Effects of exercise training on muscle wasting, muscle strength and quality of life in adults with acute burn injury.

OBJECTIVES: Exercise training during the acute phase of burns is difficult to implement but offers potential benefits. This multicenter trial explored the effects of an exercise program on muscular changes and quality of life during burn center stay. METHODS: Fifty-seven adults with burns ranging between 10% and 70% TBSA were allocated to receive either standard of care (n = 29), or additionally exercise (n = 28), consisting of resistance and aerobic training, commenced as early as possible according to safety criteria. Muscle wasting (primary outcome), quantified by ultrasound-derived quadriceps muscle layer thickness (QMLT) and rectus femoris cross-sectional area (RF-CSA), muscle strength and quality of life (Burn Specific Health Scale-Brief (BSHS-B) and EQ-5D-5L) were assessed at baseline, four and eight weeks later, or hospital discharge. Mixed models were used to analyze between-group changes over time with covariates of interest added in stepwise forward modeling. RESULTS: The addition of exercise training to standard of care induced significant improvements in QMLT, RF-CSA, muscle strength and the BSHS-B subscale hand function (ß-coefficient. 0.055 cm/week of QMLT, p = 0.005). No added benefit was observed for other quality-of-life measures. CONCLUSIONS: Exercise training, administered during the acute phase of burns, reduced muscle wasting, and improved muscle strength throughout burn center stay.

Reliability and feasibility of skeletal muscle ultrasound in the acute burn setting.

OBJECTIVES: Despite the impact of muscle wasting after burn, tools to quantify muscle wasting are lacking. This multi-centre study examined the utility of ultrasound to measure muscle mass in acute burn patients comparing different methodologies. METHODS: B-mode ultrasound was used by two raters to determine feasibility and inter-rater reliability in twenty burned adults following admission. Quadriceps muscle layer thickness (QMLT) and rectus femoris cross-sectional area (RF-CSA) were measured, comparing the use of i) a single versus average measurements, ii) a proximal versus distal location for QMLT, and iii) a maximum- versus no-compression technique for QMLT. RESULTS: Analysis of twenty burned adults (50 years [95%CI 42-57], 32%TBSA [95%CI 23-40]) yielded ICCs of> 0.97 for QMLT (for either location and compression technique) and> 0.95 for RF-CSA, using average measurements. Relative minimal detectable changes were smaller using no-compression than maximum-compression (6.5% vs. 15%). Using no-compression to measure QMLT was deemed feasible for both proximal and distal locations (94% and 96% of attempted measurements). In 9.5% of cases maximum-compression was not feasible. 95% of RF-CSA measurements were successfully completed. CONCLUSION: Ultrasound provides feasible and reliable values of quadriceps muscle architecture that can be adapted to clinical scenarios commonly encountered in acute burn settings.

The process to obtain reimbursement for enzymatic debridement in clinically deep burns.

INTRODUCTION: Burn eschar removal by enzymatic debridement with NexoBrid® (EDNX) results in a maximum preservation of all viable tissue, which is the main advantage over traditional tangential excision. The authors participated in a marketing authorization holder process to obtain reimbursement from the national health authorities in Belgium. MATERIAL AND METHODS: The reimbursement process consisted of three phases, as specified by the reimbursement regulations required by the Belgian National Institute for Health and Disability Insurance (NIHDI). RESULTS: Forty-one patients with clinically deep 2nd and 3rd degree burns, treated with EDNX in two Belgian burn centers, were included in the registry for the first phase of the reimbursement process. The total success rate of the EDNX treatment was 95.1% (39/41). Over half of the burn wounds treated with NexoBrid® (55.2%) did not require any additional surgical debridement or skin grafting. To obtain definitive reimbursement, an extra 16 patients were included. In this population, 51.4% did not require any surgical intervention. The total success rate of the EDNX debridement in this group was 100%. Based on an estimated market share of 12% and around 75 patients in the third year after final reimbursement, a market access consultant calculated that NexoBrid® will realize yearly savings for the Belgian Healthcare budget of at least €30.000. CONCLUSION: Based on the results of this Belgian registry study in combination with the yearly healthcare budget savings, the NIHDI granted a final reimbursement for EDNX treatment in adults, endorsed by the Minister of Health on November 5th, 2019.

The effects of shock wave therapy applied on hypertrophic burn scars: a randomised controlled trial.

INTRODUCTION: A wide variety of non-invasive treatments has been proposed for the management of hypertrophic burn scars. Unfortunately, the reported efficacy has not been consistent, and especially in the first three months after wound closure, fragility of the scarred skin limits the treatment options. Extracorporeal shock wave therapy (ESWT) is a new non-invasive type of mechanotherapy to treat wounds and scars. The aim of the present study was to examine the objective and subjective scar-related effects of ESWT on burn scars in the early remodelling phase. MATERIAL AND METHODS: Evaluations included the Patient and Observer Scar Assessment Scale (POSAS) for scar quality, tri-stimulus colorimetry for redness, tewametry for trans-epidermal water loss (TEWL) and cutometry for elasticity. Patients were randomly assigned to one of two groups, the low-energy intervention group or the placebo control group, and were tested at baseline, after one, three and six months. All patients were treated with pressure garments, silicone and moisturisers. Both groups received the ESWT treatment (real or placebo) once a week for 10 weeks. RESULTS: Results for 20 patients in each group after six months are presented. The objective assessments showed a statistically significant effect of ESWT compared with placebo on elasticity (P = 0.011, η2P=0.107) but revealed no significant effects on redness and TEWL. Results of the clinical assessments showed no significant interactions between intervention and time for the POSAS Patient and Observer scores. CONCLUSION: ESWT can give added value to the non-invasive treatment of hypertrophic scars, more specifically to improve elasticity when the treatment was already started in the first three months after wound closure. LAY SUMMARY: Pathological scarring is a common problem after a burn injury. A wide variety of non-invasive treatments has been proposed for the management of these scars. Unfortunately, the reported efficacy of these interventions has not been consistent, and especially in the first three months after wound closure, fragility of the scarred skin limits the treatment options. Extracorporeal shock wave therapy (ESWT) is a relatively new non-invasive therapy to treat both wounds and scars. The aim of the present study was to examine the scar-related effects of ESWT on burn scars in the early phase of healing.The scars were subjectively assessed for scar quality by the patient and an observer using the Patient and Observer Scar Assessment Scale (POSAS). Objective assessments included measurements to assess redness, water loss and elasticity. Forty patients were randomly assigned to one of two groups, the low-energy intervention group or the placebo control group (the device simulated the sound of an ESWT treatment but no real shocks were applied), and were tested at four timepoints up to six months. All patients were treated with pressure garments, silicone and moisturisers. Both groups received the ESWT treatment (real or placebo) once a week for 10 weeks.The objective assessments showed a significant improvement of elasticity in the intervention group when compared with placebo but revealed no significant effects on redness and water loss. Results of the clinical assessments showed no differences between the groups for the POSAS Patient and Observer scores.ESWT can give added value to the non-invasive treatment of pathological scars more specifically to improve elasticity in the early phase of healing.

Can a Cohesive Silicone Bandage Outperform an Adhesive Silicone Gel Sheet in the Treatment of Scars? A Randomized Comparative Trial.

BACKGROUND: The use of topical silicone to treat scars is widespread, and various studies have demonstrated its efficacy to treat scars. A new form of silicone application is a cohesive elastic bandage. The aim of this study was to compare the effects of this bandage versus an adhesive silicone gel sheet on scar elasticity after burn injury. METHODS: A total of 60 patients were enrolled in a randomized, prospective, single-blind, single-center, comparative, parallel-group study. The participants were assigned randomly to one of two treatment arms: one for treatment with a cohesive silicone bandage, and the other with a silicone gel sheet. The color was measured objectively using a Chromameter, and the Cutometer was used to assess vertical elasticity. For subjective assessment of the scars, the authors used the Patient and Observer Scar Assessment Scale. RESULTS: The results reveal that there were no significant differences between the two interventions for most subjective assessments and color measurements. However, the group that received treatment with the cohesive silicone bandage did seem to perform statistically significantly better than the silicone gel sheet group for vertical elasticity and the global score of the Patient and Observer Scar Assessment Scale (observer scale). This was probably because of the unique microstructure of the bandage that ensured a standardized pressure together with uninterrupted contact with the skin. CONCLUSIONS: An elastic cohesive silicone bandage seems to outperform silicone gel sheets for vertical elasticity when treating hypertrophic burn scars. The authors recommend including timing of application and duration of application in future studies. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Influence on clinical parameters of depressomassage (part I): The effects of depressomassage on color and transepidermal water loss rate in burn scars: A pilot comparative controlled study.

OBJECTIVE: Depressomassage is a non-invasive massage technique using a mechanical suction device that is used in the treatment of traumatic or burn scars. Since color and transepidermal water loss (TEWL) are respectively the most important physical and physiological characteristic of hypertrophic scar formation, we wanted to investigate the effects of depressomassage on the recovery of color and TEWL in burn scars compared to the traditional physiotherapy. METHODS: In this pilot comparative controlled study a total 43 burn patients were included and allocated into 2 groups. All patients received standard physical therapy, and the test group received additional depressomassage during 6 months. Color was assessed using the POSAS questionnaire (for color, vascularity and pigmentation) and the Minolta Chromameter. TEWL was measured using DermaLab. RESULTS: Patients of both groups were evaluated at baseline, after 1, 3 and 6 months and after 1year. The evidence for a difference in evolution of color and TEWL between both groups in our study was minimal. CONCLUSIONS: In practice, precise indications to begin depressomassage have to be kept in mind. Perhaps other scar abnormalities such as decreased elasticity, increased thickness, excessive pain or itching could be sufficient reasons to begin depressomassage and should be assessed.

Short-term effects of vacuum massage on epidermal and dermal thickness and density in burn scars: an experimental study.

BACKGROUND: Vacuum massage is a non-invasive mechanical massage technique invented to treat burns and scars. To date, no effects of vacuum massage on thickness and density of human scar tissue have been reported. The process in which external stimuli are converted into biochemical responses in the cell is known as mechanotransduction. In the skin endothelial cells, fibroblasts and myofibroblasts embedded in the extracellular matrix (ECM) sense mechanical stimuli (created by vacuum massage) and may promote intracellular processes leading to matrix remodelling. Since mechanotransduction could be a plausible working mechanism for vacuum massage as an anti-scarring therapy, this study aims to investigate the short-term effects of vacuum massage on thickness and density of epidermis and dermis in burn scars in order to find proof of ECM remodelling. METHODS: A one group experimental study was performed. Patients with burn scars on upper extremities, lower extremities, and trunk were recruited for participation in this study. The DUB®cutis 22 MHz ultrasound scanner was used to assess thickness and density of the epidermal and dermal skin layers. After baseline measurements, vacuum massage was performed according to a pre-defined protocol. Measurements were carried out at 5 min, 30 min, 1 h, and 2 h post-intervention. RESULTS: Thirteen scar sites from 9 different patients were investigated. In 8 out of the 13 scar sites, a disruption of the epidermis was noticed after the vacuum massage. Five minutes after the intervention, epidermal density decreased statistically significantly (p = .022) and dermal thickness increased (p = .018). Both changes lasted for more than 1 h, but after 2 h, the changes were no longer statistically significant. Dermal density decreased significantly (p = .048) immediately after the intervention, and this decrease was still present after 2 h (p = .011). CONCLUSIONS: Preliminary results show that the disruption of the epidermis may indicate that vacuum massage could be able to actually breach the skin barrier. The statistically significant changes in the dermal layers could suggest an increased ECM production after vacuum massage.