Status of adult inpatient burn rehabilitation in Europe: Are we neglecting metabolic outcomes?

Effects of exercise training on muscle wasting, muscle strength and quality of life in adults with acute burn injury

OBJECTIVES

Exercise training during the acute phase of burns is difficult to implement but offers potential benefits. This multicenter trial explored the effects of an exercise program on muscular changes and quality of life during burn center stay.

METHODS

Fifty-seven adults with burns ranging between 10% and 70% TBSA were allocated to receive either standard of care (n = 29), or additionally exercise (n = 28), consisting of resistance and aerobic training, commenced as early as possible according to safety criteria. Muscle wasting (primary outcome), quantified by ultrasound-derived quadriceps muscle layer thickness (QMLT) and rectus femoris cross-sectional area (RF-CSA), muscle strength and quality of life (Burn Specific Health Scale-Brief (BSHS-B) and EQ-5D-5L) were assessed at baseline, four and eight weeks later, or hospital discharge. Mixed models were used to analyze between-group changes over time with covariates of interest added in stepwise forward modeling.

RESULTS

The addition of exercise training to standard of care induced significant improvements in QMLT, RF-CSA, muscle strength and the BSHS-B subscale hand function (ß-coefficient. 0.055 cm/week of QMLT, p = 0.005). No added benefit was observed for other quality-of-life measures.

CONCLUSIONS

Exercise training, administered during the acute phase of burns, reduced muscle wasting, and improved muscle strength throughout burn center stay.

Effectiveness of Early Physiotherapy Rehabilitation Approach for Split Skin Grafting Post-burn in a Pediatric Patient

Childhood is critical for developing social, physical, and cognitive functioning. Burns in children are very different from burns in adults because it is difficult for them to save themselves. Their skin is more sensitive and less heat-resistant; their exposure may last longer, worsening the burn. When neglected, severe disabling and deforming contractures caused by burns in children can result in substantial impairment. Therefore, burn rehabilitation should not be carried out by one person but rather by a multidisciplinary team to ensure that all of the patients' physical, psychological, and social requirements are met while the child is in the hospital and after discharge. The treatment of young burn victims requires a multidisciplinary approach that begins the day of the accident and lasts for several years. To reduce the consequences of the patient's post-traumatic stress and increase functional independence, a thorough rehabilitation programme is needed. The burn team members' dedication, commitment to the patient's care, and encouragement of patient participation and full engagement in rehabilitation can make a difference to juvenile burn patients' long-term quality of life (QOL). We present a seven-year-old female who suffered from a superficial burn over the lateral aspect of her right thigh. Exercise prescriptions should be thoroughly customized to provide the best possible success in rehabilitation, considering the degree of burns and physical limitations. This case report is intended to serve as a practical manual for the necessary clinical knowledge and therapy intervention approaches for managing burn patients successfully.

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.

Reliability and feasibility of skeletal muscle ultrasound in the acute burn setting

OBJECTIVES

Despite the impact of muscle wasting after burn, tools to quantify muscle wasting are lacking. This multi-centre study examined the utility of ultrasound to measure muscle mass in acute burn patients comparing different methodologies.

METHODS

B-mode ultrasound was used by two raters to determine feasibility and inter-rater reliability in twenty burned adults following admission. Quadriceps muscle layer thickness (QMLT) and rectus femoris cross-sectional area (RF-CSA) were measured, comparing the use of i) a single versus average measurements, ii) a proximal versus distal location for QMLT, and iii) a maximum- versus no-compression technique for QMLT.

RESULTS

Analysis of twenty burned adults (50 years [95%CI 42-57], 32%TBSA [95%CI 23-40]) yielded ICCs of> 0.97 for QMLT (for either location and compression technique) and> 0.95 for RF-CSA, using average measurements. Relative minimal detectable changes were smaller using no-compression than maximum-compression (6.5% vs. 15%). Using no-compression to measure QMLT was deemed feasible for both proximal and distal locations (94% and 96% of attempted measurements). In 9.5% of cases maximum-compression was not feasible. 95% of RF-CSA measurements were successfully completed.

CONCLUSION

Ultrasound provides feasible and reliable values of quadriceps muscle architecture that can be adapted to clinical scenarios commonly encountered in acute burn settings.

Effects of enteral nutrition with different energy supplies on metabolic changes and organ damage in burned rats

BACKGROUND

Enteral nutrition (EN) is an important treatment for burn patients. However, severe gastrointestinal damage caused by major burns often leads to EN intolerance. Trophic EN solves this problem basically, but how to transition from trophic EN to standard EN smoothly is still a challenge in burn clinical nutrition. The aim of this study is to investigate the effects of EN with different energy supplies on metabolic changes, organ damage and prognosis in burned rats.

METHODS

Different feeding regimens were designed based on the continuous monitoring of resting energy expenditure in rats. Thirty-two Sprague-Dawley rats were randomly divided into a normal control group, burn +50% REE group, burn +75% REE group and burn +100% REE group. At the end of a nutritional treatment cycle (14th day), nuclear magnetic resonance spectroscopy, blood biochemistry analysis and quantification of subscab bacteria were performed to explore the differences in metabolic changes, degrees of organ damage and prognoses between the groups.

RESULTS

Sixteen metabolites involving seven metabolic pathways were identified from the different energy supply groups. After burn injury, resting energy consumption and body weight loss increased obviously. Meanwhile, weight loss was inversely related to energy supply. The greatest changes in the degree of organ damage, the level of plasma proteins, lipids and endotoxins, as well as the quantification of subscab bacteria were observed in the 50% REE group, followed by the 75 and 100% groups.

CONCLUSIONS

Achieving an early balance between energy supply and expenditure is conducive to mitigating metabolic disorders and improving prognosis after burn injury.

Adherence with early allied health assessments in specialist burn services

Appropriate multidisciplinary allied health assessment during the early stages of admission following burn injury positively influences recovery and quality of life. Variation in allied health care may affect patient outcomes. We aimed to explore adherence in providing early allied health assessments in accordance with local parameters. Associations between the number of assessments and hospital length of stay (LOS) were also explored. The Burns Registry of Australia and New Zealand was queried for adult (≥ 16 years) burn injured patients admitted to a specialist burn service for > 48 hours between July 2016 and June 2020. Quality indicator data relating to allied health assessment processes were examined; patients were grouped according to the number of assessments they received within 48 hours of admission. Of the 5789 patients included in the study, 5598 (97%) received at least one allied health assessment within 48 hours of admission and 3976 (69%) received all three assessments. A greater proportion of patients who received no assessments were admitted on a Saturday. Patients receiving three assessments had more severe injuries compared to their counterparts who received fewer assessments. Hospital LOS was not associated with the number of allied health assessments during an acute admission following burn injury after accounting for confounding factors, particularly TBSA. Multidisciplinary allied health teams provide routine burn care to Australian and New Zealand burns patients at a consistent level. Further, this study provides evidence that allied health input is prioritised towards patients with increasing severity of burn injury, playing an integral role in early rehabilitation.