The effects of exercise programming vs traditional outpatient therapy in the rehabilitation of severely burned children

Effect of anti-gravity treadmill (Alter G) training on gait characteristics and postural stability in adult with healed burns: A single blinded randomized controlled trial

BACKGROUND

Burns constitute one of the foremost contributors to premature mortality and morbidity, and the recovery process from burn injuries is characterized by its intricate and protracted nature.

OBJECTIVE

The principal aim of this study was to assess the influence of an anti-gravity treadmill (Alter G) training program on both gait characteristics and postural stability indices (PSI) in adult individuals who have recovered from burns.

DESIGN

This study followed a single-blind, randomized, controlled design.

METHODS

A total of 45 adults, aged 18-35 years, with healed lower extremity burns that were circumferential and encompassed 35-50% of their total body surface area (TBSA) were randomly allocated to either the anti-gravity treadmill (Alter G) Training group (n = 22) or the traditional physical therapy program (TPTP) group (n=23). The TPTP group received conventional physical therapy, while the anti-gravity treadmill (Alter G) training group engaged in anti-gravity treadmill exercises alongside the traditional physical therapy program. The primary outcome measures, evaluated at both baseline and the conclusion of the 12-week intervention, included gait characteristics assessed using the GAITRite system and PSI measured by the Biodex Balance System (BBS).

RESULTS

The anti-gravity treadmill (Alter G) training group exhibited significantly greater enhancements than the TPTP group in terms of mean values and percentage changes in gait characteristics and PSI. Specifically, the percentage changes for the Alter G group were as follows: stride length (20.57%), step time (22.58%), step length (20.47%), velocity (15.67%), cadence (23.28%), and double support time (29.03%). In contrast, the TPTP group's percentage changes were: 6.73%, 8.19%, 7.65%, 7.75%, 8.89%, and 9.37%, respectively. Concerning PSI, the Alter G group exhibited percentage changes of 55.17% for the medio-lateral stability index (MLI), 48.21% for antero-posterior stability index (API), and 48.48% for the overall stability index (OSI). The TPTP group's corresponding percentage changes were 20%, 14.03%, and 16.41%.

CONCLUSIONS

The amalgamation of anti-gravity treadmill training with the traditional physical therapy program yields greater efficacy than TPTP in isolation. Consequently, the findings underscore the efficiency of anti-gravity treadmill (Alter G) Training as a valuable tool for rehabilitating patients with burn injuries.

Key Exercise Concepts in the Rehabilitation from Severe Burns

This article presents information on the benefits of exercise in counteracting the detrimental effects of bed rest, and/or severe burns. Exercise is key for maintaining physical function, lean body mass, metabolic recovery, and psychosocial health after major burn injuries. The details of an exercise training program conducted in severely burned persons are presented, as well as information on the importance of proper regulation of body temperature during exercise or physical activity. The sections on exercise and thermoregulation are followed by a section on the role of exercise in scarring and contractures. Finally, gaps in the current knowledge of exercise, thermoregulation, and contractures are presented.

Exploring what is important during burn recovery: a qualitative study investigating priorities of patients and healthcare professionals over time

OBJECTIVES

This qualitative study aimed to investigate: (1) priorities of patients and healthcare professionals during recovery from a burn injury, (2) how priorities change over time and (3) how priorities map to outcomes currently reported in burns research.

DESIGN

Semi-structured interviews were conducted. Interviews were audio recorded, transcribed and analysed thematically.

SETTING, PARTICIPANTS

A total of 53 patients and healthcare professionals were recruited from four National Health Service (NHS) burn services across England and Wales across England and Wales. Patient participants (n=32) included adults, adolescents and parents of paediatric patients, with a variety of burn injuries in terms of severity and cause of burn injury. Healthcare professionals (n=21) were NHS staff members involved in burn care and included professionals with a range of clinical experience and roles (eg, nurses, surgeons, occupational therapists, physiotherapist, administration).

RESULTS

Ten themes relating to priorities (outcomes) during recovery from a burn injury were identified for patients and professionals. Of those, six were identified for patients and professionals ('pain and discomfort', 'psychological well-being', 'healing', 'scarring', 'function', 'infection'), three were unique to professionals ('patient knowledge, understanding and support', 'sense of control', 'survival') and one was unique to patients ('uncertainty'). Results highlighted that importance of these priorities changes over time (eg, 'survival' was only a concern in the short term). Likewise, priorities differed between patients and professionals (eg, 'pain' was important to patients throughout their recovery, but not for professionals). Seven out of 10 themes overlapped with outcomes commonly assessed in burn research.

CONCLUSION

Professionals' and patients' priorities (important outcomes) change over time after burn injury and differ between those groups. Burn care research should consider measuring outcomes at different time points during the recovery from a burn injury to accurately reflect complexity of burn recovery.

The effects of resistance training on children with burns: a meta-analysis

The aim of this study was to evaluate effectiveness and safety of resistance training (RT). Data were retrieved from Medline, EMBASE, PubMed, CINAHL and Cochrane Central Register of Controlled Trials (Central) databases from inception to April 2020. Quantitative studies on RT for muscle strength, lean body mass, cardiopulmonary function, metabolism, quality of life, and pain in burned children were included in this study. Twelve RCTs (379 patients) were identified. Meta-analysis showed RT significant increase in muscle strength [SMD = 2.18, 95% CI (0.79, 3.56), p = 0.002]. However, training showed no significant effect on muscle endurance [MD = 10.00, 95% CI (- 0.22, 20.22), p = 0.06]. Notably, training significantly increases total lean body mass [MD = 2.10, 95% CI (1.28, 2.92), p < 0.001]. In addition, training significantly increased leg lean body mass [MD = 2.10, 95% CI (1.28, 2.92), p < 0.001]. Moreover, training significantly increased VO₂peak [MD = 5.83, 95% CI (3.52, 8.13), p < 0.001]. Meta-analysis showed that training significantly increases gait parameters, including stride length, step length, velocity and cadence. Furthermore, training significantly increased explosive capacity of lower limb muscles (p < 0.001). Meta-analysis of 6-min walking test results showed that training significantly improves walking speed (p = 0.0008). Notably, all studies showed unclear or high risk of bias; whereas, quality of the evidence was moderate or low. Analysis showed that RT significantly improves clinical outcomes. However, more high-quality, double-blind, randomized control trials should be performed to explore the effects of RT to ensure successful implementation in rehabilitation.

Rehabilitative Exercise Training for Burn Injury

Due to improvements in acute burn care over the last few decades, most patients with severe burns (up to 90% of the total body surface) survive. However, the metabolic and cardiovascular complications that accompany a severe burn can persist for up to 3 years post injury. Accordingly, there is now a greater appreciation of the need for strategies that can hasten recovery and reduce long-term morbidity post burn. Rehabilitation exercise training (RET) is a proven effective treatment to restore lean body mass, glucose and protein metabolism, cardiorespiratory fitness, and muscle strength in burn survivors. Despite this, very few hospitals incorporate RET in programs to aid the rehabilitation of patients with severe burns. Given that RET is a safe and efficacious treatment that restores function and reduces post-burn morbidity, we propose that a long-term exercise prescription plan should be considered for all patients with severe burns. In this literature review, we discuss the current understanding of burn trauma on major organ systems, and the positive benefits of incorporating RET as a part of the long-term rehabilitation of severely burned individuals. We also provide burn-specific exercise prescription guidelines for clinical exercise physiologists.

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.

Effect of Exercise Training on the Frequency of Contracture-Release Surgeries in Burned Children

BACKGROUND

Intensive physical exercise (IPE) increases strength, lean body mass, aerobic capacity, and range of motion in children with extensive burns. However, whether IPE decreases the frequency of burn scar contracture-releasing procedures in children with extensive burns is unknown.

MATERIALS AND METHODS

Prospectively collected surgical records of 184 children who had undergone axilla, elbow, and/or wrist contracture-releasing procedures were reviewed. All children were 7 years or older and had sustained burns of at least 40% of the total body surface area. Eighty-two children completed an IPE program, and 102 children did not. For both groups, the axilla, elbow, and wrist were examined for tightness and restricted movement. Children with contractural difficulty were prescribed a releasing procedure. Logistic regression was used to model the relationship between multiple release surgeries and group.

RESULTS

Patients in both groups had comparable injury severity. A total of 120 releases were carried out in the 82 IPE patients. In contrast, 211 releases were needed in the 102 non-IPE patients. An approximately 60% decrease in the frequency of rerelease operations was noted in IPE patients (12.5% for the IPE group and 31.8% for non-IPE group; P < 0.05).

CONCLUSIONS

When used as an adjunct therapy in postburn rehabilitation, IPE may be useful for reducing the need for contracture release. The mechanisms underlying the beneficial effects of exercise remain undefined and should be investigated.

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.

One-Year Comparison of a Community-Based Exercise Program Versus a Day Hospital-Based Exercise Program on Quality of Life and Mental Health in Severely Burned Children

OBJECTIVE

To compare the effects of long-term psychosocial functioning and mental health of a "day hospital"-based exercise program (DAYEX) versus a community-based exercise program (COMBEX).

DESIGN

A prospective design that consisted of 2 groups (DAYEX and COMBEX).

SETTING

A children's hospital specialized in burn care.

PARTICIPANTS

Patients (N=18; DAYEX [n=9], COMBEX [n=9]) were assessed at intensive care unit discharge and up to 1 year postburn.

INTERVENTIONS

The Child Health Questionnaires (CHQ-Child Form [CHQ-CF87] and CHQ-Parent Form [CHQ-PF28]) were used to assess changes in quality of life from discharge to 1 year postburn.

MAIN OUTCOME MEASURES

CHQ-PF28 and CHQ-CF87.

RESULTS

Demographic characteristics and total body surface area burned were similar in both groups. Length of hospital stay was significant in the COMBEX group. CHQ-CF87 and CHQ-PF28 documented significant improvements in both groups between discharge and 1 year. Significance was evident in Physical Functioning, Bodily Pain, Self-Esteem, Change in Health, and Family Activities. CHQ-CF87 showed improvement in Family Cohesion in COMBEX more than DAYEX. CHQ-PF28 showed improvement in Role/Social Limitations-Emotional, Bodily Pain, and Family Activities in COMBEX more than DAYEX.

CONCLUSIONS

The proposed COMBEX program is feasible and beneficial physically, psychosocially, and mentally. The results show some improvements in the COMBEX group in optimizing function and health in severely burned children. The COMBEX group performed at least as well as the DAYEX group. Larger-scale studies are needed to validate current findings.

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.

Rehabilitation in the Acute Versus Outpatient Setting

Rehabilitation of patients with burn injuries aims to restore strength, coordination, and mobility as closely to normal as possible and should begin immediately after initial admission. In the acute phase, baseline assessments are made against which all subsequent rehabilitation success is held. In the intermediate phase, active, full range-of-motion movement, ambulation of steadily increasing distances, and resistive exercise and stretching aid in the prevention of muscle and bone atrophy and preserve muscle memory and coordination. In the long-term outpatient rehabilitation phase, individualized patient-centered exercise programs can be advantageous in achieving measurable and lasting positive rehabilitation outcomes.

Metabolic and Endocrine Considerations After Burn Injury

Severe burn injury is followed by a profound hypermetabolic response that persists up to 2 years after injury. It is mediated by up to 50-fold elevations in plasma catecholamines, cortisol, and glucagon that lead to whole-body catabolism, elevated resting energy expenditures, and multiorgan dysfunction. Modulation of the response by early excision and grafting of burn wounds, thermoregulation, control of infection, early and continuous enteral nutrition, and pharmacologic treatments aimed at mitigating physiologic derangements have markedly decreased morbidity.

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.

Functional Outcomes of Burn Patients with or without Rehabilitation in Mainland China

Background/Objective

To evaluate the functional outcomes of moderate to severe burn patients with and without rehabilitation in terms of self-care performance and quality of life (QOL).

Methods

Fifty-five patients with total burn surface area of 30% or more were divided into two groups: rehabilitation and conventional care groups. The rehabilitation group underwent comprehensive rehabilitation interventions (e.g., occupational therapy, physiotherapy, and patient and family education) in addition to standard clinical interventions received by the conventional care group. The outcomes included self-care performance (Modified Barthel Index [MBI]), QOL (World Health Organization Quality of Life-BREF), pain and itchiness (Visual Analogue Scale [VAS]), quality of sleep, and mental health (Self-Rating Depression Scale [SDS] and Self-Rating Anxiety Scale) measured before and 3 months after the intervention.

Results

After the intervention, significant improvements were found in MBI, all dimensions of QOL, pain, and SDS in the rehabilitation group (all p < .05). In the conventional care group, significant improvements were found only in MBI (p < .001), the physical health dimension of QOL (p < .01), and pain (p < .001). Group comparisons showed that the rehabilitation group achieved significantly better outcomes after the intervention in MBI (p < .001), VAS score of itching (p = .009), and the physical health (p = .002), psychological health (p = .021), and social relationships dimensions of QOL (p < .001).

Conclusion

Patients with moderate to severe burn injuries can benefit from rehabilitation interventions in terms of physical health, mental health, performance of daily living, and QOL.

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.

Aerobic exercise training in modulation of aerobic physical fitness and balance of burned patients

[Purpose] This study aimed to determine the impact of aerobic exercise on aerobic capacity, balance, and treadmill time in patients with thermal burn injury. [Subjects and Methods] Burned adult patients, aged 20–40 years (n=30), from both sexes, with second degree thermal burn injuries covering 20–40% of the total body surface area (TBSA), were enrolled in this trial for 3 months. Patients were randomly divided into; group A (n=15), which performed an aerobic exercise program 3 days/week for 60 min and participated in a traditional physical therapy program, and group B (n=15), which only participated in a traditional exercise program 3 days/week. Maximal aerobic capacity, treadmill time, and Berg balance scale were measured before and after the study. [Results] In both groups, the results revealed significant improvements after treatment in all measurements; however, the improvement in group A was superior to that in group B. [Conclusion] The results provide evidence that aerobic exercises for adults with healed burn injuries improve aerobic physical fitness and balance.

Exercise behaviors and barriers to exercise in adult burn survivors: A questionnaire survey

Exercise is a key component of burn rehabilitation across all phases of care. Supervised outpatient exercise programs have been shown to improve outcomes following burn injury. However, little is known about the exercise behaviors of burn survivors who do not undertake such programs. This study aimed to investigate self-reported exercise behaviors and barriers to exercise in adult burn survivors. A short questionnaire survey was conducted on adult burn survivors attending the ambulatory burns clinic of a tertiary hospital over a 6-week period. The collected data were subjected to paired t-tests and Pearson’s correlation test. A total of 63 adult burn survivors (mean age 36.5 years) completed the questionnaire. Participants reported exercising less frequently and engaged in fewer different types of exercise compared with pre-burn (P < 0.05). Poor physical conditions and low motivation and enthusiasm were the major barriers to exercise. Participation in supervised exercise programs can be limited by a range of factors including the availability of resources and access to facilities. This preliminary study suggests that there is a need to improve compliance with outpatient exercise programs. Burn survivors appear to exercise less frequently after burn injury. Barriers to exercise following burn injury include poor physical condition and reduced motivation. Further investigation into overall physical activity following burn injury and potential physical and psychological limitations is warranted. Burn clinicians should highly encourage injury survivors to participate in supervised exercise programs when available or to do exercises at home to maximize post-burn injury recovery.

Keeping up with video game technology: objective analysis of Xbox Kinect™ and PlayStation 3 Move™ for use in burn rehabilitation

Commercially available interactive video games are commonly used in rehabilitation to aide in physical recovery from a variety of conditions and injuries, including burns. Most video games were not originally designed for rehabilitation purposes and although some games have shown therapeutic potential in burn rehabilitation, the physical demands of more recently released video games, such as Microsoft Xbox Kinect™ (Kinect) and Sony PlayStation 3 Move™ (PS Move), have not been objectively evaluated. Video game technology is constantly evolving and demonstrating different immersive qualities and interactive demands that may or may not have therapeutic potential for patients recovering from burns. This study analyzed the upper extremity motion demands of Kinect and PS Move using three-dimensional motion analysis to determine their applicability in burn rehabilitation. Thirty normal children played each video game while real-time movement of their upper extremities was measured to determine maximal excursion and amount of elevation time. Maximal shoulder flexion, shoulder abduction and elbow flexion range of motion were significantly greater while playing Kinect than the PS Move (p≤0.01). Elevation time of the arms above 120° was also significantly longer with Kinect (p<0.05). The physical demands for shoulder and elbow range of motion while playing the Kinect, and to a lesser extent PS Move, are comparable to functional motion needed for daily tasks such as eating with a utensil and hair combing. Therefore, these more recently released commercially available video games show therapeutic potential in burn rehabilitation. Objectively quantifying the physical demands of video games commonly used in rehabilitation aides clinicians in the integration of them into practice and lays the framework for further research on their efficacy.

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).

Intensive exercise after thermal injury improves physical, functional, and psychological outcomes

BACKGROUND

Although exercise programs after burns are considered a standard of care, there is limited evidence for efficacy in adult patients. This study aimed to investigate the effects of an exercise program on physical, functional, and quality of life measures.

METHODS

A quasi-experimental controlled trial was instituted after final grafting. Both groups completed stretching, and the intervention group underwent a supervised high-intensity (80% maximal heart rate and 70% three repetition maximum) combined aerobic or resisted exercise program for 6 weeks, with outcome measures at baseline, 6 weeks, and 3 months by a blinded assessor. Analysis was by intention to treat.

RESULTS

Thirty patients (24 men) with a mean age of 34.3 years (± 13.1 years) and mean total body surface area 42.9% (± 13.3%) were enrolled. Inequalities at baseline (age and total body surface area %) were adjusted statistically. A between within repeated measures analysis of variance found significant group × time effects between the groups. Mean change scores from baseline to 12 weeks between control and intervention groups, respectively, were strength (kg): quadriceps (17.5 vs. 66.87), latissimus dorsi (6.07 vs. 27.82), right (4.86 vs. 14.86) and left (7.26 vs. 16.83) hand grip; fitness: peak oxygen consumption (L/min; 0.11 vs. 0.93) and shuttle walk distance (m; 168.93 vs. 459); function: lower extremity function score (8.87 vs. 27.31) and QuickDash (-5.7 vs. -23.98); and health-related quality of life: Burns-Specific Health Scale-Abbreviated (-7.64 vs. 35.13). There were no adverse events during either testing or training.

CONCLUSION

A high-intensity cardiovascular or resisted exercise program resulted in significant improvements in functional, physical, and psychologic measures and should be mandatory for all burns patients. Larger multicenter trials with longer follow-up periods are required.

LEVEL OF EVIDENCE

Therapeutic study, level III.

Effects of exercise training on resting energy expenditure and lean mass during pediatric burn rehabilitation

Severe burns cause profound hormonal and metabolic disturbances resulting in hypermetabolism, reflected in extreme elevation of resting energy expenditure (REE) and extensive skeletal muscle catabolism. Aerobic and resistive exercise programs during rehabilitation have shown substantial benefits, although whether such training potentially exacerbates basal metabolism is unknown. Therefore, the effects of exercise training on REE during the rehabilitation of severely burned pediatric patients were examined. Children with 40% total body surface area burns and greater were enrolled at admission to the burn intensive care unit to participate in a 12-week, hospital-based exercise program (EX) or a home-based standard of care program (SOC), commencing 6 months after injury. Twenty-one patients (aged 7-17 years) were enrolled and randomized to SOC (n = 10) or EX (n = 11). Age, sex, and total body surface area burned were similar. Mean change (+/-standard deviation) in REE, normalized to individual lean body mass, was almost negligible between SOC and EX group patients (SOC, 0.03 +/- 17.40% vs EX, 0.01 +/- 26.38%). A significant increase in lean body mass was found for EX patients (SOC, 2.06 +/- 3.17% vs EX, 8.75 +/- 5.65%; P = .004), which persisted when normalized to height (SOC, 0.70 +/- 2.39% vs EX, 6.14 +/- 6.46%; P = .02). Peak torque also improved significantly more in EX patients (SOC, 12.29 +/- 16.49% vs EX, 54.31 +/- 44.25%; P = .02), reflecting improved strength. Exercise training significantly enhanced lean mass and strength, without observed exacerbation of postburn hypermetabolism. Therefore, the use of exercise conditioning as a safe and effective component of pediatric burn rehabilitation is advocated.

Managing the relationship between quality and cost-effective burn care

In the modern era of fiscal prudence, managing the relationship between quality health care and cost reduction is a complex and challenging task for policy makers and health care providers. Health economics is an applied field that aids in assessing the feasibility of incorporating new interventions in a certain field. Applying these tools when allocating funds for burn care is even more complicated due to the lack of clinical data regarding the cost effectiveness of different aspects in burn care. Herein we review the existing literature and summarize different approaches for achieving cost effective health care in general and in burn care specifically. Special considerations to funds allocation in burn care are also discussed.

The hypermetabolic response to burn injury and interventions to modify this response

Severe burn injury is followed by a profound hypermetabolic response that persists up to 24 months after injury. It is mediated by up to 50-fold elevations in plasma catecholamines, cortisol, and inflammatory cells that lead to whole-body catabolism, elevated resting energy expenditures, and multiorgan dysfunction. All of these metabolic and physiologic derangements prevent full rehabilitation and acclimatization of burn survivors back into society. Modulation of the response by early excision and grafting of burn wounds, thermoregulation, early and continuous enteral feeding with high-protein high-carbohydrate feedings, and pharmacologic treatments have markedly decreased morbidity.

Burn rehabilitation and research: proceedings of a consensus summit

Burn rehabilitation is an essential component of successful patient care. In May 2008, a group of burn rehabilitation clinicians met to discuss the status and future needs of burn rehabilitation. Fifteen topic areas pertinent to clinical burn rehabilitation were addressed. Consensus positions and suggested future research directions regarding the physical aspects of burn rehabilitation are shared.

Effects of a 12-week rehabilitation program with music & exercise groups on range of motion in young children with severe burns

Previous studies indicate that rehabilitation programs supplemented with a strength and endurance-based exercise program improve lean body mass, pulmonary function, endurance, strength, and functional outcomes in severely burned children over the age of 7-years when compared with standard of care (SOC). To date, supplemental exercise programming for severely burned children under the age of 7-years has not yet been explored. The purpose of this study was to determine if a 12-week rehabilitation program supplemented with music & exercise, was more effective in improving functional outcomes than the SOC alone. This is a descriptive study that measured elbow and knee range of motion (ROM) in 24 severely burned children between ages 2 and 6 years. Groups were compared for demographics as well as active and passive ROM to bilateral elbows and knees. A total of 15 patients completed the rehabilitation with supplemental music and exercise, and data was compared with 9 patients who received SOC. Patients receiving the 12-week program significantly improved ROM in all joints assessed except for one. Patients receiving SOC showed a significant improvement in only one of the joints assessed. Providing a structured supplemental music and exercise program in conjunction with occupational and physical therapy seems to improve both passive and active ROM to a greater extent than the SOC alone.

A clarion to recommit and reaffirm burn rehabilitation

Burn rehabilitation has been a part of burn care and treatment for many years. Yet, despite of its longevity, the rehabilitation outcome of patients with severe burns is less than optimal and appears to have leveled off. Patient survival from burn injury is at an all-time high. Burn rehabilitation must progress to the point where physical outcomes parallel survival statistics in terms of improved patient well-being. This position article is a treatise on burn rehabilitation and the state of burn rehabilitation patient outcomes. It describes burn rehabilitation interventions in brief and why a need is felt to bring this issue to the forefront. The article discusses areas for change and the challenges facing burn rehabilitation. Finally, the relegation and acceptance of this responsibility are addressed.

Assessment of muscle function in severely burned children

INTRODUCTION

The posttraumatic response to a severe burn leads to marked and prolonged skeletal muscle catabolism and weakness, which persist despite standard rehabilitation programs of occupational and physical therapy. We investigated the degree to which the prolonged skeletal muscle catabolism affects the muscle function of children 6 months after severe burn.

METHODS

Burned children, with >40% total body surface area burned, were assessed at 6 months after burn in respect to lean body mass and leg muscle strength at 150 degrees /s. Lean body mass was assessed using dual-energy X-ray absorptiometry. Leg muscle strength was assessed using isokinetic dynamometry. Nonburned children were assessed similarly, and served as controls.

RESULTS

We found that severely burned children (n=33), relative to nonburned children (n=46) had significantly lower lean body mass. Additionally they had significantly lower peak torque as well total work performance using the extensors of the thigh.

CONCLUSIONS

Our results serve as an objective and a practical clinical approach for assessing muscle function and also aid in establishing potential rehabilitation goals, and monitoring progress towards these goals in burned children.

Burn rehabilitation: an overview

Burn injuries result in significant physical and psychologic complications that require comprehensive rehabilitation treatment and coordination with the acute care burn team. This interdisciplinary rehabilitation treatment is focused on preventing long-term problems with scarring, contractures, and other problems that limit physical function. Adequate pain management and recognition of psychologic issues are important components of treatment after burn injuries. Burn injuries present significant barriers to community integration, but many people can successfully return to work and other activities.

Physical and psychologic rehabilitation outcomes for young adults burned as children

OBJECTIVE

To report physical and psychologic outcomes for young adult survivors of pediatric burns.

DESIGN

Prospective, correlational study.

SETTING

Acute and rehabilitation pediatric burn care facility.

PARTICIPANTS

Eighty-three young adult survivors of pediatric burns, who were 18 to 28 years of age, with total body surface area (TBSA) burns of 30% or greater, and were at least 2 years postburn.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Physical outcomes were assessed by muscle strength tests, grip and pinch measurements, mobility levels, and self-care (activities of daily living) skills. Psychologic outcomes included behavioral problems, personality disorder, and incidence of psychiatric illness. An individually administered Structured Clinical Interview for Diagnosis, based on the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, for psychiatric diagnosis, was used to assess mental health, and behavioral problems were assessed with the Young Adult Self-Report. Participants reported educational achievement, employment status, state of transition from family of origin (home) to independent living, and pair bonding. The Short-Form 36-Item Health Survey and the Quality of Life Questionnaire were used to assess each participant's self-reported general health and quality of life.

RESULTS

The majority of subjects had physical and psychologic outcomes that were within the normal range when compared with age-mates who had not experienced burns. The areas that were most likely to be impaired involved peripheral strength (wrist and grip). These deficits affected some self-care skills and correlated with TBSA. Standardized diagnostic interviews showed that greater than 50% of subjects qualified for a psychiatric diagnosis, with anxiety disorders as the most frequently occurring diagnosis. There were few significant correlations of the physical measurements or self-care skills with the burn size, psychologic problems, or social outcomes, and none appeared to be clinically important.

CONCLUSIONS

Most of the people in this sample were functioning physically and psychosocially within normal limits as they reached adulthood. Although they appeared to function well as measured by standardized assessments, there were indications of private suffering that suggested they may not be functioning at an optimal level. The findings suggest that rehabilitation professionals could improve outcomes by including programs to develop overall muscle strength in severely burned children and by addressing concerns related to anxiety and other symptoms of psychologic distress.

Outcome measures in burn care. Is mortality dead?

Health care systems constantly struggle with ways to provide higher quality care in a cost-effective manner. Outcome measures serve to evaluate what works and what does not. Whether they are used for research or for the improvement of clinical practice, they are as such, efficiency markers and the first step in determining the consequences of health care. The accomplishments of the past decade have placed us in the midst of an exciting paradigm shift from what used to be primary concern (i.e. mortality), to areas that are more likely to enhance the quality of life of burn survivors. Optimal management of severely burned persons is enormously expensive, and even after survival is ensured, may require a protracted period of surgical, medical and psychological rehabilitative measures for many years. This article aims to review the outcome measures in the acute phase of burn management (mortality and morbidity from the post-burn hypermetabolic response). We further discuss long-term outcome measures (such as, quality of life measures, exercise tolerance and evaluation of return to pre-burn activities) that are now becoming of equal importance as the numbers of burn survivors increase.

Support of the metabolic response to burn injury

Severe burn causes metabolic disturbances that can last for a year after injury; persistent and profound catabolism hampers rehabilitative efforts and delays the meaningful return of individuals to society. The simplest, effective anabolic strategies for severe burn injuries are: early excision and grafting of the wound; prompt treatment of sepsis; maintenance of environmental temperature at 30-32 degrees C; continuous feeding of a high carbohydrate, high protein diet, preferably by the enteral route; and early institution of vigorous and aerobic resistive exercise programmes. To further keep erosion of lean body mass to a minimum, administration of anabolic agents, recombinant human growth hormone, insulin, oxandrolone, or anticatabolic drugs such as propranolol are alternative approaches. Exogenous continuous low-dose insulin infusion, beta blockade with propranolol, and use of the synthetic testosterone analogue oxandrolone are the most cost effective and least toxic pharmacological treatments to date.