Critical Care Rehabilitation of the Burn Patient.

Despite the fact that modern burn care has significantly reduced the mortality associated with severe burn injuries, the rehabilitation and community reintegration of survivors continues to be a challenge. An interprofessional team approach is essential for optimal outcomes. This includes early occupational and physical therapy, beginning in the intensive care unit (ICU). Burn-specific techniques (edema management, wound healing, and contracture prevention) are successfully integrated into the burn ICU. Research demonstrates that early intensive rehabilitation of critically ill burn patients is safe and effective. Further work on the physiologic, functional, and long-term impact of this care is needed.

The Interplay of Nutrition, Physical Activity, Severity of Illness, and Mortality in Critically Ill Burn Patients: Is There a Connection?

The purpose of this project was to evaluate the relationships between nutrition, physical activity levels (PALs), severity of illness (SOI), and survival in critically ill burn patients. We conducted a retrospective evaluation of consecutively admitted adult patients who had an intensive care unit stay ≥8 days after ≥20% TBSA burns. Linear regression was used to assess the association between SOI (sequential organ failure assessment scores) and PALs as well as between SOI and nutritional intake. After univariate analysis comparing survivors and nonsurvivors, factors with P < .10 were analyzed with multiple logistic regression. Characteristics of the 45 included patients were: 42 ± 15 years old, 37 ± 17% TBSA burns, 22% mortality. Factors independently associated with survival were burn size (negatively) (P = .018), height (positively) (P = .006), highest PAL during the first eight intensive care unit days (positively) (P = .016), and kcal balance during the fifth through the eighth intensive care unit days (positively) (P = .012). Sequential organ failure assessment scores had a significant (P < .001) but weak association with nutrition intake (R2 = 0.05) and PALs (R2 = 0.25). Higher nutritional intake and activity were significantly associated with lower mortality in critically ill burn patients. Given the weak associations between both nutritional intake and PALs with SOI, the primary barrier in achieving nutrition and activity goals was not SOI. We recommend that physical rehabilitation and nutritional intake be optimized in an effort to improve outcomes in critically ill burn patients.

Influence of upper extremity positioning on pain, paresthesia, and tolerance: advancing current practice.

Loss of upper extremity motion caused by axillary burn scar contracture is a major complication of burn injury. Positioning acutely injured patients with axillary burns in positions above 90° of shoulder abduction may improve shoulder motion and minimize scar contracture. However, these positions may increase injury risk to the nerves of the brachial plexus. This study evaluated the occurrence of paresthesias, pain, and positional intolerance in four shoulder abduction positions in healthy adults. Sixty men and women were placed in four randomly assigned shoulder abduction positions for up to 2 hours: 1) 90° with elbow extension (90 ABD); 2) 130° with elbow flexion at 110° (130 ABD); 3) 150° with elbow extension (150 ABD); and 4) 170° with elbow extension (170 ABD). Outcome measures were assessed at baseline and every 30 minutes and included the occurrence of upper extremity paresthesias, position comfort/tolerance, and pain. Transient paresthesias, lasting less than 3 minutes, occurred in all test positions in 10 to 37% of the cases. Significantly fewer subjects reported paresthesias in the 90 ABD position compared with the other positions (P < .01). Pain was reported more frequently in the 170° position (68%) compared with the other positions (P < .01). Positioning with the elbow flexed or in terminal extension is not recommended, regardless of the degree of shoulder abduction. Positioning patients in a position of 150° of shoulder abduction was shown to be safe and well tolerated. Consideration of positions above this range should be undertaken cautiously and only with strict monitoring in alert and oriented patients for short time periods.

Positioning, splinting, and contracture management.

Whether a patient with burn injury is an adult or child, contracture management should be the primary focus of burn rehabilitation throughout the continuum of care. Positioning and splinting are crucial components of a comprehensive burn rehabilitation program that emphasizes contracture prevention. The emphasis of these devices throughout the phases of rehabilitation fluctuates to meet the changing needs of patients with burn injury. Early, effective, and consistent use of positioning devices and splints is recommended for successful management of burn scar contracture.

Rehabilitation of the burned hand.

Successful outcomes following hand burn injury require an understanding of the rehabilitation needs of the patient. Rehabilitation of hand burns begins on admission, and each patient requires a specific plan for range of motion and/or immobilization, functional activities, and modalities. The rehabilitation care plan typically evolves during the acute care period and during the months following injury.

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.

Identification of cutaneous functional units related to burn scar contracture development.

The development of burn scar contractures is due in part to the replacement of naturally pliable skin with an inadequate quantity and quality of extensible scar tissue. Predilected skin surface areas associated with limb range of motion (ROM) have a tendency to develop burn scar contractures that prevent full joint ROM leading to deformity, impairment, and disability. Previous study has documented forearm skin movement associated with wrist extension. The purpose of this study was to expand the identification of skin movement associated with ROM to all joint surface areas that have a tendency to develop burn scar contractures. Twenty male subjects without burns had anthropometric measurements recorded and skin marks placed on their torsos and dominant extremities. Each subject performed ranges of motion of nine common burn scar contracture sites with the markers photographed at the beginning and end of motion. The area of skin movement associated with joint ROM was recorded, normalized, and quantified as a percentage of total area. On average, subjects recruited 83% of available skin from a prescribed area to complete movement across all joints of interest (range, 18-100%). Recruitment of skin during wrist flexion demonstrated the greatest amount of variability between subjects, whereas recruitment of skin during knee extension demonstrated the most consistency. No association of skin movement was found related to percent body fat or body mass index. Skin recruitment was positively correlated with joint ROM. Fields of skin associated with normal ROM were identified and subsequently labeled as cutaneous functional units. The amount of skin involved in joint movement extended far beyond the immediate proximity of the joint skin creases themselves. This information may impact the design of rehabilitation programs for patients with severe burns.

Military return to duty and civilian return to work factors following burns with focus on the hand and literature review.

Functional recovery and outcome from severe burns is oftentimes judged by the time required for a person to return to work (RTW) in civilian life. The equivalent in military terms is return to active duty. Many factors have been described in the literature as associated with this outcome. Hand function, in particular, is thought to have a great influence on the resumption of preburn activities. The purpose of this investigation was to compare factors associated with civilian RTW with combat injured military personnel. A review of the literature was performed to assimilate the many factors reported as involved with RTW or duty. Additionally, a focus on the influence of hand burns is included. Thirty-four different parameters influencing RTW have been reported inconsistently in the literature. In a military population of combat burns, TBSA burn, length of hospitalization and intensive care and inhalation injury were found as the most significant factors in determining return to duty status. In previous RTW investigations of civilian populations, there exists a scatter of factors reported to influence patient disposition with a mixture of conflicting results. In neither military nor civilian populations was the presence of a hand burn found as a dominant factor. Variety in patient information collected and statistical approaches used to analyze this information were found to influence the results and deter comparisons between patient populations. There is a need for a consensus data set and corresponding statistical approach used to evaluate RTW and duty outcomes after burn injury.

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.

Incidence and severity of combat hand burns after All Army Activity message.

BACKGROUND: Operations Enduring Freedom and Iraqi Freedom have resulted in severe burns to the hands. Because of the frequency and severity of hand burns, an All Army Activity (ALARACT) message was distributed emphasizing the importance of hand protection (HP). Our purpose was to assess the effectiveness of the ALARACT in reducing the incidence and severity of hand burns. METHODS: A retrospective review of the US Army Institute of Surgical Research Burn Registry for active duty personnel with hand burns 17 months before and after the ALARACT was conducted. Data include percentage total body surface area (% TBSA), % full-thickness injury, depth of hand burn, and ratio of hand burn to TBSA. Statistical analysis was performed using Mann-Whitney U test. RESULTS: Four hundred fifty-one military personnel were admitted during the 34-month period: 257 (56.9%) pre-ALARACT; 194 (43.1%) post-ALARACT. Two hundred thirty-nine (52.9%) sustained hand burns: 138 (53.7%) pre-ALARACT; 101 (52.1%) post-ALARACT (p = NS). Mean TBSA: 21.5% pre-ALARACT; 28.8% post- ALARACT (p = 0.01). Mean full-thickness TBSA: 14.5% pre-ALARACT; 21.9% post-ALARACT (p = 0.02). Mean hand TBSA: 3.2% pre-ALARACT; 3.2% post-ALARACT (p = NS). Mean ratio, hand burn to TBSA: 36% pre-ALARACT; 25% post-ALARACT (p < 0.001). DISCUSSION: Post-ALARACT, the incidence of hand burns remained unchanged. Despite an increase in burn severity, ratio of hand burn to TBSA decreased, suggesting a possible relationship between increased awareness and use of HP and decreased injury. Based on the data collected, the impact of the ALARACT is unclear. The importance of HP remains a priority. The fact that the incidence of hand burns remains unchanged demands our continued awareness and increased efforts.

Two simple leg net devices designed to protect lower-extremity skin grafts and donor sites and prevent decubitus ulcer.

Burn therapists routinely are tasked to position the lower extremities of burn patients for pressure ulcer prevention, skin graft protection, donor site ventilation, and edema reduction. We developed two durable and low-maintenance devices that allow effective positioning of the lower extremities. The high-profile and low-profile leg net devices were simple to fabricate and maintain. The frame was assembled using a three-quarter-inch diameter copper pipe and copper fittings (45 degrees, 90 degrees, and tees). A double layer of elasticized tubular netting was pulled over the frame and doubled back for leg support to complete the devices. The devices can be placed on any bed surface. The netting can be exchanged when soiled and the frame can be disinfected between patients using standard techniques. Both devices were used on approximately 250 patients for a total of 1200 treatment days. No incidence of pressure ulcer was observed, and graft take was not adversely affected. The devices have not required repairs or replacement. Medical providers reported they are easy to apply and effectively maintain proper positioning throughout application. Neither device interfered with the application of other positioning devices. Both devices were found to be an effective method of positioning lower extremities to prevent pressure ulcer, minimize graft loss and donor site morbidity, and reduce edema. The devices allowed for proper wound ventilation and protected grafted lower extremities on any bed surface. The devices are simple to fabricate and maintain. Both devices can be effectively used simultaneously with other positioning devices.

The reliability and concurrent validity of the figure-of-eight method of measuring hand edema in patients with burns.

OBJECTIVE: Water volumetry is considered the "gold standard" for hand edema assessment. This technique requires considerable time, staff, and specialized equipment. The figure-of-eight method for hand edema assessment has been tested only in the orthopedic population. The objective of this study was to test the reliability and concurrent validity of the figure-of-eight method of measuring hand edema in the burn patient population. METHODS: We conducted a prospective blinded study with 20 burned patients (33 edematous hands) admitted from February to May 2005. Two testers performed three separate blinded measurements on each edematous hand, using the figure-of-eight technique. A third tester performed two measurements, using water volumetry. An independent investigator recorded all measurements. Intratester and intertester reliability were analyzed. Concurrent validity was examined and compared with water volumetry measurements. RESULTS: Intraclass correlation coefficients (ICC) for the intratester reliability of the figure-of-eight method were 0.96 for tester 1 and 0.97 for tester 2. The ICC for intertester reliability of the figure-of-eight measurements was 0.94. The intratester ICC for volumetric measurements was 0.99. Correlation coefficient (Pearson's) for tester 1 was 0.83 (P < .01), and for tester 2, 0.89 (P < .01). CONCLUSION: The figure-of-eight technique is a reliable and valid measurement tool for measuring hand edema. This technique is a more clinically feasible tool than water volumetry in the burn patient population.