Feasibility of Brief, Hypnotic Enhanced Cognitive Therapy for SCI-related Pain During Inpatient Rehabilitation.

OBJECTIVES: (1) Adapt evidence-based hypnosis-enhanced cognitive therapy (HYP-CT) for inpatient rehabilitation setting; and (2) determine feasibility of a clinical trial evaluating the effectiveness of HYP-CT intervention for pain after spinal cord injury (SCI). STUDY DESIGN: Pilot non-randomized controlled trial. SETTING: Inpatient rehabilitation unit. PARTICIPANTS: English-speaking patients admitted to inpatient rehabilitation after SCI reporting current pain of at least 3 on a 0-10 scale. Persons with severe psychiatric illness, recent suicide attempt or elevated risk, or significant cognitive impairment were excluded. Consecutive sample of 53 patients with SCI-related pain enrolled, representing 82% of eligible patients. INTERVENTION: Up to 4 sessions of HYP-CT Intervention, each 30-60 minutes long. METHODS: Participants were assessed at baseline and given the choice to receive HYP-CT or Usual Care. MAIN OUTCOME MEASURES: Participant enrollment and participation and acceptability of intervention. Exploratory analyses examined the effect of intervention on pain and cognitive appraisals of pain. RESULTS: In the HYP-CT group, 71% completed at least 3 treatment sessions and reported treatment benefit and satisfaction with the treatment; no adverse events were reported. Exploratory analyses of effectiveness found pre-post treatment pain reductions after HYP-CT with large effect (P<.001; ß=-1.64). While the study was not powered to detect significant between-group differences at discharge, effect sizes revealed decreases in average pain (Cohen's d=-0.13), pain interference (d=-0.10), and pain catastrophizing (d=-0.20) in the HYP-CT group relative to control and increases in self-efficacy (d=0.27) and pain acceptance (d=0.15). CONCLUSIONS: It is feasible to provide HYP-CT to inpatients with SCI, and HYP-CT results in substantial reductions in SCI pain. The study is the first to show a psychological-based nonpharmacologic intervention that may reduce SCI pain during inpatient rehabilitation. A definitive efficacy trial is warranted.

A Case Study of Hypnosis Enhanced Cognitive Therapy for Pain in a Ventilator Dependent Patient during Inpatient Rehabilitation for Spinal Cord Injury.

Early, acute pain following spinal cord injury (SCI) is common, can negatively impact SCI rehabilitation, and is frequently not responsive to biomedical treatment. Nonpharmacological interventions show promise in reducing pain for individuals with SCI. However, most psychological interventions rely heavily on verbal interaction between the individual being treated and the clinician, making them inaccessible for individuals with impaired verbal output due to mechanical ventilation. This case study aims to describe the adaptation and implementation of hypnotic cognitive therapy (HYP-CT) intervention for early SCI pain in the context of mechanical ventilation dependence and weaning. The participant was a 54-year-old male with C2 AIS A SCI requiring mechanical ventilation. Four sessions of HYP-CT were provided during inpatient rehabilitation with assessment prior to intervention, after the intervention sessions, and prior to discharge. The participant reported immediate reductions in pain intensity following each intervention session. Overall, he reported increases in self-efficacy and pain acceptance. He did not report any negative treatment effects and thought the intervention provided support during mechanical ventilation weaning. During treatment, he discontinued opioid pain medications and reported actively using intervention strategies. Our results support the potential for early, hypnotic cognitive therapy for individuals with SCI experiencing pain or distress while dependent on mechanical ventilation.

Trajectories of physical health-related quality of life among adults living with burn injuries: A burn model system national database investigation to improve early intervention and rehabilitation service delivery.

INTRODUCTION: Understanding trajectories of recovery in key domains can be used to guide patients, families, and caregivers. The purpose of this study was to describe common trajectories of physical health over time and to examine predictors of these trajectories. METHOD: Adults with burn injuries completed self-reported assessments of their health-related quality of life (HRQOL) as measured by the SF-12® Physical Component Summary (PCS) score at distinct time points (preinjury via recall, index hospital discharge, and at 6-, 12-, and 24 months after injury). Growth mixture modeling (GMM) was used to model PCS scores over time. Covariables included burn size, participant characteristics, and scores from the Community Integration Questionnaire (CIQ)/Social Integration portion, Satisfaction With Life Scale (SWLS), and Satisfaction With Appearance Scale (SWAP). RESULTS: Data from 939 participants were used for complete-case analysis. Participants were 72% male, 64% non-Hispanic White, with an average age of 44 years and an average burn size of 20% of total body surface area (TBSA). The best fitting model suggested three distinct trajectories (Class 1 through 3) for HRQOL. We titled each Class according to the characteristics of their trajectory. Class 1 (recovering; n = 632), Class 2 (static; n = 77), and Class 3 (weakened; n = 205) reported near average HRQOL preinjury, then reported lower scores at discharge, with Class 1 subsequently improving to preinjury levels and Class 3 improving but not reaching their preinjury quality of life. Class 3 experienced the largest decrease in HRQOL. Class 2 reported the lowest preinjury HRQOL and remained low for the next 2 years, showing minimal change in their HRQOL. CONCLUSIONS: These findings emphasize the importance of early universal screening and sustained intervention for those most at risk for low HRQOL following injury. For Class 2 (static), lower than average HRQOL before their injury is a warning. For Class 3 (weakened), if the scores at 6 months show a large decline, then the person is at risk for not regaining their HRQOL by 24 months and thus needs all available interventions to optimize their outcomes. Results of this study provide guidance for how to identify people with burn injury who would benefit from more intensive rehabilitation to help them achieve or regain better HRQOL. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A comparison of interactive immersive virtual reality and still nature pictures as distraction-based analgesia in burn wound care.

PURPOSE: Non-pharmacologic adjuncts to opioid analgesics for burn wound debridement enhance safety and cost effectiveness in care. The current study explored the feasibility of using a custom portable water-friendly immersive VR hardware during burn debridement in adults, and tested whether interactive VR would reduce pain more effectively than nature stimuli viewed in the same VR goggles. METHODS: Forty-eight patients with severe burn injuries (44 adults and 4 children) had their burn injuries debrided and dressed in a wet wound care environment on Study Day 1, and 13 also participated in Study Day 2. INTERVENTION: The study used a within-subject design to test two hypotheses (one hypothesis per study day) with the condition order randomized. On Study Day 1, each individual (n = 44 participants) spent 5 min of wound care in an interactive immersive VR environment designed for burn care, and 5 min looking at still nature photos and sounds of nature in the same VR goggles. On Study Day 2 (n = 12 adult participants and one adolescent from Day 1), each participant spent 5 min of burn wound care with no distraction and 5 min of wound care in VR, using a new water-friendly VR system. On both days, during a post-wound care assessment, participants rated and compared the pain they had experienced in each condition. OUTCOME MEASURES ON STUDY DAYS 1 AND 2: Worst pain during burn wound care was the primary dependent variable. Secondary measures were ratings of time spent thinking about pain during wound care, pain unpleasantness, and positive affect during wound care. RESULTS: On Study Day 1, no significant differences in worst pain ratings during wound care were found between the computer-generated world (Mean = 71.06, SD = 26.86) vs. Nature pictures conditions (Mean = 68.19, SD = 29.26; t < 1, NS). On secondary measures, positive affect (fun) was higher, and realism was lower during computer-generated VR. No significant differences in pain unpleasantness or "presence in VR" between the two conditions were found, however. VR VS. NO VR. (STUDY DAY 2): Participants reported significantly less worst pain when distracted with adjunctive computer generated VR than during standard wound care without distraction (Mean = 54.23, SD = 26.13 vs 63.85, SD = 31.50, t(11) = 1.91, p < .05, SD = 17.38). In addition, on Study Day 2, "time spent thinking about pain during wound care" was significantly less during the VR condition, and positive affect was significantly greater during VR, compared to the No VR condition. CONCLUSION: The current study is innovative in that it is the first to show the feasibility of using a custom portable water-friendly immersive VR hardware during burn debridement in adults. However, contrary to predictions, interactive VR did not reduce pain more effectively than nature stimuli viewed in the same VR goggles.

Clinical Practice Guideline: Early Mobilization and Rehabilitation of Critically Ill Burn Patients.

This Clinical Practice Guideline addresses early mobilization and rehabilitation (EMR) of critically ill adult burn patients in an intensive care unit (ICU) setting. We defined EMR as any systematic or protocolized intervention that could include muscle activation, active exercises in bed, active resistance exercises, active side-to-side turning, or mobilization to sitting at the bedside, standing, or walking, including mobilization using assistance with hoists or tilt tables, which was initiated within at least 14 days of injury, while the patient was still in an ICU setting. After developing relevant PICO (Population, Intervention, Comparator, Outcomes) questions, a comprehensive literature search was conducted with the help of a professional medical librarian. Available literature was reviewed and systematically evaluated. Recommendations were formulated through the consensus of a multidisciplinary committee, which included burn nurses, physicians, and rehabilitation therapists, based on the available scientific evidence. No recommendation could be formed on the use of EMR to reduce the duration of mechanical ventilation in the burn ICU, but we conditionally recommend the use of EMR to reduce ICU-acquired weakness in critically ill burn patients. No recommendation could be made regarding EMR's effects on the development of hospital-acquired pressure injuries or disruption or damage to the skin grafts and skin substitutes. We conditionally recommend the use of EMR to reduce delirium in critically ill burn patients in the ICU.

Posttraumatic Stress Disorder Symptom Clusters as Predictors of Pain Interference in Burn Survivors: A Burn Model System National Database Study.

Individuals who experience burns are at higher risk of developing posttraumatic stress disorder and chronic pain. A synergistic relationship exists between posttraumatic stress disorder and chronic pain. We sought to evaluate the role of individual posttraumatic stress disorder symptom clusters as predictors of pain interference. We hypothesized that the hyperarousal and emotional numbing symptom clusters would be predictive of pain interference, even when accounting for the other two posttraumatic stress disorder symptom clusters, pain intensity, and other covariates. Multivariate linear regression analyses were completed using data from the Burn Model System National Database. A total of 439 adult participants had complete responses on self-report measures assessing posttraumatic stress disorder symptoms, pain intensity, and pain interference at 6-month after discharge and were included in analyses. Results indicate hyperarousal (B = .10, p = .03) and emotional numbing (B = .13, p = .01) posttraumatic stress disorder symptom clusters were each significantly associated with pain interference, even when accounting for pain intensity (B = .64, p < .001). Results highlight the importance of the emotional numbing and hyperarousal posttraumatic stress disorder symptom clusters in explaining pain interference. Findings suggest that when posttraumatic stress disorder symptoms or chronic pain are present, screening for and treating either condition may be warranted to reduce pain interference. Further, psychological interventions that target emotional numbing and hyperarousal posttraumatic stress disorder symptoms may be fruitful for promoting better coping with chronic pain and reducing pain interference.

The Impact of Virtual Reality Hypnosis on Pain and Anxiety Caused by Trauma: Lessons Learned from a Clinical Trial.

This randomized, controlled trial tested the impact that hypnosis delivered through immersive virtual reality technology on background pain, anxiety, opioid use, and hospital length of stay in a sample of patients hospitalized for trauma. Participants were randomly assigned to receive either virtual-reality-induced hypnosis, virtual reality for distraction, or usual care during the course of their hospitalization. Mean number of treatment sessions was 3. A total of 153 patients participated in the study. Results indicated no significant differences between the experimental and control conditions on any outcome measures. This study used an early version of virtual reality technology to induce hypnosis and highlighted several important lessons about the challenges of implementation of this technology and how to improve its use in clinical settings.

The relation between satisfaction with appearance and race and ethnicity: A National Institute on Disability, Independent Living, and Rehabilitation Research burn model system study.

Research supports that people of color in the U.S. have poorer outcomes after burn injury compared to White individuals. The current study sought to explore burn health disparities by testing the relationship between racial and ethnic minority status, a proxy for systemic discrimination due to race and ethnicity, with two key constructs linked to functional outcomes, satisfaction with appearance and social community integration. Participants included 1318 burn survivors from the Burn Model System National Database (mean age = 40.2, SD = 12.7). Participants completed measures of satisfaction with appearance and social community integration at baseline, 6-, 12-, and 24-months after burn injury. Linear regressions revealed that racial and ethnic minority status significantly related to lower satisfaction with appearance and social community integration compared to White individuals at all time points. In addition, satisfaction with appearance continued to significantly relate to greater social community integration even while accounting for race and ethnicity, age, sex, burn size, and physical disability at 6-, 12-, and 24-month time points. Overall, the study supports that racial and ethnic minority burn survivors report greater dissatisfaction with their appearance and lower social community reintegration after burn injury.

Predicting Depression and Posttraumatic Stress Symptoms Following Burn Injury: A Risk Scoring System.

Depression and posttraumatic stress (DPTS) are common psychiatric comorbidities following burn injury. The purpose of this study was to develop an admission scoring system that assesses the risk of development of depression or posttraumatic symptoms in the burn population. This study is a retrospective review of the prospectively collected Burn Model System National Database. Adult burn survivors enrolled from 2014 to 2018 (n = 486) were included. The primary outcome was the presence of DPTS symptoms at 6, 12, or 24 months postinjury. Logistic regression analysis was used to identify demographic and clinical predictors of DPTS symptoms. A risk scoring system was then created based on assigning point values to relevant predictor factors. The study population had a mean age of 46.5 ± 15.8 years, mean burn size of 18.3 ± 19.7%, and was 68.3% male. Prior to injury, 71.3% of the population was working, 47.9% were married, and 50.8% had completed more than a high school education. An 8-point risk scoring system was developed using the following predictors of DPTS symptom development: gender, psychiatric treatment in the past year, graft size, head/neck graft, etiology of injury, and education level. This study is the first to develop a DPTS symptom risk scoring system for burn injury. This scoring system will aid in identifying burn survivors at high risk of long-term psychiatric symptoms that may be used to improve screening, monitoring, timely diagnosis, and interventions.

Adolescents with and without head and neck burns: comparison of long-term outcomes in the burn model system national database.

INTRODUCTION: Facial burns account for persistent differences in psychosocial functioning in adult burn survivors. Although adolescent burn survivors experience myriad chronic sequelae, little is known about the effect of facial injuries. This study examines differences in long-term outcomes with and without head and neck involvement. METHODS: Data collected for 392 burn survivors between 14-17.9 years of age from the Burn Model System National Database (2006-2015) were analyzed. Comparisons were made between two groups based on presence of a head and neck burn (H&N) using the following patient reported outcome measures: Satisfaction with Appearance Scale, Satisfaction with Life Scale, Community Integration Questionnaire, and Short Form-12 Health Survey at 6, 12, and 24 months after injury. Regression analyses were used to assess association between outcome measures and H&N group at 12-months. RESULTS: The H&N group had more extensive burns, had longer hospital stays, were more likely to be burned by fire/flame and were more likely to be Hispanic compared to the non-H&N group. Regression analysis found that H&N burn status was associated with worse SWAP scores. No significant associations were found between H&N burn status and other outcome measures. CONCLUSIONS: Adolescents with H&N burn status showed significantly worse satisfaction with appearance at 12-months after injury. Future research should examine interventions to help improve body image and coping for adolescent burn survivors with head and neck burns.

Hypnotic Enhancement of Virtual Reality Distraction Analgesia during Thermal Pain: A Randomized Trial.

Excessive pain during medical procedures is a pervasive health challenge. This study tested the (additive) analgesic efficacy of combining hypnotic analgesia and virtual reality (VR) pain distraction. A single blind, randomized, and controlled trial was used to study 205 undergraduate volunteers aged 18 to 20. The individual and combined effects of hypnotic analgesia (H) and VR distraction on experimentally induced acute thermal pain were examined using a 2 X 2, between-groups parallel design (4 groups total). Participants in groups that received hypnosis remained hypnotized during the test phase pain stimulus. The main outcome measure was "worst pain" ratings. Hypnosis reduced acute pain even for people who scored low on hypnotizability. As predicted, H+ VR was significantly more effective than VR distraction alone. However, H+ VR was not significantly more effective than hypnotic analgesia alone. Being hypnotized during thermal pain enhanced VR distraction analgesia.

American Burn Association Guidelines on the Management of Acute Pain in the Adult Burn Patient: A Review of the Literature, a Compilation of Expert Opinion, and Next Steps.

The ABA pain guidelines were developed 14 years ago and have not been revised despite evolution in the practice of burn care. A sub-committee of the American Burn Association's Committee on the Organization and Delivery of Burn Care was created to revise the adult pain guidelines. A MEDLINE search of English-language publications from 1968 to 2018 was conducted using the keywords "burn pain," "treatment," and "assessment." Selected references were also used from the greater pain literature. Studies were graded by two members of the committee using Oxford Centre for Evidence-based Medicine-Levels of Evidence. We then met as a group to determine expert consensus on a variety of topics related to treating pain in burn patients. Finally, we assessed gaps in the current knowledge and determined research questions that would aid in providing better recommendations for optimal pain management of the burn patient. The literature search produced 189 papers, 95 were found to be relevant to the assessment and treatment of burn pain. From the greater pain literature 151 references were included, totaling 246 papers being analyzed. Following this literature review, a meeting to establish expert consensus was held and 20 guidelines established in the areas of pain assessment, opioid medications, nonopioid medications, regional anesthesia, and nonpharmacologic treatments. There is increasing research on pain management modalities, but available studies are inadequate to create a true standard of care. We call for more burn specific research into modalities for burn pain control as well as research on multimodal pain control.

Exploring the Burn Model System National Database: Burn injuries, substance misuse, and the CAGE questionnaire.

Burn survivors who misuse alcohol and/other substances have been associated with poorer long-term outcomes and clinical complications following injury. The self-reported CAGE questionnaire (Cut down, Annoyed, Guilty, and Eye-opener) is an outcomes assessment tool used to screen for potential substance misuse. Understanding the persistence and emergence of potential substance misuse through examination of CAGE scores may provide important information about this population. Using data collected from the Burn Model System National Database, demographic and clinical characteristics of individuals who reported positive CAGE scores (total score of ≥2) and those who reported negative CAGE scores (total score of 0 or 1) for either alcohol or other drugs were compared.

An Examination of Follow-up Services Received by Vulnerable Burn Populations: A Burn Model System National Database Study.

While disparities in healthcare outcomes and services for vulnerable populations have been documented, the extent to which vulnerable burn populations demonstrate disparities in long-term care is relatively underexplored. This study's goal was to assess for differences in long-term occupational or physical therapy (OT/PT) and psychological service use after burn injury in vulnerable populations. Data from the Burn Model System National Database (2006-2015) were analyzed. The vulnerable group included participants in one or more of these categories: 65 years of age or older, nonwhite, no insurance or Medicaid insurance, preinjury receipt of psychological therapy or counseling, preinjury alcohol and/or drug misuse, or with a preexisting disability. Primary outcomes investigated were receipt of OT/PT and psychological services. Secondary outcomes included nine OT/PT subcategories. Outcomes were examined at 6, 12, and 24 months postinjury. One thousand one hundred thirty-six burn survivors (692 vulnerable; 444 nonvulnerable) were included. The vulnerable group was mostly female, unemployed at time of injury, and with smaller burns. Both groups received similar OT/PT and psychological services at all time points. Adjusted regression analyses found that while the groups received similar amounts services, some vulnerable subgroups received significantly more services. Participants 65 years of age or older, who received psychological therapy or counseling prior to injury, and with a preexisting disability received more OT/PT and psychological or peer support services at follow-up. Overall, vulnerable and nonvulnerable groups received comparable OT/PT and psychological services. The importance of long-term care among vulnerable subgroups of the burn population is highlighted by this study. Future work is needed to determine adequate levels of follow-up services.

Using a Biopsychosocial Model to Understand Long-Term Outcomes in Persons With Burn Injuries.

OBJECTIVE: To determine the importance of preburn adjustment, injury-related variables, and selection of coping style in various outcome measures using a biopsychosocial model. DESIGN: Longitudinal study. SETTING: Outpatient burn clinics. PARTICIPANTS: Burn survivors (N=231) who participated in this study as part of a larger burn model system study of 645 patients with major burn injuries. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The 36-Item Short-Form Health Survey was used to assess preburn adjustment. Other outcome measures entered into the model included the Ways of Coping Checklist Revised, the Brief Symptom Inventory, the Beck Depression Inventory-II, and the Davidson Trauma Scale. RESULTS: Correlational and mediational analyses revealed that preburn emotional health predicted better adjustment at year 1 and more posttraumatic stress disorder symptoms at year 2. Better preburn emotional health was also related to less use of avoidance coping strategies, which was found to be a mediator of the effect of preburn emotional health and posttraumatic stress disorder symptoms. Burn injury characteristics were not significantly associated with psychological adjustment at either year 1 or year 2. CONCLUSIONS: The results indicate that there is a complex relation between premorbid mental health and the selection of coping strategies that affect long-term adjustment in persons recovering from a burn injury. This relation seems to have greater effect on long-term outcomes than does preburn emotional or physical health alone or the severity of the burn.

Exploratory analysis of long-term physical and mental health morbidity and mortality: A comparison of individuals with self-inflicted versus non-self-inflicted burn injuries.

INTRODUCTION: Self-inflicted burn (SIB) injuries are relatively rare, but patients may experience complex biopsychosocial challenges. This study aimed to compare long-term physical and psychological outcomes for individuals with SIB and non-SIB injuries. METHODS: Records of adult SIB (n = 125) and non-SIB (n = 3604) injuries were collected from U.S. burn centers within the Burn Model System between 1993 and 2018. Assessments were administered at discharge, 6 months, 24 months, 5 years, and 10 years. RESULTS: SIB patients were more often younger, unmarried, unemployed, male, struggling with pre-morbid psychiatric issues, and injured by fire/flame (all p < 0.001). SIB injury predicted prolonged mechanical ventilation, hospitalization, and rehabilitation (all p < 0.001). After injury, SIB patients had increased anxiety at 24 months (p = 0.0294), increased suicidal ideation at 5 years (p = 0.004), and clinically worse depression at 10 years (p = 0.0695). SIB patients had increased mortality across 24 months compared to non-SIB patients (OR = 4.706, p = 0.010). CONCLUSION: SIB injuries are associated with worse physical and psychological outcomes compared to non-SIB injuries including complicated hospitalizations and chronic problems with anxiety, depression, suicidality, and mortality, even when controlling for common indicators of severity such as burn size. This underscores the importance of multidisciplinary treatment, including mental healthcare, and long-term follow-up for SIB patients. Identified pre-morbid risk factors indicate the need for targeted injury prevention.

Factors Associated with Attrition of Adult Participants in a Longitudinal Database: A National Institute on Disability, Independent Living, and Rehabilitation Research Burn Model System Study.

Participant attrition in longitudinal studies can lead to substantial bias in study results, especially when attrition is nonrandom. A previous study of the Burn Model System (BMS) database prior to 2002 identified participant and study-related factors related to attrition. The purpose of the current study was to examine changes in attrition rates in the BMS longitudinal database since 2002 and to revisit factors associated with attrition. Individuals 18 years and older enrolled in the BMS database between 2002 and 2018 were included in this study. Stepwise logistic regression models identified factors significantly associated with attrition at 6, 12, and 24 months postburn injury. The percentage of individuals lost to follow-up was 26% at 6 months, 33% at 12 months, and 42% at 24 months. Factors associated with increased risk of loss to follow-up across two or more time points include male sex, lower TBSA burn size, being unemployed at the time of burn, shorter duration of acute hospital stay, younger age, not having private health insurance or workers' compensation, and a history of drug abuse. Retention levels in the BMS have improved by at least 10% at all time points since 2002. The BMS and other longitudinal burn research projects can use these results to identify individuals at high risk for attrition who may require additional retention efforts. Results also indicate potential sources of bias in research projects utilizing the BMS database.

Satisfaction With Life Over Time in People With Burn Injury: A National Institute on Disability, Independent Living, and Rehabilitation Research Burn Model System Study.

OBJECTIVE: To examine trajectories of satisfaction with life (SWL) of burn survivors over time and their clinical, demographic, and other predictors. DESIGN: Longitudinal survey. SETTING: Not applicable. PARTICIPANTS: Individuals ≥18 years of age who underwent burn-related surgery and met one of the following criteria: (1) >10% total body surface area (TBSA) burn and ≥65 years of age; (2) >20% TBSA burn and 18 to 64 years of age; (3) electrical high voltage/lightning injury; or (4) burn injury to the hands, face, or feet. The participants (N=378) had data on all variables of interest and were included in the analyses. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Satisfaction With Life Scale. RESULTS: Growth mixture modeling identified 2 classes with different trajectories of SWL. The mean SWL of the unchanged class (n=224, 60%) was flat over 2 years with high initial SWL scores. The SWL of the dissatisfied class (n=154, 40%) was at the low end of average and got progressively worse over time. CONCLUSIONS: SWL after burn injury can be described by 2 different trajectories with substantially different outcomes. Older age, worse mental health, and unemployment prior to injury predicted membership in the dissatisfied class. Additional services could be provided to those at high risk for low SWL to achieve better outcomes.

Racial/Ethnic Disparities in Longitudinal Trajectories of Community Integration After Burn Injury.

OBJECTIVES: The aim of this study was to examine potential racial/ethnic disparities in community integration for the 2 yrs after burn injury. DESIGN: A sample of 1773 adults with burn injury from the Burn Model Systems database was used with data on community integration collected at discharge (preinjury recall), 6, 12, and 24 mos after discharge. METHODS: Four sets of hierarchal linear models determined the most appropriate model for understanding racial/ethnic differences in Community Integration Questionnaire trajectories over time. RESULTS: Data indicated a decrease in community integration between discharge and 6 mos, a slight increase between 6 mos and 1 yr, and then a plateau between 1 and 2 yrs. White individuals had higher community integration score trajectories over time than black (b = 0.53, P < 0.001) and Hispanic (b = 0.58, P < 0.001) individuals, and community integration scores were similar between black and Hispanic individuals (b = -0.05, P = 0.788). These racial/ethnic disparities remained after accounting for age, sex, total burned surface area, number of days in rehabilitation, and active range of motion deficits. CONCLUSIONS: Additional rehabilitation resources should be targeted to helping black and Hispanic individuals integrate back into their communities after burn injury.