A Descriptive Review of Neuropathic-Like Pain After Burn Injury

Surgical Management of Chronic Neuropathic Burn Pain

Burn-related chronic neuropathic pain can contribute to a decreased quality of life. When medical and pharmacologic therapies prove ineffective, patients should undergo evaluation for surgical intervention, consisting of a detailed physical examination and elective diagnostic nerve block, to identify an anatomic cause of pain. Based on symptoms and physical examination findings, particularly Tinel's sign, treatments can vary, including a trial of laser therapies, fat grafting, or nerve surgeries (nerve decompression, neuroma excision, targeted muscle reinnervation, regenerative peripheral nerve interfaces, and vascularized denervated muscle targets). It is essential to counsel patients to establish appropriate expectations prior to treatment with a multidisciplinary team.

Neuropathic pain in burn patients - A common problem with little literature: A systematic review

BACKGROUND

The prevalence of neuropathic pain (NP) in burn patients is reported in the literature to be as high as 80%1. Given the complexity of NP in burn patients and the wide range of treatments available, a systematic review of the literature is warranted to summarize our current understanding of management and treatment of NP in this population.

METHODS

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The following databases were queried to identify relevant articles: PubMed, Cochrane, Embase, Scopus, Ovid, and Web of Science. The main outcome measures were incidence and management of NP. Secondary outcomes included risk factors for NP.

RESULTS

Included articles presented findings from 11 different countries, capturing outcomes for 4366 patients. Risk factors for neuropathic pain in burn patients were identified, including older age, alcohol and substance abuse, current daily smoking, greater % total body surface area burns (TBSA), and longer hospitalizations. Pharmacologic treatments included gabapentin/pregabalin (n = 7), ascorbic acid (n = 1), and lidocaine (n = 1). Overall, the studies showed varied results regarding the efficacy of pharmacological treatments. While certain studies demonstrated gabapentanoids to be effective in reducing neuropathic symptoms, others found conflicting results. With regards to non-pharmacologic treatments, electroconvulsive therapy (n = 1), electropuncture (n = 1), nerve release/reconstruction (n = 2), and somatosensory feedback rehabilitation (n = 1) were used and demonstrated promise in reducing pain intensity and improving functionality.

CONCLUSIONS

Despite NP afflicting the majority of burn patients long after their injury, this systematic review demonstrates insufficient evidence on the pathophysiology, outcomes, and risk factors in NP, as well as the efficacy of various therapies. Future prospective and randomized studies evaluating the etiology of these factors can substantially improve our treatment strategies. This can allow for the development of well-delineated and evidence-based protocols in NP management in hopes of improving quality of life and both psychological and physical function in burn patients.

An Overview of Recent Developments in the Management of Burn Injuries

According to the World Health Organization (WHO), around 11 million people suffer from burns every year, and 180,000 die from them. A burn is a condition in which heat, chemical substances, an electrical current or other factors cause tissue damage. Burns mainly affect the skin, but can also affect deeper tissues such as bones or muscles. When burned, the skin loses its main functions, such as protection from the external environment, pathogens, evaporation and heat loss. Depending on the stage of the burn, the patient's condition and the cause of the burn, we need to choose the most appropriate treatment. Personalization and multidisciplinary collaboration are key to the successful management of burn patients. In this comprehensive review, we have collected and discussed the available treatment options, focusing on recent advances in topical treatments, wound cleansing, dressings, skin grafting, nutrition, pain and scar tissue management.

Psychological Issues

Psychological distress is common following a burn injury, and many burn survivors have pre-morbid psychiatric illnesses including mood and trauma-related disorders, and substance and alcohol use. This article is intended to be used by all interdisciplinary health care team members to improve the identification and treatment of common psychological concerns experienced by survivors and is organized to follow the general recovery timeline.

Serial Casting as an Effective Method for Burn Scar Contracture Rehabilitation: A Case Series

Guidelines and protocols for orthoses in burn scar contracture rehabilitation are limited. The current study aims to determine the optimal frequency of casting, potentially facilitating the development of a serial casting protocol. Previous literature supporting casting has low generalizability due to methodology limitations. Seven patients with burn scar contracted joints, who did not respond to traditional therapy, were recruited in this study. Patients were serially casted once, three times, or five times a week. Joint range of motion was maximized with stretching and exercise techniques before every new cast application. Across all patients, active range of motion increased from 65.8 ± 27.8° to 108.1 ± 23.3° with casting; or from 57.8 ± 16.2% to 96.7 ± 2.9% of normal. Similarly, scars improved from 9.5 ± 1.5 to 4.9 ± 1.4 on the Modified Vancouver Scar Scale score. This therapeutic effect was achieved within an average of 8.5 ± 3.7 d and 4.0 ± 2.2 new cast applications. Given the study findings, the procedures outlined could be used to develop a standardized serial casting protocol for burn scar contracture rehabilitation.

Treatment of Chronic Hypertrophic Burn Scars With a Fractional CO 2 Laser Is Well Tolerated in an Outpatient Clinic Setting

INTRODUCTION

The necessity of treating hypertrophic burn scars has expanded significantly with increased burn survivorship. Ablative lasers, such as carbon dioxide (CO 2 ) lasers, have been the most common nonoperative option for improving functional outcomes in severe recalcitrant hypertrophic burn scars. However, the overwhelming majority of ablative lasers used for this indication require a combination of systemic analgesia, sedation, and/or general anesthesia due to the painful nature of the procedure. More recently, the technology of ablative lasers has advanced and is more tolerable than their first-generation counterparts. Herein, we hypothesized that refractory hypertrophic burn scars can be treated by a CO 2 laser in an outpatient clinic.

METHODS

We enrolled 17 consecutive patients with chronic hypertrophic burn scars that were treated with a CO 2 laser. All patients were treated in the outpatient clinic with a combination of a topical solution (23% lidocaine and 7% tetracaine) applied to the scar 30 minutes before the procedure, Cryo 6 air chiller by Zimmer, and some patients received a mixture of N 2 O/O 2 . Laser treatments were repeated every 4 to 8 weeks until the patient's goals were met. Each patient completed a standardized questionnaire to assess tolerability and patient satisfaction of functional results.

RESULTS

All patients tolerated the laser well in the outpatient clinic setting, with 0% indicating "not tolerable," 70.6% "tolerable," and 29.4% "very tolerable." Each patient received more than 1 laser treatment for the following complaints: decreased range of motion (n = 16, 94.1%), pain (n = 11, 64.7%), or pruritis (n = 12, 70.6%). Patients were also satisfied with the results of the laser treatments ("no improvement or worsened" = 0%, "improved" = 47.1%, and "significant improvement" = 52.9%). The age of patient, type of burn, location of burn, presence of skin graft, or age of scar did not significantly affect the tolerability of treatment or satisfaction of outcome.

CONCLUSIONS

The treatment of chronic hypertrophic burn scars with a CO 2 laser is well tolerated in an outpatient clinic setting in select patients. Patients reported a high level of satisfaction with notable improvement in functional and cosmetic outcomes.

Spinal Irisin Gene Delivery Attenuates Burn Injury-Induced Muscle Atrophy by Promoting Axonal Myelination and Innervation of Neuromuscular Junctions

Muscle loss and weakness after a burn injury are typically the consequences of neuronal dysregulation and metabolic change. Hypermetabolism has been noted to cause muscle atrophy. However, the mechanism underlying the development of burn-induced motor neuropathy and its contribution to muscle atrophy warrant elucidation. Current therapeutic interventions for burn-induced motor neuropathy demonstrate moderate efficacy and have side effects, which limit their usage. We previously used a third-degree burn injury rodent model and found that irisin-an exercise-induced myokine-exerts a protective effect against burn injury-induced sensory and motor neuropathy by attenuating neuronal damage in the spinal cord. In the current study, spinal irisin gene delivery was noted to attenuate burn injury-induced sciatic nerve demyelination and reduction of neuromuscular junction innervation. Spinal overexpression of irisin leads to myelination rehabilitation and muscular innervation through the modulation of brain-derived neurotrophic factor and glial-cell-line-derived neurotrophic factor expression along the sciatic nerve to the muscle tissues and thereby modulates the Akt/mTOR pathway and metabolic derangement and prevents muscle atrophy.

Role of burn severity and posttraumatic stress symptoms in the co-occurrence of itch and neuropathic pain after burns: A longitudinal study

Itch and pain are common after burns. Neuropathic mechanisms may underlie both modalities but remain not well-understood. This study aims to prospectively document neuropathic pain symptoms and to identify potential itch symptom profiles that differ regarding duration and co-occurrence with neuropathic pain which may inform underlying pathophysiological mechanisms and respond to different treatments. Adult burn survivors (n = 192) self-reported itch and neuropathic pain at 2 weeks post-discharge, 3, 6, 12, and 18 months post-burn. Based on the presence of itch and pain symptoms over time, participants were allocated to one itch profile: transient itch/pain, chronic itch, or chronic itch & pain. Profiles were compared on itch intensity over time using General Linear Modeling. Age, gender, burn severity, posttraumatic stress (PTS) symptoms and baseline itch intensity were examined as potential predictors of the profiles in a Multi-nominal regression analysis. Neuropathic pain occurred in 54% after discharge which decreased to 24% 18 months later. Itch intensity was highest in the chronic itch & pain profile. Compared to the transient itch profile, the chronic itch & pain profile was associated with higher burn severity and more PTS symptoms. Compared to the chronic itch profile, the chronic itch & pain profile was associated with more PTS symptoms. Findings suggest that biological and psycho-dermatological processes underlie both chronic neuropathic pain and itch processes in burn scars. Further research should elucidate the mechanisms underlying the different itch profiles, with specific focus on skin innervation and psychological factors.

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.

Burn Wound Healing: Clinical Complications, Medical Care, Treatment, and Dressing Types: The Current State of Knowledge for Clinical Practice

According to the World Health Organization (WHO), it is estimated that each year approximately 11 million people suffer from burn wounds, 180,000 of whom die because of such injuries. Regardless of the factors causing burns, these are complicated wounds that are difficult to heal and are associated with high mortality rates. Medical care of a burn patient requires a lot of commitment, experience, and multidirectional management, including surgical activities and widely understood pharmacological approaches. This paper aims to comprehensively review the current literature concerning burn wounds, including classification of burns, complications, medical care, and pharmacological treatment. We also overviewed the dressings (with an emphasis on the newest innovations in this field) that are currently used in medical practice to heal wounds.

Chronic Nerve Pain after Burn Injury: An Anatomical Approach and the Development and Validation of a Model to Predict a Patient's Risk

BACKGROUND

A model that predicts a patient's risk of developing chronic, burn-related nerve pain may guide medical and/or surgical management. This study determined anatomy-specific variables and constructed a mathematical model to predict a patient's risk of developing burn-related nerve pain.

METHODS

A retrospective analysis was conducted from 1862 adults admitted to a burn center from 2014 to 2019. One hundred thirteen patients developed burn-related nerve pain. Comparisons were made using 11 anatomy-specific locations between patients with and without burn-related nerve pain. The modified Delphi technique was used to select 14 potential risk variables. Multivariate regression techniques, Brier scores, area under the curve, Hosmer-Lemeshow goodness-of-fit, and stratified K-fold cross-validation was used for model development. Chronic pain was defined as pain lasting 6 or more months after release from the Burn Center.

RESULTS

Prevalence rates of burn-related nerve pain were similar in the development (6.1 percent) and validation (5.4 percent) cohorts [Brier score = 0.15; stratified K-fold cross-validation (K = 10): area under the curve, 0.75; 95 percent CI, 0.68 to 0.81; Hosmer-Lemeshow goodness-of-fit, p = 0.73; n = 10 groups]. Eight variables were included in the final equation. Burn-related nerve pain risk score = -6.3 + 0.02 (age) + 1.77 (tobacco use) + 1.04 (substance abuse) + 0.67 (alcohol abuse) + 0.84 (upper arm burn) + 1.28 (thigh burn) + 0.21 (number of burn operations) + 0.01 (hospital length-of-stay). Burn-related nerve pain predicted probability = 1 - 1/[1 + exp(burn-related nerve pain risk score)] for 6-month burn-related nerve pain risk score. As the number of risk factors increased, the probability of pain increased.

CONCLUSIONS

Risk factors were identified for developing burn-related nerve pain at 11 anatomical locations. This model accurately predicts a patient's risk of developing burn-related nerve pain at 6 months. Age, tobacco use, substance abuse, alcohol abuse, upper arm burns, thigh burns, the number of burn operations, and hospital length of stay represented the strongest predictors.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Analysis of the predictors of hypertrophic scarring pain and neuropathic pain after burn

INTRODUCTION

Burn hypertrophic scarring pain is a common and perennial complaint which not only affects patients' quality of life, but also their recovery and reintegration. Physical therapy and medicine regimens are all available for the treatment of hypertrophic scarring pain. Unfortunately, the efficacy of clinical practice is not very satisfactory and the management of hypertrophic scarring pain remains challenging. Therefore, it is of utmost importance to explore the risk factors for hypertrophic scarring pain and further identify whether it is neuropathic pain, aiming to guide the clinical therapy and help patients live a pain-free life.

METHODS

This retrospective study enrolled patients with postburn hypertrophic scarring pain between 2017 and 2020 in a burn center in Shanghai. Research objects were included strictly according to the inclusion criteria and every enrolled patient was included in the study only once. Demographic information, burn and scar characteristics, and pain scores were collected through the Changhai Hospital Medical Information System, patient questionnaire and physician assessment. Using SPSS 26.0 software, the data were first processed by descriptive statistics, and linear and logistic regression analyses were further employed to explore the significant factors.

RESULTS

The sample involving 123 patients was consisted of 56.9% males, 79.7% caused by fire with a median age 40.5 years, total body surface burn-area (TBSA) 44.4%, wound healing time of target scar 57.9 days, hyperplasia time 9.3 months and the scar location mainly in the limbs (55.3%). Of all the included objects, the modified Vancouver Scar Scale (mVSS) total, visual analogue scale (VAS) score, brief pain inventory (BPI) total and the percentage of neuropathic pain were 9.6, 3.3, 36.0 and 74.8%, respectively. Integrating covariates with a P value of <0.10 through preliminary univariate analysis, multivariable linear regression showed sex (P = 0.049), age (P = 0.020), target scar location (P = 0.017, P = 0.254), and pliability (P = 0.016) were linked with severe VAS score; and burn depth of target scar (P = 0.023), hyperplasia time (P = 0.027, P = 0.001), vascularity (P = 0.028), and pliability (P = 0.001) were associated with higher BPI score. Adjusting for potential confounders, hyperplasia time (P = 0.005, P = 0.039) was found to be the only independent risk factor for hypertrophic scarring neuropathic pain in the multivariate logistic regression analysis, with mVSS total of P = 0.062.

CONCLUSIONS

The model in our study has clarified that sex, age, target scar location, burn depth of target scar, hyperplasia time, and vascularity, especially pliability, may provide excellent prediction of hypertrophic scarring pain outcome; for neuropathic pain, only hyperplasia time has further prospects, with mVSS total as a potential forecast. In an era increasingly aware of life quality, this work may contribute to the elaboration of strategies to hypertrophic scarring pain management, provide an individualized therapy, and help patients live a pain-free life.

Nerve Pain after Burn Injury: A Proposed Etiology-Based Classification

BACKGROUND

Understanding the mechanism of nerve injury may facilitate managing burn-related nerve pain. This proposed classification, based on cause of nerve injury, was developed to enhance the understanding and management of burn-related nerve pain.

METHODS

This retrospective investigation included patients aged 15 years or older admitted to the burn center from 2014 to 2019. Burn-related nerve pain was patient-reported and clinically assessed as pain 6 months or more after burn injury, unrelated to preexisting illnesses/medications. The pain classification consisted of direct nerve injury, nerve compression, electrical injury, and nerve dysfunction secondary to systemic injury. The four categories were statistically analyzed between groups, using 52 variables.

RESULTS

Of the 1880 consecutive burn patients, 113 developed burn-related nerve pain and were eligible for validation of the classification: direct nerve injury, n = 47; nerve compression, n = 12; electrical injury, n = 7; and nerve dysfunction secondary to systemic injury, n = 47. Factors, significantly increased, that distinguished one category from another were as follows: for direct nerve injury, continuous symptoms (p < 0.001), refractory nerve release response (p < 0.001), nerve repair (p < 0.001), and pruritus (p < 0.001); for nerve compression, Tinel signs (p < 0.001), shooting pain (p < 0.001), numbness (p = 0.003), intermittent symptoms (p < 0.001), increased percentage total body surface area burned (p = 0.019), surgical procedures (p < 0.001), and nerve release (p < 0.001); and for electrical injury, Tinel sign (p < 0.001), intermittent symptoms (p = 0.002), amputations (p = 0.002), fasciotomies (p < 0.001), and nerve release (p < 0.001). Nerve dysfunction secondary to systemic injury was distinguished by significantly less Tinel signs (p < 0.001), shooting pain (p < 0.001), numbness and tingling (p < 0.001), pruritus (p < 0.001), fascial excision (p = 0.004), skin grafts (p < 0.001), amputation (p = 0.004), nerve releases (p < 0.001), and third-degree burns (p = 0.002).

CONCLUSION

A classification consisting of direct nerve injury, nerve compression, electrical injury, and nerve dysfunction secondary to systemic injury is presented that may guide patient management and research methods, with the goal of improving pain outcomes in burn-related nerve pain.

Scar quality in children with burns 5-7 years after injury: A cross-sectional multicentre study

Long-term scar formation is an important adverse consequence in children with burns, however, information regarding scar quality in the long-term is lacking. Therefore, we evaluated scar quality and its predictors in children with burns 5-7 years after injury. Parents of children with mild/intermediate burns (≤10% total body surface area burned), and of children with severe burns (>10% burned) completed the patient scale of the Patient and Observer Scar Assessment Scale (POSAS 2.0) for their children's-in their opinion-worst scar 5-7 years post-burn. Outcomes and predictive factors of scar quality were studied, and, for children with severe burns, POSAS parent scores were compared with observer scores. We included 103 children with mild/intermediate burns and 28 with severe burns (response rate: 51%). Most children (87%) had scars that differed from normal skin, with most differences reported for colour, and least for pain. Except for colour, children with severe burns had significantly higher scores (difference 0-2 points) on all scar characteristics (representing poorer scar quality) compared with children with mild/intermediate burns. Parent POSAS scores were on average 2.0-2.6 points higher compared to observer scores. Number of surgeries predicted both the mean POSAS and the mean overall opinion of a scar. In conclusion, 5-7 years post-burn, the scar of the majority of children differed from normal skin, especially on the characteristic colour. The uncovered insights are useful in counselling of children and their parents on expectations of the final outcome of their (children's) scar(s), and help in further targeting scar prevention strategies for the individual child.

A review of burn symptoms and potential novel neural targets for non-invasive brain stimulation for treatment of burn sequelae

Burn survivors experience myriad associated symptoms such as pain, pruritus, fatigue, impaired motor strength, post-traumatic stress, depression, anxiety, and sleep disturbance. Many of these symptoms are common and remain chronic, despite current standard of care. One potential novel intervention to target these post burn symptoms is transcranial direct current stimulation (tDCS). tDCS is a non-invasive brain stimulation (NIBS) technique that modulates neural excitability of a specific target or neural network. The aim of this work is to review the neural circuits of the aforementioned clinical sequelae associated with burn injuries and to provide a scientific rationale for specific NIBS targets that can potentially treat these conditions. We ran a systematic review, following the PRISMA statement, of tDCS effects on burn symptoms. Only three studies matched our criteria. One was a feasibility study assessing cortical plasticity in chronic neuropathic pain following burn injury, one looked at the effects of tDCS to reduce pain anxiety during burn wound care, and one assessed the effects of tDCS to manage pain and pruritus in burn survivors. Current literature on NIBS in burn remains limited, only a few trials have been conducted. Based on our review and results in other populations suffering from similar symptoms as patients with burn injuries, three main areas were selected: the prefrontal region, the parietal area and the motor cortex. Based on the importance of the prefrontal cortex in the emotional component of pain and its implication in various psychosocial symptoms, targeting this region may represent the most promising target. Our review of the neural circuitry involved in post burn symptoms and suggested targeted areas for stimulation provide a spring board for future study initiatives.

Chronic Neuropathic Pain Following Hand Burns: Etiology, Treatment, and Long-Term Outcomes

PURPOSE

Chronic neuropathic pain (CNP) after burn injury to the hand/upper extremity is relatively common, but not well described in the literature. This study characterizes patients with CNP after hand/upper extremity burns to help guide risk stratification and treatment strategies. We hypothesize that multiple risk factors contribute to the development of CNP and refractory responses to treatment.

METHODS

Patients older than 15 years admitted to the burn center after hand/upper extremity burns, from January 1, 2014, through January 1, 2019, were included. Chronic neuropathic pain was defined as self-described pain for longer than 6 months after burn injury, not including pain due to preexisting illness/medications. Two analyses were undertaken: (1) determining risk factors for developing CNP among patients with hand/upper extremity burns, and (2) determining risk factors for developing refractory pain (ie, nonresponsive to treatment) among hand/upper extremity burn patients with CNP.

RESULTS

Of the 914 patients who met the inclusion criteria, 55 (6%) developed CNP after hand/upper extremity burns. Twenty-nine of these patients (53%) had refractory CNP. Significant risk factors for developing CNP after hand/upper extremity burns included history of substance abuse and tobacco use. Among CNP patients, significant risk factors for developing refractory pain included symptoms of burning sensations. In all CNP patients, gabapentin and ascorbic acid were associated with significant decreases in pain scores on follow-up.

CONCLUSIONS

Substance abuse and tobacco use may contribute to the development of CNP after hand/upper extremity burns. Those who developed refractory CNP were more likely to use the pain descriptor, burning sensations. Pharmacological pain management with gabapentin or pregabalin and ascorbic acid may provide the most relief of CNP symptoms.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Irisin Gene Delivery Ameliorates Burn-Induced Sensory and Motor Neuropathy

Burn-related neuropathy is common and often involves pain, paresthesia, or muscle weakness. Irisin, an exercise-induced myokine after cleavage from its membrane precursor fibronectin type III domain-containing 5 (FNDC5), exhibits neuroprotective and anti-inflammatory activities. A rat model of third-degree burn on the right hind paw was used to investigate the therapeutic role of irisin/FNDC5. Rats received burn injury and were treated with intrathecal recombinant adenovirus containing the irisin sequence (Ad-irisin) at 3 weeks postburn. One week later, mechanical allodynia was examined. The expression of irisin in cerebrospinal fluid (CSF) was detected. Ipsilateral gastrocnemius muscle and lumbar spinal cord were also obtained for further investigation. Furthermore, the anti-apoptotic effect of recombinant irisin in SH-SY5Y cells was evaluated through tumor necrosis factor alpha (TNFα) stimulus to mimic burn injury. We noted intrathecal Ad-irisin attenuated pain sensitization and gastrocnemius muscle atrophy by modulating the level of irisin in CSF, and the expression of neuronal FNDC5/irisin and TNFα in the spinal cord. Ad-irisin also ameliorated neuronal apoptosis in both dorsal and ventral horns. Furthermore, recombinant irisin attenuated TNFα-induced SH-SY5Y cell apoptosis. In summary, irisin attenuated allodynia and muscle wasting by ameliorating neuroinflammation-induced neuronal apoptosis.

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.

Post-Burn Pruritus

Post-burn pruritus is the pruritus that occurs after burn during the rehabilitation and healing process of burn wounds. The post-burn pruritus is a common and serious complication of burn injury, which severely lowers the quality of life of the patient. Many potential treatments are available for pruritus but there is no consensus of the best single treatment yet. The precise mechanism of post-burn pruritus has not been elucidated, but it appears to have pruritogenic and neuropathic aspects. Clinically, post-burn pruritus tends to be intractable to conventional treatment but rather responds to neuroleptic agents, such as gabapentin and pregabalin. During wound healing, various neuropeptides secreted from the nerves of the skin control epidermal and vascular proliferation and connective tissue cells. When keratinocytes are activated by an itch-inducing substance, they secrete a variety of inflammatory substances that increase the susceptibility of the itch receptor. There are two mechanisms underlying post-burn neuropathic pruritus. The first one is peripheral sensitization. The second one is the intact nociceptor hypothesis. An effective treatment for post-burn pruritus will also be effective in other neuropathic and intractable itching. In this review, we summarized the interaction and mechanism of keratinocytes, immune cells, and nerve fibers related to post-burn pruritus.

Prevalence and associated predictors for patients developing chronic neuropathic pain following burns

BACKGROUND

Chronic pain, unrelated to the burn itself, can manifest as a long-term complication in patients sustaining burn injuries. The purpose of this study was to determine the prevalence of chronic neuropathic pain (CNP) and compare burn characteristics between patients who developed CNP and patients without CNP who were treated at a burn center.

METHODS

A single-center, retrospective analysis of 1880 patients admitted to the adult burn center was performed from 1 January 2014 to 1 January 2019. Patients included were over the age of 15 years, sustained a burn injury and were admitted to the burn center. CNP was diagnosed clinically following burn injury. Patients were excluded from the definition of CNP if their pain was due to an underlying illness or medication. Comparisons between patients admitted to the burn center with no pain and patients admitted to the burn center who developed CNP were performed.

RESULTS

One hundred and thirteen of the 1880 burn patients developed CNP as a direct result of burn injury over 5 years with a prevalence of 6.01%. Patients who developed CNP were a significantly older median age (54 years vs. 46 years, p = 0.002), abused alcohol (29% vs. 8%, p < 0.001),abused substances (31% vs. 9%, p < 0.001), were current daily smokers (73% vs. 33%, p < 0.001), suffered more full-thickness burns (58% vs. 43%, p < 0.001), greater median percent of total body surface area (%TBSA) burns (6 vs. 3.5, p < 0.001), were more often intubated on mechanical ventilation (33% vs. 14%, p < 0.001), greater median number of surgeries (2 vs. 0, p < 0.001) and longer median hospital length of stay (LOS) (10 days vs. 3 days, p < 0.001), compared to those who did not develop CNP, respectively. Median patient follow-up was 27 months.

CONCLUSIONS

The prevalence of CNP over 5 years was 6.01% in the burn center. Older ages, alcohol abuse, substance abuse, current daily smoking, greater percent of total body surface area (%TBSA) burns, third degree burns, being intubated on mechanical ventilation, having more surgeries and longer hospital LOS were associated with developing CNP following burn injury, compared to patients who did not develop CNP following burn injury.

Drug-specific differences in the ability of opioids to manage burn pain

Burn injury pain is a significant public health problem. Burn injury treatment has improved tremendously in recent decades. However, an unintended consequence is that a larger number of patients now survive more severe injuries, and face intense pain that is very hard to treat. Although many efforts have been made to find alternative treatments, opioids remain the most effective medication available. Burn patients are frequently prescribed opioids in doses and durations that are significantly higher and longer than standard analgesic dosing guidelines. Despite this, many continue to experience unrelieved pain. They are also placed at a higher risk for developing dependence and opioid use disorder. Burn injury profoundly alters the functional state of the immune system. It also alters the expression levels of receptor, effector, and signaling molecules within the spinal cord's dorsal horn. These alterations could explain the reduced potency of opioids. However, recent studies demonstrate that different opioids signal preferentially via differential signaling pathways. This ligand-specific signaling by different opioids implies that burn injury may reduce the antinociceptive potency of opioids to different degrees, in a drug-specific manner. Indeed, recent findings hint at drug-specific differences in the ability of opioids to manage burn pain early after injury, as well as differences in their ability to prevent or treat the development of chronic and neuropathic pain. Here we review the current state of opioid treatment, as well as new findings that could potentially lead to opioid-based pain management strategies that may be significantly more effective than the current solutions.

Pain is Associated With Increased Physical and Psychosocial Impairment in Youth With a History of Burn Injuries

Burn injuries are significantly painful and associated with physical and psychological impairment. However, little research to-date has examined the potential role of the subjective experience of pain in either physical or psychological impairment in this population. This may be particularly important to examine, given that the pain experience can often be a significant barrier to recovery in other pediatric populations. The current study examined the cross-sectional and predictive relationships between patient-reported experience of pain (operationalized as PROMIS pain interference and self-reported pain intensity) and physical and psychosocial outcomes. Data were gathered as part of the Burn Model System National Database (1994-2018) with the data request inclusive of pediatric self-report PROMIS measures, child PTSD, and post-traumatic growth symptoms assessed at 6- and 12-month postdischarge following initial injury. A total of 65 youth between the ages of 6 and 16 years at the time of their injury were included in the dataset. Correlational and regression analyses indicated that pain interference was cross-sectionally and longitudinally associated with decreased physical functioning, depressive symptoms, and peer relationships. Pain intensity was significantly associated with and predictive of physical functioning and pain interference. Results of the current study are an important first step in understanding the pain experience and associated outcomes in youth with a history of burn injuries. Future research is needed to further examine these relationships. PERSPECTIVE: This study presents preliminary findings from a national database on pain-related outcomes both cross-sectionally and longitudinally in youth with a history of burn injury. To-date, pain-related outcomes are poorly understood in this population and the results of this study serve to inform future research and treatment-related efforts.

A Review of Adjunctive Therapies for Burn Injury Pain During the Opioid Crisis

Opioids are the mainstay of pain management after burn injury. The United States currently faces an epidemic of opioid overuse and abuse, while simultaneously experiencing a nationwide shortage of intravenous narcotics. Adjunctive pain management therapies must be sought and utilized to reduce the use of opioids in burn care to prevent the long-term negative effects of these medications and to minimize the dependence on opioids for analgesia. The purpose of this review was to identify literature on adjunctive pain management therapies that have been demonstrated to reduce pain severity or opioid consumption in adult burn patients. Three databases were searched for prospective studies, randomized controlled trials, and systematic reviews that evaluated adjunctive pain management strategies published between 2008 and 2019 in adult burn patients. Forty-six studies were analyzed, including 24 randomized controlled trials, six crossover trials, and 10 systematic reviews. Various adjunctive pain management therapies showed statistically significant reduction in pain severity. Only one randomized controlled trial on music therapy for acute background pain showed a reduction in opioid use. One cohort study on hypnosis demonstrated reduced opioid use compared with historical controls. We recommend the development of individualized analgesic regimens with the incorporation of adjunctive therapies in order to improve burn pain management in the midst of an abuse crisis and concomitant national opioid shortage.

The IASP classification of chronic pain for ICD-11: chronic postsurgical or posttraumatic pain

Chronic pain after tissue trauma is frequent and may have a lasting impact on the functioning and quality of life of the affected person. Despite this, chronic postsurgical and posttraumatic pain is underrecognised and, consequently, undertreated. It is not represented in the current International Classification of Diseases (ICD-10). This article describes the new classification of chronic postsurgical and posttraumatic pain for ICD-11. Chronic postsurgical or posttraumatic pain is defined as chronic pain that develops or increases in intensity after a surgical procedure or a tissue injury and persists beyond the healing process, ie, at least 3 months after the surgery or tissue trauma. In the classification, it is distinguished between tissue trauma arising from a controlled procedure in the delivery of health care (surgery) and forms of uncontrolled accidental damage (other traumas). In both sections, the most frequent conditions are included. This provides diagnostic codes for chronic pain conditions that persist after the initial tissue trauma has healed and that require specific treatment and management. It is expected that the representation of chronic postsurgical and posttraumatic pain in ICD-11 furthers identification, diagnosis, and treatment of these pain states. Even more importantly, it will make the diagnosis of chronic posttraumatic or postsurgical pain statistically visible and, it is hoped, stimulate research into these pain syndromes.

Longitudinal Clinical Trial Recruitment and Retention Challenges in the Burn Population: Lessons Learned From a Trial Examining a Novel Intervention for Chronic Neuropathic Symptoms

Long-term trials are key to understanding chronic symptoms such as pain and itch. However, challenges such as high attrition rates and poor recruitment are common when conducting research. The aim of this work was to explore these issues within a long-term randomized control trial using transcranial direct current stimulation to treat pain and itch. This parallel double blinded, placebo-controlled randomized trial was comprised of 15 transcranial direct current stimulation visits and 7 follow-up visits. Participants were over the age of 18, had a burn injury that occurred at least 3 weeks before enrollment, and reported having pain and/or itch that was moderate to severe in intensity. A total of 31 subjects were randomized into either an active or sham transcranial direct current stimulation groups. There were no significant differences between the groups in terms of age, race, education, baseline depression, or anxiety. The median dropout time was at visit 19 (visit 16 [SE = 1.98] for the sham group and visit 19 [SE = 1.98] for the active group). Analysis showed no differences in the dropout rate between groups [χ2(1) = 0.003, P = .954]. The dropout rate was 46.7% for the sham group and 43.8% for the active group. Overall, 45.2% of the subjects dropped out of the trial. Long-term clinical trials are an essential part of evaluating interventions for symptoms such as chronic pain and itch. However, as seen in this trial, long-term studies in the burn population often face recruitment and adherence challenges.

Distinct behavioral response of primary motor cortex stimulation in itch and pain after burn injury

It is still unclear whether chronic neuropathic pain and itch share similar neural mechanisms. They are two of the most commonly reported challenges following a burn injury and can be some of the most difficult to treat. Transcranial direct current stimulation (tDCS) has previously been studied as a method to modulate pain related neural circuits. Therefore, we aimed to test the effects of tDCS on post-burn neuropathic pain and itch as to understand whether this would induce a simultaneous modulation of these two sensory manifestations. We conducted a pilot randomized controlled clinical trial comprised of two phases of active or sham M1 tDCS (Phase I: 10 sessions followed by a follow-up period of 8 weeks; Phase II: additional 5 sessions followed by a follow-up period of 8 weeks, and a final visit 12 months from baseline). Pain levels were assessed with the Brief Pain Inventory (BPI) and levels of itch severity were assessed with the Visual Analogue Scale (VAS). Measurements were collected at baseline, after the stimulation periods, at 2, 4 and 8-week follow up both for Phase I and II, and at the final visit. Sixteen patients were assigned to the active group and 15 to the sham group. Ten sessions of active tDCS did not reduce the level of pain or itch. We identified that itch levels were reduced at 2-week follow-up after the sham tDCS session, while no placebo effect was found for the active group. No difference between active and sham groups was observed for pain. We did not find any treatment effects during Phase II. Based on these findings, it seems that an important placebo effect occurred during sham tDCS for itch, while active M1 tDCS seems to disrupt sensory compensatory mechanisms. We hypothesize that pain and itch are complementary but distinct mechanisms of adaptation after peripheral sensory injury following a burn injury and need to be treated differently.

Genetic influence on scar height and pliability after burn injury in individuals of European ancestry: A prospective cohort study

After similar extent of injury there is considerable variability in scarring between individuals, in part due to genetic factors. This study aimed to identify genetic variants associated with scar height and pliability after burn injury. An exome-wide array association study and gene pathway analysis were performed on a prospective cohort of 665 patients treated for burn injury. Outcomes were scar height (SH) and scar pliability (SP) sub-scores of the modified Vancouver Scar Scale (mVSS). DNA was genotyped using the Infinium^® HumanCoreExome-24 BeadChip. Associations between genetic variants (single nucleotide polymorphisms) and SH and SP were estimated using an additive genetic model adjusting for age, sex, number of surgical procedures and % total body surface area of burn in subjects of European ancestry. No individual genetic variants achieved the cut-off threshold of significance. Gene regions were analysed for spatially correlated single nucleotide polymorphisms and significant regions identified using comb-p software. This gene list was subject to gene pathway analysis to find which biological process terms were over-represented. Using this approach biological processes related to the nervous system and cell adhesion were the predominant gene pathways associated with both SH and SP. This study suggests genes associated with innervation may be important in scar fibrosis. Further studies using similar and larger datasets will be essential to validate these findings.

The biopsychosocial model of pain in the context of pediatric burn injuries

BACKGROUND

Burns are a common and traumatic source of childhood injury in the United States. The treatment and recovery from burn injuries can be significantly painful and may lead to chronic or persistent pain for years following the initial incident. Further, burn injuries in youth have been found to increase the potential for significant psychosocial (e.g., anxiety, depression, PTSD) and physical (e.g., decreased mobility) impairment. Relatedly, the general experience and processing of pain in youth can also be associated with greater psychosocial (e.g., anxiety, depression) impairment and functional disability over time. However, the phenomenology and associated characteristics of the pain experience following burn injury and, in particular, the potential for combined impact on physical and psychosocial outcomes in youth with severe and/or prolonged pain and a history of burn injury is poorly understood.

METHODS

A review of the literature was performed in the areas of burn injuries and outcomes associated with both acute and chronic pain with youth and adult populations.

RESULTS

The current review highlights current gaps in the literature in important areas of function in youth with a history of burn injuries using the biopsychosocial model of pain. Future research and considerations for practice are also outlined.

CONCLUSIONS

Gaining a greater understanding of the relationship between pain, physical impairment, and psychosocial functioning in these youth is significantly important in order to provide greater preventative and treatment-related intervention going forward.

SIGNIFICANCE

Using a biopsychosocial framework, this review highlights the need for a greater understanding of pain processing and the long-term potential for persistent pain and pain-related impairment (e.g., functional disability) in youth with a history of burn injuries.

A Preliminary Study on qEEG in Burn Patients With Chronic Pruritus

Objective

To explore and determine the reorganizational changes in the cortical neural circuits associated with pruritis, this study was undertaken to compare the electroencephalography (EEG) changes in burn patients having primary symptoms of chronic itching (pruritis) and their paired healthy subjects.

Methods

Eight subjects were recruited for this exploratory pilot study: 4 patients with pruritus after burn injury matched by gender and age with 4 healthy subjects. EEG recordings were analyzed for absolute alpha, low beta, high beta, and theta power for both groups.

Results

The mean age of the burn patients was 41.75 years; while the mean age for the matched healthy subjects was 41.5 years. All subjects were male. A decreased alpha activity was observed in the occipital channels (0.82 vs. 1.4; p=0.01) and a decreased low beta activity in the frontal area (0.22 vs. 0.4; p=0.049) in eyes closed conditions. An overall decreased theta trend was observed in both the eyes open and eyes closed conditions in burn patients, compared to healthy individuals.

Conclusion

This preliminary study presents initial evidence that chronic pruritus in burn subjects may be associated with brain reorganizational changes at the cortical level characterized by an EEG pattern.

Peripheral Neuropathy and Nerve Compression Syndromes in Burns

Peripheral neuropathy and nerve compression syndromes lead to substantial morbidity following burn injury. Patients present with pain, paresthesias, or weakness along a specific nerve distribution or experience generalized peripheral neuropathy. The symptoms manifest at various times from within one week of hospitalization to many months after wound closure. Peripheral neuropathy may be caused by vascular occlusion of vasa nervorum, inflammation, neurotoxin production leading to apoptosis, and direct destruction of nerves from the burn injury. This article discusses the natural history, diagnosis, current treatments, and future directions for potential interventions for peripheral neuropathy and nerve compression syndromes related to burn injury.

Spinal Cord Stimulation Treatment for Persistent Pain After a Burn Injury: A Case Report

Spinal cord stimulation (SCS) is used to treat neuropathic pain, but there are no published studies on its use to treat burn pain. We used SCS to treat a 67-year-old man suffering from burn pain that could not be managed with high-dose opioids or adjuvant neuropathic analgesics. A trial of SCS markedly reduced the visual analog scale score for pain in the left lateral abdominal and gluteal regions. He underwent permanent implantation of a SCS and achieved an opioid-free state. This case suggests that SCS treatment is a therapeutic option for burn pain refractory to conventional therapy.

Surgical treatment and management of the severely burn patient: Review and update

Since one of the main challenges in treating acute burn injuries is preventing infection, early excising of the eschar and covering of the wound becomes critical. Non-viable tissue is removed by initial aggressive surgical debridement. Many surgical options for covering the wound bed have been described, although split-thickness skin grafts remain the standard for the rapid and permanent closure of full-thickness burns. Significant advances made in the past decades have greatly improved burns patient care, as such that major future improvements in survival rates seem to be more difficult. Research into stem cells, grafting, biomarkers, inflammation control, and rehabilitation will continue to improve individualized care and create new treatment options for these patients.

Complex regional pain syndrome in burn pathological scarring: A case report and review of the literature

Chronic pain in burn pathological scarring is not an uncommon occurrence. The mechanisms of pain are not clearly understood and hence the management approach is often a daunting task. However, meticulous physical examination of these patients may classify them as complex regional pain syndrome, type I. We present a patient with classic signs and symptoms of complex regional pain syndrome associated with burn pathological scarring of her left forearm that had a favourable response to a thoracoscopic sympathectomy. The possible pathological mechanisms of burn pathological scarring, mechanisms of pain, and complex regional pain syndrome are reviewed.

Quantifying Risk Factors for Long-Term Sleep Problems After Burn Injury in Young Adults

Restorative sleep is an important component of quality of life. Disturbances in sleep after burn injury were reported but all based on uncontrolled or nonstandardized data. The occurrence and the effect of long-term sleep problems in young adult burn survivors have not been well defined. This 5-year (2003-2008) prospective multicenter longitudinal study included adults with burn injuries ages 19 to 30 years who completed the Young Adult Burn Outcome Questionnaire (YABOQ) up to 36 months after injury. The items measured 15 patient-reported outcomes including physical, psychological, and social statuses and symptoms such as itch and pain. Scores of these 15 YABOQ outcome domains were standardized to a mean of 50 and a SD of 10 based on an age-matched nonburned reference group of young adults. Sleep quality was assessed using the item 'How satisfied are you now with your sleep,' rated by a 5-point Likert scale. Patients responding with very and somewhat dissatisfied were classified as having sleep dissatisfaction and the remaining as less or not dissatisfied. The associations between sleep dissatisfaction (yes/no) and YABOQ outcome domains were analyzed longitudinally using mixed-effect generalized linear models, adjusted for %TBSA burned, age, gender, and race. Generalized estimating equations were used to take into account correlated error resulting from repeated surveys on each patient over time. One hundred and fifty-two burn survivors participated in the YABOQ survey at baseline and during the follow-up who had at least one survey with a response to the sleep item. Among them, sleep dissatisfaction was twice as prevalent (76/152, 50%) when compared with the nonburned reference group (29/112, 26%). The likelihood of a burn survivor being dissatisfied with sleep was reduced over time after the burn injury. Sleep dissatisfaction following burns was significantly associated, in a dose-dependent manner, with increasing burn size (P = .001). Better sleep was associated with better outcomes in all domains (P < .05) except Fine Motor Function, and this association was significantly more apparent in the longer term compared with the shorter term with the same domains (P < .05). Dissatisfaction with sleep is highly prevalent following burn injuries in young adults. Lower satisfaction with sleep is associated with poorer scores in nearly all quality of life measures. Satisfaction with sleep should be addressed during the long-term clinical follow-up of young adults with burn injuries. Further research should be undertaken to understand the components of sleep quality that are important to burn survivors and which ones might be modified and tested in future intervention studies.

Health-related quality of life (EQ-5D) early after injury predicts long-term pain after burn

BACKGROUND

Chronic pain after burn can have severe physical and psychological effects on former patients years after the initial injury. Although the issue of pain after burn has gained increased attention over the past years, prospective, longitudinal studies are scarce. Our aim was to prospectively investigate consecutive burn patients for pain severity over time and to evaluate the prevalence and characteristics of post-burn pain to 2-7 years after the burn. As an additional aim, the effects of burn and individual-related factors, especially health-related Quality of Life (HRQoL), were investigated.

METHOD

Sixty-seven consecutive burn patients were assessed during acute care at 3, 6, 12 and 24 months, as well as at 2-7 years post-burn. HRQoL, symptoms of post-traumatic stress disorder (PTSD) and other psychiatric disorders were investigated. During the interviews that took place 2-7 years after the injury (mean 4.6±1.9 years), current chronic post-burn pain was assessed using the Brief Pain Inventory-Short Form (BPI-SF).

RESULTS

One-third of the patients still reported pain 2-7 years after the injury. Pain severity and interference with daily life were mainly mild to moderate though they were found to be associated with significantly lower HRQoL. Chronic pain after burn was associated with both burn- and individual-related factors. In logistic regression analysis HRQoL at 3 and 12 months and symptoms of PTSD at 12 months were independent factors in predicting chronic pain after burn.

CONCLUSION

Pain after burn becomes a chronic burden for many former burn patients and decreases HRQoL. A novel finding in this study was that HRQoL assessed early after burn was a predictor for the development of chronic pain. This finding may help to predict future pain problems and serve as an indicator for pain preventive measures.

Progress of clinical practice on the management of burn-associated pain: Lessons from animal models

Opioid-based analgesics provide the mainstay for attenuating burn pain, but they have a myriad of side effects including respiratory depression, nausea, impaired gastrointestinal motility, sedation, dependence, physiologic tolerance, and opioid-induced hyperalgesia. To test and develop novel analgesics, validated burn-relevant animal models of pain are indispensable. Herein we review such animal models, which are mostly limited to rodent models of burn-induced, inflammatory, and neuropathic pain. The latter two are pain syndromes that provide insight into the pain caused by systemic pro-inflammatory cytokines and direct injury to nerves (e.g., after severe burn), respectively. To date, no single animal model optimally mimics the complex pathophysiology and pain that a human burn patient experiences. No currently available burn-pain model examines effects of pharmacological intervention on wound healing. As cornerstones of pain and wound healing, pro-inflammatory mediators may be utilized for insight into both processes. Moreover, common clinical concerns such as systemic inflammatory response syndrome and multiple organ dysfunction remain unaddressed. For development of analgesics, these aberrations can significantly alter the potential efficacy and/or adverse effects of a prescribed analgesic following burn trauma. We therefore suggest that a multi-model strategy would be the most clinically relevant when evaluating novel analgesics for use in burn patients.

The molecular basis of hypertrophic scars

Hypertrophic scars (HTS) are caused by dermal injuries such as trauma and burns to the deep dermis, which are red, raised, itchy and painful. They can cause cosmetic disfigurement or contractures if craniofacial areas or mobile region of the skin are affected. Abnormal wound healing with more extracellular matrix deposition than degradation will result in HTS formation. This review will introduce the physiology of wound healing, dermal HTS formation, treatment and difference with keloids in the skin, and it also review the current advance of molecular basis of HTS including the involvement of cytokines, growth factors, and macrophages via chemokine pathway, to bring insights for future prevention and treatment of HTS.

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.

Coping with burns: the role of coping self-efficacy in the recovery from traumatic stress following burn injuries

We conducted a three-wave prospective study among patients with burns (N = 178) to examine the prospective influence of coping self-efficacy (CSE) perceptions on trajectories of posttraumatic stress symptoms in the first 12 months after burn injuries. Using linear growth curve modeling, we corrected for demographics, the number of surgeries during initial admittance, trait coping styles, and changing levels of health-related quality of life. CSE during initial admission was by far the strongest predictor of both initial PTSD symptoms and degree of symptom change with higher CSE levels associated with lower initial symptoms and a steeper decline of symptoms over time. Of the other variables only avoidant coping was associated with higher initial symptom levels, and only emotional expression associated with greater rate of recovery. Current findings suggest that CSE plays a pivotal role in recovery from posttraumatic stress after a burn injury, even when the role of burn-related impairments is taken into consideration. Implications of findings are discussed.

Physical and psychiatric recovery from burns

Burn injuries pose complex biopsychosocial challenges to recovery and improved comprehensive care. The physical and emotional sequelae of burns differ, depending on burn severity, individual resilience, and stage of development when they occur. Most burn survivors are resilient and recover, whereas some are more vulnerable and have complicated outcomes. Physical rehabilitation is affected by orthopedic, neurologic, and metabolic complications and disabilities. Psychiatric recovery is affected by pain, mental disorders, substance abuse, and burn stigmatization. Individual resilience, social supports, and educational or occupational achievements affect outcomes.