Adjunctive Nonpharmacologic Interventions for the Management of Burn Pain: A Systematic Review

Burn pain management in a female patient with severe burn injuries in Nepal: a case study and review

Burn injuries in low-resource settings like Nepal present significant public health challenges, leading to substantial morbidity, mortality and severe pain. This paper assesses burn pain management in Nepal, emphasizing the need for enhanced strategies. A case study of a female patient with severe burn injuries from a rural village in Western Nepal illustrates current challenges. Reviewing studies on burn pain management in Nepal shows limited access to specialized facilities, inadequate palliative care, medication shortages and insufficient healthcare professionals. Pharmacological interventions are impacted by financial constraints and a lack of protocols, while nonpharmacological approaches have not been explored and contextualized for the Nepalese context due to similar financial issues. Comprehensive burn pain management requires addressing resource constraints through collaborative health-aid partnerships.

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.

Age and Sex Differences of Virtual Reality Pain Alleviation Therapeutic During Pediatric Burn Care: A Randomized Clinical Trial

Virtual reality (VR) effectively alleviates pain for pediatric patients during many medical procedures, such as venipuncture and burn care. In our previously published randomized clinical trial among 90 pediatric burn patients, participants in the active VR group had significantly lower scores for overall pain compared with participants in the standard care control and for worst pain compared with participants in the passive VR and control group. However, whether VR differs by a patient's age or sex remains unresolved. Thus, we reanalyzed our data by comparing the active and passive VR participants to evaluate how age and sex affect VR pain alleviation during dressing care for pediatric burns. In total, 90 patients aged 6-17 years (inclusive) with burn injuries were recruited from an outpatient burn clinic of an American Burn Association-verified pediatric burn center. Before randomization, VR helpfulness and need expectations were assessed on a visual analog scale (0-100). Participants were randomly assigned to active VR, passive VR, or control for one dressing change. Immediately following the dressing change, active and passive VR participants self-reported pain and the time spent thinking about pain and rated the VR features on the degree of realism, pleasure/fun, and perceived engagement level. Path analyses assessed how these VR features were interrelated and how they affected self-reported pain by age and sex. Patients aged 6-9 years reported higher mean expectations of VR helpfulness and need (mean = 73.6 and 94.5, respectively) than 10-12-year-olds (mean = 55.7 and 84.2, respectively) and 13-17-year-olds (mean = 68.6 and 77.4, respectively). The path analysis indicated VR engagement and fun were significantly correlated (p-value < 0.05). VR engagement significantly negatively impacted overall pain scores (coefficient = -0.45, -0.41; p-value < 0.05) and significantly positively impacted time thinking of pain (coefficient = 0.38, 0.32; p-value < 0.05). Younger patients had the highest expectations of VR helpfulness and need. VR game realism, fun, and engagement features were not statistically different between age groups and sexes. VR engagement and thinking of pain during burn dressing significantly positively affected self-reported pain (p-value < 0.05), suggesting an analgesic mechanism beyond distraction alone. Younger patients benefited more from VR than older patients.

Effects of non-pharmacological interventions on pain intensity of children with burns: A systematic review and meta-analysis

Pain is one of the complications associated with burns, which can lead to anxiety and sleeplessness in children. Various studies evaluated the effects of non-pharmacological interventions on burn wound care. The present study was conducted to determine the effects of non-pharmacological interventions on pain intensity of children with burns. A comprehensive systematic search was conducted in various international electronic databases, such as Scopus, PubMed, Web of Science, and Persian electronic databases such as Iranmedex, and Scientific Information Database using keywords extracted from Medical Subject Headings such as 'Non-pharmacological', 'Virtual reality', 'Pain', 'Burn', 'Wound' and 'Child' from the earliest to December 1, 2022. The risk of bias in the final articles was also assessed with the Version 2 of the Cochrane risk-of-bias tool for randomised trials (RoB 2). Finally, a total of 1005 burn patients were included in 19 studies. The age range of the patients was from 0.5 to 19 years. Of the participants, 50.05% were in the intervention group. All studies had a randomised clinical trial design. The results found that non-pharmacological interventions significantly reduced pain intensity in children (ES: -0.73, 95% CI: -1.08 to -0.38, Z = 4.09, I2 :79.8, P < .001). Virtual reality (VR) (ES: -0.54, 95% CI: -1.19 to -0.18, Z = 2.90, I2 :72.9%, P = .004) and non-VR (ES: -0.86, 95% CI: -1.45 to -0.27, Z = 2.86, I2 :91.4%, P = .04) interventions decreased pain intensity significantly in children based sub-group analysis. Non-pharmacological interventions significantly reduced the pain intensity of dressing removal (ES: -0.77, 95% CI: -1.34 to -0.20, Z = 66.3, I2 :91.8%, P = .008), dressing application (ES: -0.53, 95% CI: -0.97 to -0.09, Z = 2.37, I2 :60.8%, P = .02), and physical therapy (ES: -1.18, 95% CI: -2.10 to -0.26, Z = 2.51, I2 :88.0%, P = .01). Also, interventions reduced the pain of burn wound care (ES: -0.29, 95% CI: -1.01 to 0.44, Z = 0.78, I2 :72.6%, P = .43), but it was statistically insignificant. In sum, the result of the present study indicated that using non-pharmacological interventions significantly reduced pain intensity in children. The reduction of pain intensity was greater in non-VR than in VR interventions. Future studies should focus on comparing VR interventions with non-VR and single versus multi-modal distraction to clarify the effectiveness of each.

A Systematic Review of Pediatric Nonaccidental Burns: Protecting the Children Through Knowledge, Vigilance, and Prevention

BACKGROUND

Inflicted burns on children are a particularly difficult medical and psychosocial issue. Pediatric nonaccidental burns (PNABs) are unfortunately relatively common. In our study, we aim to present the key findings on PNABs with the intention of raising awareness, improving early, and recognizing accurately by identifying red flags, developing triage tools, and establishing prevention strategies for this sensitive issue.

METHODS

A computerized literature search was conducted on PubMed, Google Scholar, and Cochrane for articles published until November 2020. The online screening process was performed by 3 independent reviewers with the Covidence tool against set inclusion/exclusion criteria. The protocol was reported using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) protocol. The study was registered with the International Prospective Register of Systematic Reviews (PROSPERO).

RESULTS

A total of 12 studies were included for analysis. Scald burns via forced immersion accounted for the majority of reported PNABs affecting both feet and hands. Complications included wound infection, sepsis, requiring systemic antibiotics, or intensive care. Abused children's parents had a history of mental illness, unemployment, substance abuse, incarceration, and/or low annual income.

CONCLUSIONS

Scalds via forced immersion remain the most common mechanism of PNABs. All health care professionals must remain vigilant, be able to recognize subtle signs of abuse, triage patients appropriately, report to police and/or social services, and ensure no further harm is made to the child or children. Repeated abuse with burns can lead to death. Prevention and education are the cornerstones for addressing this social phenomenon.

Researches on cognitive sequelae of burn injury: Current status and advances

Burn injury is a devastating disease with high incidence of disability and mortality. The cognitive dysfunctions, such as memory defect, are the main neurological sequelae influencing the life quality of burn-injured patients. The post-burn cognitive dysfunctions are related to the primary peripheral factors and the secondary cerebral inflammation, resulting in the destruction of blood-brain barrier (BBB), as is shown on Computed Tomography (CT) and magnetic resonance imaging examinations. As part of the neurovascular unit, BBB is vital to the nutrition and homeostasis of the central nervous system (CNS) and undergoes myriad alterations after burn injury, causing post-burn cognitive defects. The diagnosis and treatment of cognitive dysfunctions as burn injury sequelae are of great importance. In this review, we address the major manifestations and interventions of post-burn cognitive defects, as well as the mechanisms involved in memory defect, including neuroinflammation, destruction of BBB, and hormone imbalance.

Application of Virtual Reality Technology in Clinical Practice, Teaching, and Research in Complementary and Alternative Medicine

Background

The application of virtual reality (VR) in clinical settings is growing rapidly, with encouraging results. As VR has been introduced into complementary and alternative medicine (CAM), a systematic review must be undertaken to understand its current status.

Aim

This review aims to evaluate and summarize the current applications of VR in CAM, as well as to explore potential directions for future research and development.

Methods

After a brief description of VR technology, we discuss the past 20 years of clinical VR applications in the medical field. Then, we discuss the theoretical basis of the combination of VR technology and CAM, the research thus far, and practical factors regarding usability, etc., from the following three main aspects: clinical application, teaching, and scientific research. Finally, we summarize and propose hypotheses on the application of VR in CAM and its limitations.

Results

Our review of the theoretical underpinnings and research findings to date leads to the prediction that VR and CAM will have a significant impact on future research and practice.

Conclusion

Although there is still much research needed to advance the science in this area, we strongly believe that VR applications will become indispensable tools in the toolbox of CAM researchers and practitioners and will only grow in relevance and popularity in the era of digital health.