parents signaling poorer general health in their child and cognitive beliefs that the child is at risk for harm when active and parents who themselves show signs of psychological symptoms.

The Fear-avoidance Components Scale (FACS): Development and Psychometric Evaluation of a New Measure of Pain-related Fear Avoidance

Pain-related fear avoidance (FA), a common problem for patients with painful medical conditions, involves pain-related catastrophizing cognitions, hypervigilance, and avoidance behaviors, which can ultimately lead to decreased functioning, depression, and disability. Several patient-reported instruments have been developed to measure FA, but they have been criticized for limited construct validity, inadequate item specificity, lack of cutoff scores, and missing important FA components. The Fear-Avoidance Components Scale (FACS) is a new patient-reported measure designed to comprehensively evaluate FA in patients with painful medical conditions. It combines important components of FA found in prior FA scales, while trying to correct some of their deficiencies, within a framework of the most current FA model. Psychometric evaluation of the FACS found high internal consistency (α = 0.92) and high test/retest reliability (r = 0.90-0.94, P < 0.01). FACS scores differentiated between 2 separate chronic pain patient samples and a nonpatient comparison group. When clinically relevant severity levels were created, FACS severity scores were highly associated with FA-related patient-reported psychosocial and objective lifting performance variables. These results suggest that the FACS is a psychometrically strong and reliable measure that can help healthcare providers assess FA-related barriers to function and recovery.

The psychiatric sequelae of burn injury

OBJECTIVE

To examine factors predicting psychiatric morbidity, taking into account the full range of psychiatric disorders before and after burn injury.

METHODS

A cohort of 107 patients consecutively admitted to a Swedish national burn center was examined for lifetime psychiatric morbidity, as well as 94 patients at 1 year postinjury. Sixty-seven individuals, some from that same cohort, were interviewed at 2 to 7years postinjury. The predictive effects of psychiatric history, personality and other risk factors for psychiatric morbidity following burn were evaluated with multiple regression analyses.

RESULTS

The prevalence of having a psychiatric disorder preburn was 57%. One year postinjury 19% had minor or major depression and 23% had subsyndromal or full posttraumatic stress disorder. At 2 to 7years, 31% fulfilled the criteria for a psychiatric disorder. The strongest contributing factors were a history of psychiatric morbidity and neuroticism.

CONCLUSIONS

Two-thirds of the patients had a lifetime psychiatric disorder, and one-third had a psychiatric diagnosis 2 to 7years postburn. Mental health problems can have a major impact on daily life and functional abilities. Thus, identification and treatment of a range of psychiatric disorders, taking into account preburn psychiatric disorders and personality, is important for optimal adjustment after burn.

Impact of personality disorders on health-related quality of life one year after burn injury

PURPOSE

Personality disorders (PDs) are associated with significant distress, disability, and cause great difficulties in life. PDs have been suggested to influence adaptation after major burns, but the potential relationship has not been fully elucidated. This study aimed to describe the prevalence of PDs in 107 patients with major burn injury, and to identify the impact of PDs on perceived patient outcome assessed as health-related quality of life (HRQoL) one year after burn.

METHODS

One burn-specific instrument (Burn Specific Health Scale-Brief (BSHS-B)) and two generic instruments (EuroQol Five Dimensions and Short Form 36 Health Survey) were used, and Psychiatric Axis I and II disorders were assessed one year post burn.

RESULTS

This study identified an above normal prevalence of PDs among individuals afflicted by burn, and participants with PD had a significantly larger lifetime burden of Axis I disorders compared to participants without PD. Participants with PDs scored significantly lower than those without PD in the BSHS-B domain Skin involvement, and the effect of having a PD was related to the subscale Treatment regimens. There was no relationship between the presence of PD and generic HRQoL.

CONCLUSIONS

An implication of these observations is that special rehabilitation efforts including more tailored interventions must be offered to these patients to ensure that the obstacles they perceive to caring for themselves in this respect are eliminated.

IMPLICATIONS FOR REHABILITATION

This study identified an above normal prevalence of PDs among individuals afflicted by burn and these individuals reported poor burn-specific health-related quality of life. The identification of difficulties with compliance and endurance regarding daily skin care may cause negative consequences for optimal rehabilitation and underscore the importance of offering more tailored interventions in rehabilitation. Inflexible behavioral patterns related to the PD diagnosis imply the need for communication strategies by the rehabilitation team, which include flexibility, creativity, and diplomacy. There is a need for further research focusing on identifying the factors that facilitate the individual's own ability to take action and have control.

Sexuality in burn victims: an integrative literature review

AIMS

To analyze and synthesize knowledge concerning sexuality in adult burn victims through an integrative literature review.

METHOD

Two researchers independently searched six electronic databases (PUBMED, LILACS, ISI Web of Science, PSYCINFO, CINAHL and EMBASE) and also performed a hand search using the following descriptors, in different combinations: burn, sexuality, gender identity, sexual behavior and sexual factors, in order to identify the articles published in English, Portuguese or Spanish, in the last 20 years. A total of 1781 articles were found and 22 were selected based on the inclusion and exclusion criteria.

RESULTS

The findings were organized into two categories that influence sexuality: (1) studies where the main purpose was to assess sexuality in burn victims; (2) studies that indirectly assess sexuality.

CONCLUSION

The synthesis of the knowledge concerning sexuality in burn victims showed that sexual dysfunction can be related to the younger ages, TBSA > 20%, burns on the genitalia and on exposed areas, prolonged length of hospital stay, avoidance coping, and mental disorders. The multidisciplinary team should be prepared to integrate sexuality as an important variable in the continuing treatment of burn patients.

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.

Bench-to-bedside review: Burn-induced cerebral inflammation--a neglected entity?

Severe burn injury remains a major burden on patients and healthcare systems. Following severe burns, the injured tissues mount a local inflammatory response aiming to restore homeostasis. With excessive burn load, the immune response becomes disproportionate and patients may develop an overshooting systemic inflammatory response, compromising multiple physiological barriers in the lung, kidney, liver, and brain. If the blood–brain barrier is breached, systemic inflammatory molecules and phagocytes readily enter the brain and activate sessile cells of the central nervous system. Copious amounts of reactive oxygen species, reactive nitrogen species, proteases, cytokines/chemokines, and complement proteins are being released by these inflammatory cells, resulting in additional neuronal damage and life-threatening cerebral edema. Despite the correlation between cerebral complications in severe burn victims with mortality, burn-induced neuroinflammation continues to fly under the radar as an underestimated entity in the critically ill burn patient. In this paper, we illustrate the molecular events leading to blood–brain barrier breakdown, with a focus on the subsequent neuroinflammatory changes leading to cerebral edema in patients with severe burns.

Fear of movement and (re)injury in chronic musculoskeletal pain: Evidence for an invariant two-factor model of the Tampa Scale for Kinesiophobia across pain diagnoses and Dutch, Swedish, and Canadian samples

The aims of the current study were twofold. First, the factor structure, reliability (i.e., internal consistency), and validity (i.e., concurrent criterion validity) of the Tampa Scale for Kinesiophobia (TSK), a measure of fear of movement and (re)injury, were investigated in a Dutch sample of patients with work-related upper extremity disorders (study 1). More specifically, examination of the factor structure involved a test of three competitive models: the one-factor model of all 17 TSK items, a one-factor model of the TSK (Woby SR, Roach NK, Urmston M, Watson P. Psychometric properties of the TSK-11: a shortened version of the Tampa Scale for Kinesiophobia. Pain 2005;117:137-44.), and a two-factor model of the TSK-11. Second, invariance of the aforementioned TSK models was examined in patients with chronic musculoskeletal pain conditions (i.e., work-related upper extremity disorders, chronic low back pain, fibromyalgia, osteoarthritis) from The Netherlands, Sweden, and Canada was assessed (study 2). Results from study 1 showed that the two-factor model of the TSK-11 consisting of 'somatic focus' (TSK-SF) and 'activity avoidance' (TSK-AA) had the best fit. The TSK factors showed reasonable internal consistency, and were modestly but significantly related to disability, supporting the concurrent criterion validity of the TSK scales. Results from study 2 showed that the two-factor model of the TSK-11 was invariant across pain diagnoses and Dutch, Swedish, and Canadian samples. Altogether, we consider the TSK-11 and its two subscales a psychometrically sound instrument of fear of movement and (re)injury and recommend to use this measure in future research as well as in clinical settings.