Facilitators & barriers and practices of early mobilization in critically ill burn patients: A survey.

BACKGROUND: Early mobilization (EM) of intensive care (IC) patients is important but complex with facilitators and barriers. Compared to general IC patients, burn IC patients are more hyper-metabolic. They have extensive wounds, lengthy wound dressing changes, and repeated surgeries that may affect possibilities of EM. This study aimed to identify facilitators and barriers of EM in burn IC patients among all disciplines involved. Additionally, we assessed EM practices, i.e. when are which patients considered suitable for EM. METHODS: A survey was sent to 139 professionals involved in EM of burn IC patients (discipline groups: Intensivists, medical doctors, registered nurses, therapists). RESULTS: Response rate was 57 %. The majority found EM very important, yet different definitions were chosen. Perceived barriers mainly concerned patient-level factors, most frequently hemodynamic instability and excessive sedation followed by skin graft surgery, fatigue, and pain management. Most frequent barriers at the provider-level were limited staffing, safety concerns, and conflicting perceptions about the suitability of EM. At the institutional-level, we found no high barriers. Interdisciplinary variation on perceived barriers, when to initiate it, and permitted maximal activity were ascertained. CONCLUSION: Skin grafts and pain management were barriers of EM specific for burn care. Opinions on frequency, dosage and duration of EM varied widely. Improving interdisciplinary communication is key.

The degree of joint range of motion limitations after burn injuries during recovery.

INTRODUCTION: The aim of this study was to determine the degree of ROM limitations of extremities, joints and planes of motion after burns and its prevalence over time. METHOD: The database of a longitudinal multicenter cohort study in the Netherlands (2011-2012) was used. From patients with acute burns involving the neck, shoulder, elbow, wrist, hip, knee and ankle joints that had surgery, ROM of 17 planes of motion was assessed by goniometry at 3, 6 weeks, 3-6-9 and 12 months after burns and at discharge. RESULTS: At 12 months after injury, 12 out of 17 planes of motion demonstrated persistent joint limitations. The five unlimited planes of motion were all of the lower extremity. The most severely limited joints at 12 months were the neck, ankle, wrist and shoulder. The lower extremity was more severely limited in the early phase of recovery whereas at 12 months the upper extremity was more severely limited. CONCLUSION: The degree of ROM limitations and prevalence varied over time between extremities, joints and planes of motion. This study showed which joints and planes of motion should be watched specifically concerning the development of scar contracture.

The development of burn scar contractures and impact on joint function, disability and quality of life in low- and middle-income countries: A prospective cohort study with one-year follow-up.

OBJECTIVE: The aim of this study was to assess the development of burn scar contractures and their impact on joint function, disability and quality of life in a low-income country. METHODS: Patients with severe burns were eligible. Passive range of motion (ROM) was assessed using lateral goniometry. To assess the development of contractures, the measured ROM was compared to the normal ROM. To determine joint function, the normal ROM was compared to the functional ROM. In addition, disability and quality of life (QoL) were assessed. Assessments were from admission up to 12 months after injury. RESULTS: Thirty-six patients were enrolled, with a total of 124 affected joints. The follow-up rate was 83%. Limited ROM compared to normal ROM values was observed in 26/104 joints (25%) at 12 months. Limited functional ROM was observed in 55/115 joints (48%) at discharge and decreased to 22/98 joints (22%) at 12 months. Patients who had a contracture at 12 months reported more disability and lower QoL, compared to patients without a contracture (median disability 0.28 versus 0.17 (p = 0.01); QoL median 0.60 versus 0.76 (p = 0.001)). Significant predictors of developing joint contractures were patient delay and the percentage of TBSA deep burns. CONCLUSION: The prevalence of burn scar contractures was high in a low-income country. The joints with burn scar contracture were frequently limited in function. Patients who developed a contracture reported significantly more disability and lower QoL. To limit the development of burn scar contractures, timely access to safe burn care should be improved in low-income countries.

Burn scar contracture release surgery effectively improves functional range of motion, disability and quality of life: A pre/post cohort study with long-term follow-up in a Low- and Middle-Income Country.

OBJECTIVE: Burn scar contractures limit range of motion (ROM) of joints and have substantial impact on disability and the quality of life (QoL) of patients, particularly in a Low- and Middle-Income Country (LMIC) setting. Studies on the long-term outcome are lacking globally; this study describes the long-term impact of contracture release surgery performed in an LMIC. METHODS: This is a pre-post cohort study, conducted in a referral hospital in Tanzania. Patients who underwent burn scar contracture release surgery in 2017-2018 were eligible. ROM (goniometry), disability (WHODAS 2.0) and QoL (EQ-5D) were assessed. The ROM data were compared to the ROM that is required to perform activities of daily living without compensation, i.e. functional ROM. Assessments were performed preoperatively and at 1, 3, 6 and 12 months postoperatively. RESULTS: In total, 44 patients underwent surgery on 115 affected joints. At 12 months, the follow-up rate was 86%. The mean preoperative ROM was 37.3% of functional ROM (SD 31.2). This improved up to 108.7% at 12 months postoperatively (SD 42.0, p < 0.001). Disability-free survival improved from 55% preoperatively to 97% at 12 months (p < 0.001) postoperatively. QoL improved from 0.69 preoperatively, to 0.93 (max 1.0) at 12 months postoperatively (p < 0.001). Patients who regained functional ROM in all affected joints reported significantly less disability (p < 0.001) and higher QoL (p < 0.001) compared to patients without functional ROM. CONCLUSIONS: Contracture release surgery performed in an LMIC significantly improved functional ROM, disability and QoL. Results showed that regaining a functional joint is associated with less disability and higher QoL.

The prevalence and development of burn scar contractures: A prospective multicenter cohort study.

OBJECTIVE: The objective of this study was to identify the prevalence and development of after burn joint limitation by scar contracture. METHODS: In 2011-2012, consecutive patients were enrolled in this prospective multi center cohort study. Eligible were all patients admitted to the 2 participating Dutch Burn Centers with acute burns across or adjacent to the neck, shoulder, elbow, wrist, hip, knee and ankle. Passive range of motion was measured in week 3 and subsequently every 3 weeks until discharge, on discharge from the hospital and during follow-up at the outpatient clinic at 3-6-9-12 months after burn. RESULTS: Limited range of motion of non-operated burned joints (N = 195) was restored back to normal within 6-9 months. From the operated burned joints (N = 353), 58.6% demonstrated a limited range of motion at 3-6 weeks declining to 20.9% at 12 months. The upper part of the body was affected more often by scar contracture than the lower part. At 12 months, the shoulder was limited most often (51.3%) and the hip least often (0%). Reconstructive surgery was performed in 13.3% of the operated burned joints. CONCLUSIONS: Persistent joint limitations at 12 months were exclusively present in joints that needed skin grafting for rapid wound closure. The upper part of the body was more prone to contracture formation than the lower part, from which the shoulder was most often involved. More than half of the limited range of motion seen in the acute phase, resolved in the long term. The need for reconstructive surgery was less than expected.

Clinical outcome of patients with self-inflicted burns.

INTRODUCTION: Patients with self-inflicted burns (SIB) are thought to have a longer length of stay compared to patients with accidental burns. However, other predictors for a longer length of stay are often not taken into account, e.g. percentage of the body surface area burned, age or comorbidities. Therefore, we wanted to study the outcome of patients with SIB at our burn center. METHODS: A retrospective, observational study was conducted. All adult patients with acute burns admitted to the burn center of the Martini Hospital Groningen, between January 1, 2009 and December 31, 2013 were included. Data on characteristics of the patient, injury, and outcome (LOS, mortality, discharge destination) were collected. In patients with SIB, suicide attempts (SA) were distinguished from self-harm without the intention to die (non-suicidal self-injury, NSSI). To evaluate differences in outcome, each patient with SIB was matched on variables and total score of the Abbreviated Burn Severity Index (ABSI) to a patient with accidental burns (AB). RESULTS: In total 29 admissions (21 SA and 8 NSSI) were due to SIB and 528 due to accidents. Overall, when compared to AB, there were significant differences with respect to mortality and LOS for SA and/or NSSI. Mortality was higher in the SA group, while the LOS was higher in both the SA and NSSI groups compared to the AB group. However, after matching on ABSI, no statistical significant differences between the SA and SA-match or the NSSI and NSSI-match group were found. CONCLUSION: With the right and timely treatment, differences in mortality rate or length of stay in hospital could all be explained by the severity of the burn and the intention of the patient.

Effect and mechanism of hydrocortisone on organ function in patients with severe burns.

INTRODUCTION: In patients with severe burns, resuscitation with large volumes of fluid is needed, partly because of an increase in capillary leakage. Corticosteroids might be beneficial by diminishing capillary leakage. This study aimed to assess in severely burned nonseptic patients whether hydrocortisone (HC) improved outcome and diminished capillary leakage. METHODS: Retrospective analyses of a prospectively collected database were performed, including 39 patients (age 52 [35-62] years, 72% male). Patients were divided based on HC therapy. First, in patients in whom HC was started late, that is when deteriorating (late; 5-12 days postburn) data before and after start of HC were compared. Second, patients in whom HC was started day 0 or 1 postburn (upfront; within 48 hours) were compared with patients who did not receive HC (control). Outcome was assessed as organ dysfunction by Denver Multiple Organ Failure (MOF) score and Sequential Organ Failure Assessment (SOFA) score. As markers for capillary leakage and hydration state, proteinuria, B-type natriuretic peptide (BNP), and fluid administration were assessed. Follow-up was 20 days postburn. Possible adverse effects including mortality were recorded. Repeated measurement regression analyses were performed using MLwiN. RESULTS: In the late group, Denver MOF and SOFA scores significantly decreased after HC (P<.001). Proteinuria tended to decrease (P=.13), BNP increased on the days HC was used (P<.001), and amounts of fluids diminished (P<.001). In the upfront vs control group, Denver MOF and SOFA scores (P<.001) decreased more quickly. Proteinuria (P=.006) and administered fluids decreased more rapidly (P<.001). Mortality rate, numbers of positive blood cultures, incidence of pneumonia, and graft loss were similar in all groups. CONCLUSIONS: Hydrocortisone treatment in severe burned patients without sepsis might improve organ dysfunction possibly because of a reduction in capillary leakage, as reflected by a decrease of proteinuria, an increase of BNP, and diminished fluid resuscitation volumes.

Fine motor deficiencies in children diagnosed as DCD based on poor grapho-motor ability.

A sample of 125 children from grades 4 and 5 of two normal Dutch primary schools were investigated regarding the incidence of handwriting problems and other fine motor disabilities. Handwriting quality was assessed with the concise assessment method for children's handwriting (BHK) and the school questionnaire for teachers (SQT). Two groups of 12 children each were formed, one group of good writers and a group of poor writers selected from the lower performance range. The latter group was investigated in depth by assessing general and fine motor ability using the Movement Assessment Battery for Children (M-ABC test) and the Motor Performance School Readiness Test (MSRT). We hypothesised that poor handwriting is part of a wider neuromotor condition characterised by faster and cruder movements, lack of inhibition of co-movements and poor co-ordination of fine motor skills. To test the theory kinematic measures of drawing movements were collected on the flower-trail-drawing item of the M-ABC test. Moreover, the experimental group of poor writers received physiotherapy during a three-month period and was tested for handwriting proficiency after therapy and again nine months later. The results revealed that 34% of the group of 125 children displayed handwriting problems. The analysis confirmed that serious handwriting problems are accompanied by fine motor deficits. We suggest that in these children an enhanced level of neuromotor noise is compensated for by enhanced phasic stiffness of the limb system. This results in higher movement velocity and fewer velocity peaks. In the children who received physiotherapy the quality of handwriting improved.

Neuromotor task training for children with developmental coordination disorder: a controlled trial.

The aim of this study was to evaluate neuromotor task training (NTT), a recently developed child-centred and task-oriented treatment programme for children with developmental coordination disorder (DCD). A treatment and a non-treatment control group of children with DCD were included. Children were selected if they scored below the 15th centile on the Movement Assessment Battery for Children (MABC). The children in the treatment group were recently referred for physiotherapy (n=26; 20 males, 6 females; mean age 7y 2mo [SD 1y 3mo]). The parents of the non-treated children were concerned about their children's motor performance and responded to advertisements for free testing (n=13; 10 males, 3 females; mean age 7y 2mo [SD 2y 1mo]). Before and after nine weekly 30-minute sessions of NTT or at least 9 weeks of no intervention, the MABC and the Test of Gross Motor Development - 2 (TGMD-2) were administered. Therapists reported per session on treatment goals and tasks trained. The results indicate that motor performance does not improve spontaneously and that NTT is effective. During the intervention period, only the treated group improved on the MABC and the TGMD-2. Children improved most on tasks similar to those trained. In older children with poorer motor patterns, NTT's treatment success was higher. The Child Behavior Checklist subscales withdrawn, thought problems, anxious/depressed, and delinquency were determinants of effects on motor patterns.

Effectiveness of neuromotor task training for children with developmental coordination disorder: a pilot study.

The aim of this pilot study was to evaluate the effectiveness of a Neuromotor Task Training (NTT), recently developed for the treatment of children with Developmental Coordination Disorder (DCD) by pediatric physical therapists in the Netherlands. NTT is a task-oriented treatment program based upon recent insights from motor control and motor learning research. Ten children with DCD (intervention group) were tested before and after 9 and 18 treatment sessions on the Movement ABC and a dysgraphia scale in order to measure the effectiveness of treatment on gross and fine motor skills in general and handwriting in particular. Five children (no-treatment control group) were tested twice with a time lag of nine weeks on the Movement ABC in order to measure spontaneous improvement. No improvement was measured for the children in the no-treatment control group, whereas a significant improvement was found for children in the intervention group for both quality of handwriting and performance on the Movement ABC after 18 treatment sessions.