Validation of the Burn Survivor Fear-Avoidance Questionnaire and Its Association With Pain Intensity, Catastrophizing, and Disability.

According to the Fear-avoidance (FA) model, FA beliefs can lead to disability due to avoidance of activities expected to result in pain or further injury. Extensive research on the relationship of FA, pain, catastrophizing, and disability has been generated with patients suffering from chronic neck and back pain, but little research has been conducted with burn survivors. To address this need, the Burn Survivor FA Questionnaire (BSFAQ) was developed (Langlois J, Vincent-Toskin, S, Duchesne, P et al. Fear-avoidance beliefs and behaviors of burn survivors: A mixed-methods approach. Burns 2021;47:175-89.) but has not been validated. Thus, the primary objective of this study was to investigate the construct validity of the BSFAQ among burn survivors. The secondary objective was to examine the relationship between FA and 1) pain intensity and 2) catastrophizing at baseline, 3 months and 6 months postburn, and 3) disability among burn survivors at 6 months postburn. A prospective mixed-methods approach was used to examine the construct validity by comparing the quantitative scores of the BSFAQ to independently performed qualitative interviews of burn survivors (n = 31) that explored their lived experiences, to determine if the BSFAQ discriminated those who had, from those who did not have FA beliefs. Data for the secondary objective, scores of burn survivors (n = 51) pain intensity (numeric rating scale), catastrophizing (pain catastrophizing scale), and disability (Burn Specific Health Scale-brief), were collected through a retrospective chart review. For the primary objective, Wilcoxon rank sum test results showed a statistically significant difference (P = .015) between the BSFAQ scores of participants who were identified from the qualitative interviews as fear avoidant compared to those who were identified as non fear avoidant, with a receiver operating characteristic curve indicating that the BSFAQ correctly predicted FA 82.4% of the time. For the secondary objective, Spearman correlation test results showed a moderate correlation between FA and 1) pain at baseline (r = .466, P = .002), 2) catastrophizing thoughts over time (r = .557, P = .000; r = .470, P = .00; r = .559, P = .002 respectively at each time point), and 3) disability at 6 months postburn (r = -.643, P = .000). These results support that the BSFAQ is able to discriminate which burn survivors are experiencing FA beliefs. It is also consistent with the FA model since burn survivors who express FA are more likely to report higher levels of pain early during their recovery that correlates with persistently elevated catastrophizing thoughts and ultimately results in higher self-reported disability. The BSFAQ demonstrates construct validity and is able to correctly predict fear-avoidant burn survivors; however, additional research is required to further examine the BSFAQ's clinimetric properties.

Cross-cultural translation, adaptation and validation of the Burnt Hand Outcome Tool (BHOT) from English to French Canadian.

BACKGROUND: The Burnt Hand Outcome Tool (BHOT) is a comprehensive tool assessing the multiple impacts of hand burn injuries which makes it essential to burn care practice, but is currently only available in English. OBJECTIVES: To create a French-Canadian cross-cultural adaptation of the BHOT and to assess its content and construct convergent validity. METHODS: The BHOT was translated and culturally adapted according to evidence-based principles for patient-reported outcome measures. The steps included translation to French (BHOT-F), backward translation, expert committee review, and cognitive debriefing with 5 adult participants. A pre-final version of the BHOT-F was then administered to 39 adult participants with hand burn injuries to assess construct convergent validity using the shortened Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH). Content validity was evaluated based on comments from the expert committee and participant burn survivors. RESULTS: The BHOT-F was modified during the adaption process to ensure its clarity. The Cronbach's alpha value of 0.935 demonstrates the excellent internal consistency of the BHOT-F. The BHOT-F and the QuickDASH were strongly correlated (p < 0.01). Content validity was deemed satisfactory and recommendations are reported for future research. CONCLUSIONS: The BHOT-F demonstrates adequate clinimetric properties to be used in clinical practice.

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.

Longitudinal Evaluation of Pressure Applied by Custom Fabricated Garments Worn by Adult Burn Survivors.

Custom fabricated pressure garments (PGs) are commonly used to prevent or treat hypertrophic scars (HSc) after burn injury. However, there is minimal scientific evidence quantifying pressure after standard measurement and fitting techniques. Adult burn survivors whose HSc was treated with PGs were recruited. Trained fitters, blinded to study locations and results, took the garment measures. Once the PGs arrived and were fitted, baseline pressure measures at HSc and normal skin (NS) sites were determined using the Pliance X® System. Pressure readings were repeated at 1, 2, and 3 months. The mean baseline pressure was 15.3 (SD 10.4) at HSc and 13.4 (SD 11.9) at NS sites. There was a significant reduction during the first month at both sites (P = .0002 HSc; P = .0002 NS). A multivariable linear regression mixed model, adjusting for garment type, baseline pressure, and repeated measures, revealed further reduction at HSc sites between 1 and 2 months (P = .03). By 3 months, the mean pressure reduced to 9.9 (SD 6.7) and 9.15 (SD 7.2) mm Hg at HSc and NS sites, respectively. At each time point, the pressure was higher at HSc compared with NS but was significantly different only at 1 month (P = .01). PGs were worn ≥12 hr/d 7 d/wk. PGs that apply 15 to 25 mm Hg pressure significantly improve HSc; however, immediately after fitting newly fabricated PGs, the average pressure was at the bottom of the recommended range and by 1 month was significantly below. Clinicians are likely underestimating the dosage required and the significant pressure loss within the first 2 months.

Systematic Review and Expert Consensus on the Use of Orthoses (Splints and Casts) with Adults and Children after Burn Injury to Determine Practice Guidelines.

The objective of this review was to systematically evaluate the available literature addressing the use of orthoses (splints and casts) with adult and pediatric burn survivors and determine whether practice guidelines could be proposed. This review provides evidence-based recommendations specifically for rehabilitation professionals who are responsible for burn survivor rehabilitation. A summary recommendation was made after the literature was retrieved using a systematic review and critical appraisal by multiple authors. The level of evidence of the literature was determined in accordance with the Oxford Centre for Evidence-based Medicine criteria. Due to the low level of evidence in the available literature, only one practice guideline could be recommended: orthotic use should be considered as a treatment choice for improving range of motion or reducing contracture in adults who have sustained a burn injury. To address the rehabilitation-specific gaps found in the literature regarding orthotic use in burn rehabilitation and provide guidance to clinicians, a formal expert consensus exercise was conducted as a final step to the project. The resultant manuscript provides a summary of the literature regarding orthotic use with burn patients, one practice guideline, proposed orthotic terminology and additional practice recommendations based on expert opinion. The limitations in the current literature are also discussed, and suggestions are made for future studies in the area of orthotic use after burn injury.

Perceived Value of a Knowledge Translation Intervention Designed to Facilitate Burn Survivors' Work Reintegration.

Returning to work can be challenging for burn survivors. Approximately 28% never return to any form of employment, resulting in lower health-related quality of life. Open communication has been identified as a facilitator for return to work (RTW). To ease the RTW process and promote communication with coworkers and employers a knowledge translation (KT) intervention was developed for burn survivors. Following its implementation, the impact on the RTW process was evaluated. This study was a cross-sectional, mixed methods study where burn survivors included in the KT intervention were compared with a control group. Control group participants were selectively invited so that the two groups' mean age, sex, and percent total body surface area burned were similar. Semistructured interviews gathered information about their RTW process and outcomes. Qualitative data were analyzed through thematic analysis and quantitative data were summarized and compared using Mann-Whitney tests. Overall, both groups were satisfied with their RTW process. Participants from the control group identified more barriers related to support received, particularly at work, and reported more psychological symptoms such as posttraumatic stress disorder, self-consciousness, and discomfort with questions. Many participants from the KT group indicated the KT intervention gave them tools and information to provide others with a better understanding of their lived experience. It is possible that the KT intervention facilitated more open communication by empowering burn survivors to explain their situation on their own, thus reducing the prevalence of social and psychological barriers by allowing them to self-advocate for more support.

Randomized controlled trial of the immediate and long-term effect of massage on adult postburn scar.

BACKGROUND: One objective of massage therapy applied to hypertrophic scar (HSc), is to improve the structural properties so skin possesses the strength and elasticity required for normal mobility. However, research supporting this effect is lacking. The objective of this study was to characterize the changes in scar elasticity, erythema, melanin, and thickness immediately after a massage therapy session and after a 12-week course of treatment compared to intra-individual matched control scars. METHODS: We conducted a prospective, randomized, single-blinded, pragmatic, controlled, clinical trial evaluating the impact of a 12-week course of massage therapy. Seventy burn survivors consented to participate and 60 completed the study. Two homogeneous, intra-individual scars were randomized to usual care control or massage therapy plus usual care. Massage, occupational or physical therapists provided massage treatment 3x/week for 12 weeks. Scar site characteristics were evaluated weekly immediately before and after massage treatment including elasticity (Cutometer), erythema and melanin (Mexameter), and thickness (high-frequency ultrasound). Analysis of covariance (ANCOVAs) were performed to test for immediate and long-term treatment effects. A mixed-model approach was used to account for the intra-individual scars. RESULTS: Scar evaluation immediately before and after massage therapy at each time point revealed changes for all scar characteristics, but the group differences were predominantly present during the early weeks of treatment. The within group long-term analysis revealed a significant increase in elasticity, and a reduction in thickness, during the 12-week treatment period for both the control scar (CS) and massage scar (MS). The increase in elasticity reached significance at week 8 for the MS and week 10 for the CS and the reduction in thickness at week 5 for the CS and week 7 for the MS. There was no significant within group long-term differences for either erythema or melanin. There were group differences in erythema at week 8 and 11 where the CS was less erythematous than the MS. CONCLUSIONS: The immediate impact of forces applied during massage therapy may lead patients and therapists to believe that there are long-term changes in elasticity, erythema, and pigmentation, however, once baseline measures, the control scar, and time were incorporated in the analysis there was no evidence of long-term benefit. Massage therapy applied with the objective of increasing scar elasticity or reducing erythema or thickness over the long-term should be reconsidered.

Development and clinimetric evaluation of the mouth impairment and disability assessment (MIDA).

INTRODUCTION: Burns of the face and mouth region have a profound impact on function. Currently the outcome measure that is most commonly used in the burn care literature is horizontal and vertical opening. Impairment-based outcomes such as this do not capture the functional implications of these injuries in spite of the devastating impact they can have on burn survivor's lives. PURPOSE OF THE STUDY: To generate an assessment that evaluates the impairments, activity limitations, and participation restrictions associated with mouth injuries and prospectively collect data to examine the clinimetric properties. METHODS: A multistep assessment development process was undertaken including a comprehensive literature search and review, burn care expert and burn survivor interviews, generation of a preliminary version and field-testing, modifications based on field testing and updated literature review, and further field testing with data collection of 23 burn survivors. Clinimetric properties were examined by evaluating: whether there was a ceiling or floor effect, the internal consistency, construct validity, and responsiveness. RESULTS: The mouth impairment and disability assessment (MIDA) has a 28 item self-report portion, divided into four subscales, completed by the patient and an impairment-based section completed by the burn therapist. Two items demonstrated a ceiling effect, one was removed the other retained. There was strong and statistically significant (p<0.0001) correlation of the symptoms subscale as well as vertical opening with the functional activities subscale of the MIDA. The functional activities subscale demonstrated good internal consistency and the symptoms subscale was adequate. Re-evaluation approximately seven and a half months after the baseline evaluation demonstrated a statistically significant change with time and treatment. CONCLUSIONS: The MIDA now offers clinicians the ability to assess mouth impairment and disability of burn survivors who have sustained burn injuries to their face and mouth region.

Barriers and facilitators to work reintegration and burn survivors' perspectives on educating work colleagues.

INTRODUCTION: Work reintegration constitutes a major milestone in the rehabilitation process of adults who have sustained a burn. Research studies with other conditions demonstrated that open, explicit communication about the worker's condition and potential limitations may facilitate this transition. However, the best approach to enable this discussion to occur has yet to be described. The aim of this exploratory qualitative study was to investigate burn survivors' and clinicians' perspectives of the barriers and facilitators to work reintegration that could be addressed through education of work colleagues, which information to communicate to the workplace and the most effective method to disseminate this knowledge. METHODS: Five semi-structured focus groups were conducted with three groups of informants including: (1) 13 burn survivors who had already returned to work; (2) 7 who were planning on returning; and (3) 9 burn care professionals. Qualitative data were inductively analyzed employing constant comparative techniques. RESULTS: Key barriers and facilitators that were identified included residual impairments, individual characteristics, support from the social environment, work accommodations and resources from the healthcare and compensation systems. Burn survivors agreed that return to work efforts were not adequately supported and that education should be provided to work colleagues about the burn and rehabilitation process, but that information on residual impairments should be communicated judiciously as it may be used prejudiciously against those seeking new employment. In the latter case, it is preferable to inform the workplace of their strengths and abilities. CONCLUSIONS: Extensive literature demonstrating the benefits of educational programs for the peers and teachers of pediatric burn survivors when they return to school already exists. This study provides evidence that there is a need for a similar process for adult burn survivors returning to work. The educational material must be versatile enough so that it can be customized to individual burn survivor's needs and the environments in which they work.

Somatosensory Rehabilitation for Neuropathic Pain in Burn Survivors: A Case Series.

Neuropathic pain is an enormous rehabilitation challenge that has a substantial negative effect on patient function and quality of life. Somatosensory rehabilitation is a novel, nonpharmacological intervention described by Spicher based on the neuroplasticity of the somatosensory system. The rationale for somatosensory rehabilitation is that treating hypoesthesia will decrease neuropathic pain. Particularly for those with established neuropathic pain, the hypoesthesia may be masked by mechanical allodynia, which must be treated before treating the underlying hyposensitive zone. This case series describes the outcome of 17 burn survivors treated with somatosensory rehabilitation for their neuropathic pain. Before initiating treatment a modified version of the McGill Pain Questionnaire-short form (Questionnaire de la douleur St. Antoine, QDSA) was completed with the patients. The total score (×/64) was converted to percentage. The mechanical allodynia was assessed with the Rainbow Pain Scale that uses touch with the 15-g Semmes Weinstein Monofilaments (SWMs) and that was rated as painful on the visual analog scale (3/10 or resting pain + 1/10), as the criteria for mechanical allodynia. The severity level was assessed using seven predetermined SWMs to identify the smallest that elicited pain. The treatment consisted of avoiding all touch in the allodynic zone while concurrently providing proximal sensory and vibratory counter stimulation. Once the mechanical allodynia was eliminated, the underlying hypoesthesia was treated. Hypoesthesia was evaluated with the SWMs, and the percent improvement from baseline was calculated. The sensory reeducation treatment for hypoesthesia consisted of touch discrimination, texture perception, and vibratory stimulation. Seventeen patients (71/29% male/female, 21 ± 25% TBSA burned, 486 ± 596 days postburn) were evaluated and treated. Of these 15 initially presented with mechanical allodynia. The SWM scores had improved by 27 ± 21% (n = 14) and 29 ± 26% (n = 12) at 2 and 3 months posttreatment, respectively. The QDSA scores had improved by 9 ± 14% (n = 8) and 23 ± 23% (n = 6) at 2 and 3 months posttreatment, respectively. There were two patients who initially presented with hypoesthesia and six who had their zone of hypoesthesia treated after the mechanical allodynia had resolved. For these eight patients, their ability to perceive light touch improved by 27 ± 17% (n = 8) and 35 ± 25% (n = 6) at 2 and 3 months postsensory reeducation treatment initiation, respectively. The QDSA improved by 9 and 50% for the two patients who initially presented with hypoesthesia. In this case series, the majority of patients (13/17 or 76%) showed substantial improvements after somatosensory rehabilitation suggesting this is a treatment approach that should be considered with burn survivors experiencing neuropathic pain. There is a need, however, for future controlled studies to further investigate this approach and to determine if there is a subpopulation of burn survivors that are more likely than others to benefit from this approach.