The Pilot Study of Robot-Assisted Training for the Lower Extremity Rehabilitation of Burn Patients

Purpose@#Scar contracture influence the outcome of burn patients significantly. This study aims to investigate the feasibility of robot-assisted training for the lower extremity rehabilitation of burn patients. @*Methods@#This pilot study was conducted on 7 burn patients for 8 weeks between January 2019 and November 2019. Two of 7 patients withdrew from this study because one had skin abrasion on the legs which thigh fastening devices were applied on and the other was not participate in the assessment at 4 weeks after training. Final 5 patients received gait training with SUBAR Ⓡ and numeric rating scale (NRS), 6-minutes walking test, and range of motion in flexion and extension of knee and ankle joint were evaluated before training, 4 weeks and 12 weeks after training. @*Results@#The subjects had a mean age of 51.8±98 years, mean total burn surface area of 30.8±13.7%, mean duration from injury to 1 st assessment of 102.8±39.3 days. Anyone of 5 patients did not have musculoskeletal or cardiovascular side effects such as increased or decreased blood pressure or dizziness. The significant improvement in NRS, gait speed, and range of motion in knee extension and ankle plantarflexion after robotic training (all P＜0.05). @*Conclusion@#Robot-assisted training could be feasible for the rehabilitation of burn patients and it could improve muscle strength and range of motion in lower extremities, and gait function.

Wound Healing Potential of Low Temperature Plasma in Human Primary Epidermal Keratinocytes

BACKGROUND: Low temperature plasma (LTP) was recently shown to be potentially useful for biomedical applications such as bleeding cessation, cancer treatment, and wound healing, among others. Keratinocytes are a major cell type that migrates directionally into the wound bed, and their proliferation leads to complete wound closure during the cutaneous repair/regeneration process. However, the beneficial effects of LTP on human keratinocytes have not been well studied. Therefore, we investigated migration, growth factor production, and cytokine secretion in primary human keratinocytes after LTP treatment.METHODS: Primary cultured keratinocytes were obtained from human skin biopsies. Cell viability was measured with the EZ-Cytox cell viability assay, cell migration was evaluated by an in vitro wound healing assay, gene expression was analyzed by quantitative real-time polymerase chain reaction, and protein expression was measured by enzyme-linked immunosorbent assays and western blotting after LTP treatment.RESULTS: Cell migration, the secretion of several cytokines, and gene and protein levels of angiogenic growth factors increased in LTP-treated human keratinocytes without associated cell toxicity. LTP treatment also significantly induced the expression of hypoxia inducible factor-1α (HIF-1α), an upstream regulator of angiogenesis. Further, the inhibition of HIF-1α expression blocked the production of angiogenic growth factors induced by LTP in human keratinocytes.CONCLUSION: Our results suggest that LTP treatment is an effective approach to modulate wound healing-related molecules in epidermal keratinocytes and might promote angiogenesis, leading to improved wound healing.

Increased white matter diffusivity associated with phantom limb pain

BACKGROUND: We utilized diffusion tensor imaging (DTI) to evaluate the cerebral white matter changes that are associated with phantom limb pain in patients with unilateral arm amputation. It was anticipated that this would complement previous research in which we had shown that changes in cerebral blood volume were associated with the cerebral pain network. METHODS: Ten patients with phantom limb pain due to unilateral arm amputation and sixteen healthy age-matched controls were enrolled. The intensity of phantom limb pain was measured by the visual analogue scale (VAS) and depressive mood was assessed by the Hamilton depression rating scale. Diffusion tensor-derived parameters, including fractional anisotropy, mean diffusivity, axial diffusivity (AD), and radial diffusivity (RD), were computed from the DTI. RESULTS: Compared with controls, the cases had alterations in the cerebral white matter as a consequence of phantom limb pain, manifesting a higher AD of white matter in both hemispheres symmetrically after adjusting for individual depressive moods. In addition, there were associations between the RD of white matter and VAS scores primarily in the hemispheres related to the missing hand and in the corpus callosum. CONCLUSIONS: The phantom limb pain after unilateral arm amputation induced plasticity in the white matter. We conclude that loss of white matter integrity, particularly in the hemisphere connected with the missing hand, is significantly correlated with phantom limb pain.

The Application of Three-Dimensional Printed Finger Splints for Post Hand Burn Patients: A Case Series Investigation

The application of three-dimensional (3D) printing is growing explosively in the medical field, and is especially widespread in the clinical use of fabricating upper limb orthosis and prosthesis. Advantages of 3D-printed orthosis compared to conventional ones include its lower cost, easier modification, and faster fabrication. Hands are the most common body parts involved with burn victims and one of the main complications of hand burns are finger joint contractures. Applying orthotic devices such as finger splints are a well-established essential element of burn care. In spite of the rapid evolution of the clinical use of 3D printing, to our knowledge, its application to hand burn patients has not yet been reported. In this study, the authors present a series of patients with hand burn injuries whose orthotic needs were fulfilled with the application of 3D-printed finger splints.

Extracorporeal Shock Wave Therapy For Treatment of Intractable Stump Pain

Amputation stump pains can be developed in amputation sites after high voltage electrical burn injuries. We experienced one case of these severe stump pains in an upper extremity amputation patient. A 35-year-old man had a 38% total body surface area high voltage electrical burn. The patient underwent skin grafting and left shoulder disarticulation. During the rehabilitation period, he complained about severe stump area pains and phantom pains. We injected 0.5% Bupivacaine and Triamcinolone on the stump neuroma site but the pain sustained. After extracorporeal shock wave therapy (ESWT,) the pain subsided and did not recur. The patient was satisfied with functional and pain outcomes, so we report this case.

Effects of a Modified Hand Compression Bandage for Treatment of Post-Burn Hand Edemas

OBJECTIVE: To evaluate the effect of a modified hand compression bandage in patients with a post-burn hand edema. METHODS: Patients were recruited from burn centers. We classified the patients into two groups: the modified hand compression bandage group comprising of 22 patients who had a modified hand compression bandage and received conventional physical therapy and the conventionally treated group, comprising of 20 patients who received only conventional physical therapy during the 4-week period post-burn. Hand circumference, hand skin thickness, and hand function were evaluated by grip strength, active range of motion (ROM), Jebsen hand function test, and visual analogue scale (VAS). These assessments were used to evaluate treatment effectiveness prior to the first treatment, 2 weeks after the first treatment, 4 weeks after the first treatment, and 4 months after the first treatment. RESULTS: As a result of repeated-measures analysis of variance on hand circumference, skin thickness, VAS, and each metacarpophalangeal joint ROM, we found significant differences that corresponded to time effect (p0.05). CONCLUSION: The modified hand compression bandage will be clinically useful for the treatment of patients with post-burn hand edemas.

Outcomes of Ultrasound-Guided Extracorporeal Shock Wave Therapy for Painful Stump Neuroma

OBJECTIVE: To investigate the effect of extracorporeal shock wave therapy (ESWT) on painful stump neuroma. METHODS: Thirty patients with stump neuroma at the distal end of an amputation site were assigned randomly to the ESWT group (n=15) and the transcutaneous electrical nerve stimulation (TENS)+desensitization+pharmacological treatment group (n=15). For 3 weeks, the ESWT group received a weekly session involving 1,500 pulses at 0.10 mJ/mm2, while the control group was treated 10 times each, 40 minutes per day with TENS and desensitization treatment, and daily medication for 3 weeks. ESWT stimulation was given by focusing on the area at the neuroma site clearly identified by ultrasound. RESULTS: The changes in the McGill pain questionnaire were 38.8+/-9.0 prior to treatment and 11.8+/-3.1 following the treatment. The corresponding values for the control group were 37.2+/-7.7 and 28.5+/-10.3. The changes between groups were significantly different (p=0.035). The change in visual analog scale prior to and after treatment was 7.0+/-1.5 and 2.8+/-0.8 in the ESWT group, respectively, and 7.2+/-1.4 and 5.8+/-2.0 in the control group. These changes between the groups were also significantly different (p=0.010). The outcome in the pain rating scale also showed significant differences between groups (p0.05). CONCLUSION: The study findings imply that ESWT for stump neuroma is superior to conventional therapy.

The Effects of Laughter Therapy on Anxiety and Depression of Burn Patients

PURPOSE: The study was a non-equivalent control group, quasi-experimental study to find out the effect of the laughter therapy on anxiety and depression of burn patients. METHODS: Study subjects were 60 hospitalized patients with the diagnosis of 2nd degree burn (30 experimental group; 30 control group). Experimental group received laughter therapy by the certificated therapist. STAI questionnaire, blood pressure and pulse were checked before and after the laughter therapy. RESULTS: Before and after the laughter implementation, the experimental group's anxiety decreased, however, the comparison group's anxiety did not show significant difference. Moreover, experimental group's anxiety decreased after the implementation. Experimental group's systolic blood pressure and diastolic blood pressure did not decrease pre/post laughter therapy mediator. The comparison group showed that systolic blood pressure increased, and diastolic blood pressure did not show significant difference. Also, experimental group's systolic blood pressure and diastolic pressure did not show significant difference after the treatment. Pre/post laughter therapy mediation did not decrease the experimental group's pulse and comparison group's pulse. Furthermore, the experimental group's pulse did not show the significant difference after the treatment. In pre/post laughter therapy mediation, the experimental group's depression was decreased, however, the comparison did not how significance difference in pre/post depression score after the treatment. Moreover, the experimental group's depression was decreased after the treatment. CONCLUSION: According the results above, the laughter therapy had effect on decreasing anxiety and depression of the burn patients and it is efficient mediator for the burn patient. Repetitive research was needed to investigate the effect of laughter on cardiovascular system since it did not have decreasing effect on the blood pressure and pulse.

The Effect of Extracorporeal Shock Wave Therapy on the Scar Pain of Burn Patients: A Case Report

PURPOSE: Many burn patients are troubled with pain and paresthesia from healed wounds. Extracorporeal Shock Wave Therapy (ESWT) in various musculoskeletal disease and wounds is reported that it reduces the pain and promotes regenerating of tendon and healing of the wound. Therefore we investigated the effect of ESWT on the scar pain of burn patients. METHODS: On February 2014, three patients admitted to the department of rehabilitation medicine of Hangang Sacred Heart Hospital Burn Center underwent ESWT. One low-energy ESWT (0.05~0.12 mJ/mm2) a week was provided to them for 3 weeks in total. Numerical rating scale (NRS), Nirschl pain phase system, 70-point scoring system, Roles and Maudsley score were evaluated before ESWT, after first and third ESWT. RESULTS: In all three patients, the NRS score was decreased and total scores of Nirschl pain phase system and 70-point scoring system were improved after ESWT compared to before ESWT. Roles and Maudsley scores was poor in all three patients at before ESWT but was acceptable in two patients and good in one patient after third ESWT. CONCLUSION: Extracorporeal shockwave therapy (ESWT) is non-invasive, feasible and effective modality on the scar pain of burn patients.

Vitamin C and D Insufficiency in Burn Patients Undergoing Rehabilitative Therapy-Preliminary Result

PURPOSE: The burn increase the requirement for the antioxidative vitamin C and decrease the plasma concentration of vitamin D due to the loss of skin body surface area. We investigated the vitamin C and D status and the prevalence of vitamin C and D insufficiency in adult burn patients undergoing rehabilitative therapy. METHODS: 256 burn patients admitted to the department of rehabilitation medicine from April 2013 to September 2014 were tested for the plasma level of vitamin C and D[25(OH)D]. Vitamin C insufficiency was considered as or =20%, mean plasma concentration of vitamin C and vitamin D[25(OH)D] were significantly lower (P=0.023, P<0.001). With adjusting for potential confounder such as age, sex, burn type, mean serum 25 (OH)D levels was significantly decreased 0.07 ng/ml per one percent of burned surface area (beta=-0.07, P<0.001), but with adjusting for age, sex, burn type, length of ICU stay and duration from burn injury to sampling, vitamin C and vitamin D[25(OH)D] were not significantly decreased (P=0.221, P=0.142). CONCLUSION: Vitamin C and D insufficiency were common nutrient problems in burn patients undergoing rehabilitative therapy. Further studies will be needed to establish the effective way to improve vitamin C and D status and prevent nutritional complications.

Changes of the Electrophysiological Study in Dogs with Acute Spinal Cord Injury / 대한신경손상학회지

OBJECTIVE: This study describes a method for inducing spinal cord injuries in dogs by using balloon catheters via laminectomy and the subsequent changes in the electrophysiological response. METHODS: Female Beagle (Orient Bio, Seongnam, Korea) dogs weighing 10 kg at the time of injury were used. Under inhalation anesthesia, a posterior midline approach laminectomy was performed. A silicone balloon catheter (size 6 Fr; Sewoon Medical, Cheonan, Korea) was then inserted into the vertebral canal at the center of T10. The balloon was inflated to the maximum volume for 1, 2, or 3 days. Open field testing was performed for evaluating motor functions of the hindlimbs. Motor evoked potentials (MEPs) induced by electrical and magnetic stimulation were recorded before and after spinal cord injury. RESULTS: Open field testing yielded locomotor scores of 0 or 1 for dogs subjected to compression for 3 days. These dogs showed no obvious improvement throughout the observation period, and the tonus of their hindlimbs was flaccid. In contrast, motor functions of dogs that had experienced compression for 1 or 2 days were variable, and all dogs showed spastic tonus in their hindlimbs. In dogs subjected to after compression for 3 days, electrically stimulated MEPs for the hindlimbs showed a significant amplitude reduction. Further, hindlimb movements were not evoked by magnetic stimulation of the cervical spine and vertex area. CONCLUSION: Compression for 3 days with a balloon catheter is a safe, reproducible, and reliable method for evaluating electrophysiological changes in a dog model of complete spinal cord injury.

The Need for Serial Administration of Vitamin C in Treatment for the Burn Patients

PURPOSE: Burn is one of the oxidative stress generating of oxygen free radicals. It was reported that a vitamin C played an important role in the antioxidant defense mechanism by acting as antioxidants, scavenging oxygen free radicals, collagen synthesis, detoxification of histamine and inhibition of melanin synthesis. Nevertheless there is still no study on the plasma level or the effect of a vitamin C after initial management in major burn patients. Therefore we investigated the need for continuous administration of vitamin C in treatment for the burn patients. METHODS: From March 2013 to May 2013, total 36 patients admitted to the department of rehabilitation medicine of Hangang Sacred Heart Hospital Burn Center were routinely tested for the plasma level of vitamin C as a part of their nutritional screening. We also tested the plasma level of vitamin B6 and B12 with it as the control test. We compared the plasma level of vitamin C with the time between test and burn injury, and with total burn surface area. RESULTS: Of the 36 patients, 34 patients had lower plasma vitamin C level than the normal range. However there were no significant differences depending on the total surface area burned or the time between test and burn injury in their plasma vitamin C level. All patients had normal plasma vitamin B6 and vitamin B12 level. CONCLUSION: It is recommended that the continuous administration of vitamin C should be done after thermal injury.

A Preference and Satisfaction Survey on the Wound Management System

PURPOSE: The biggest problem of wound healing is a possible occurrence of lesion. Especially, in the case of patients who have a skin injury around exposed body parts, if their treatment period drag on for long time, they can suffer from after-effects and the costs can be passed on to a society. Therefore, in this research, we investigated the need to develop the effective medicine and appliances for the patients by examining which therapy methods are being applying to the skin damage and what is the advantage and limit by evaluating the patient's satisfaction level. METHODS: We carried out an online and offline survey targeting medical teams in order to analyze device for wound care. A total of 125 medical teams applied to the research, and investigate the level of customer satisfaction. RESULTS: The moist dressings are the most used method for wound healing. When it comes to the level of customer satisfaction, biological dressing product also has a high satisfaction level. However its high cost tends to limit the use. CONCLUSION: This research reached a conclusion that it is need to develop a low cost and high efficiency wound care product considering the fact that its high cost and low efficiency induced economic problems. Generally, it is needed to develop a product for skin regeneration based on biological technologies, not a product just for damage cure.

The Effect of Extracorporeal Shock Wave Therapy on Myofascial Pain Syndrome

OBJECTIVE: To investigate the effect of extracorporeal shock wave therapy (ESWT) on myofascial pain syndrome (MPS). METHOD: Thirty patients with MPS in trapezius muscle were randomly divided into two groups, ESWT group (n=15), and trigger point injections (TPI)+transcutaneous electrical nerve stimulation (TENS) group (n=15). For a total of 3 weeks, ESWT was undertaken with 1,500 pulse each time at one week interval totaling 4,500 pulse, TPI for once a week totaling three times and TENS for five times a week totaling three weeks. RESULTS: The changes in pain threshold (lb/cm2) showed the values of 6.86+/-1.35 before first therapy, 11.43+/-0.27 after first therapy, and 12.57+/-0.72 after third therapy, while TPI+TENS group showed the values of 6.20+/-1.92 before first therapy, 8.80+/-0.48 after first therapy, and 9.60+/-2.19 after third therapy, and the changes between the groups were significantly different (p=0.045). The changes in visual analog scale were estimated to be 6.86+/-0.90 before first therapy, 2.86+/-0.90 after first therapy, and 1.86+/-0.69 after third therapy in case of ESWT group, whereas the figures were estimated to be 7.20+/-1.30 before first therapy, 4.60+/-0.55 after first therapy, and 2.80+/-0.84 after third therapy in case of TPI+TENS group, and the changes between the groups were significantly different (p=0.010). The changes in McGill pain questionnaire (p=0.816) and pain rating scale (p=0.644) between the groups were not significantly different. The changes in neck ROM were also not significantly different between the groups (p>0.05). CONCLUSION: The ESWT in patients with MPS in trapezius muscle are as effective as TPI and TENS for the purpose of pain relief and improving cervical range of motion.

The Factors Associated with Contact Burns from Therapeutic Modalities

OBJECTIVE: To understand the injury pattern of contact burns from therapeutic physical modalities. METHOD: A retrospective study was done in 864 patients with contact burns who discharged from our hospital from January 2005 to December 2008. The following parameters were compared between patients with contact burns from therapeutic modalities and from other causes: general characteristics, burn extent, cause of burn injury, place of occurrence, burn injury site, treatment methods, prevalence of underlying disease, and length of hospital stay were compared between patients with contact burns. RESULTS: Of the 864 subjects, 94 patients were injured from therapeutic modalities. A hot pack (n=51) was the most common type of therapeutic modality causing contact burn followed by moxibustion (n=21), electric heating pad (n=16), and radiant heat (n=4). The lower leg (n=31) was the most common injury site followed by the foot & ankle (n=24), buttock & coccyx (n=9), knee (n=8), trunk (n=8), back (n=6), shoulder (n=4), and arm (n=4). Diabetes mellitus was associated with contact burns from therapeutic modalities; the odds ratio was 3.99. Injuries took place most commonly at home (n=56), followed by the hospital (n=33), and in other places (n=5). CONCLUSION: A hot pack was the most common cause of contact burns from therapeutic modalities, and the lower leg was the most common injury site. Injuries took place most commonly at home. The patients with contact burns from therapeutic modalities showed high correlation to presence of diabetes mellitus. These results would be helpful for the prevention of contact burns due to therapeutic modalities.

Myoelectric Hand Rehabilitation in the Bilateral Upper Extremity Amputee of Burn Patients: Two Cases Report

Bilateral upper extremity amputee is rare and also complex, difficult process to apply the prosthesis to daily life. In Korea, there is no case report of bilateral myoelectric hand training, which is installed to bilateral upper extremity amputee due to electrical burn. We present usual 2 cases, who underwent bilateral transradial amputee, were fitted with a bilateral myoelectric prosthetic hand with an adaptive grip. It's not just long-term issues like the prosthesis prescription, but it is important functional problem whether or not to use actually. Especially the unique features of hand grasp function and writing can be the scale that measure recovery of the patient. The development of modern science and technology applications in clinical medicine cause the innovation of a prosthetic hand. In our two cases, good acceptance and functional improvement were noted. The information obtained in this case would be expected to be helpful in the bilateral amputee prosthetic prescription and training for their welfare.

Extremity Operation by a Use of Fibrin Sealant in Burn Patient

PURPOSE: The surgical treatment of burn patient is associated with substantial blood loss. Therefore, multiple hemostatic techniques have been proposed for this problem. Unfortunately, a clear conclusion as to the best hemostatic agent cannot be made. Then, we present our experience of using Fibrin sealant (TISSEEL(TM)) in extremity operation. METHODS: We reviewed the medical records of 10 patients treated in our burn center who conducted the extremity operation using Fibrin sealant from January 2010 to December 2010. RESULTS: The mean tourniquet time is within 60 minutes and no need of transfusion during the operation in all patients. The average take rate for skin graft is over the 98%. No one has nerve injury and other problems. CONCLUSION: Fibrin sealant is a human derived factors that are designed to reproduce the final step of the physiologic coagulation cascade of a stable fibrin clot. In addition, Fibrin sealant has the advantage of being biocompatible and biodegradable, without inducing inflammation, foreign body reaction, and tissue necrosis. Fibrin sealant is shown to be effective methods to achieve hemostasis for the extremity burn surgery.

Intra-articular Injection of Hyaluronic Acid to Rehabilitate Post-burn Elbow Contracture

PURPOSE: Limitation of motion of the elbow joint causes upper extremity dysfunction and limitation in activities of daily living. Hyaluronic acid (HA) is a glycosaminoglycan (GAG), which is a substance that attaches to collagen and elastin to form cartilage. HA not only helps keep the cartilage that cushions joints strong and flexible, but also helps to increase supplies of joint-lubricating synovial fluid. We investigated the effect of intraarticularly applied HA on the post-burn contracture of the elbow. METHODS: Total 14 patients were randomized into HA and control groups. The treatment group who treated with HA intra-articular injection once a week for 3 times. A control group was not injected. The effect of HA injection was evaluated by range of motion (ROM) of elbow, grip strength, patient's visual analogue scale (VAS) of pain and functional independence measure (FIM) scale before the first injection as well as after 1 and 3 months. RESULTS: The change in elbow flexion ROM was 29.2+/-19 for HA vs 1.4+/-2.4 for control (P<0.05). The change in VAS pain was 2.9+/-1.3 for HA vs 1+/-1.3 for control (P<0.05). These beneficial effects of HA are sustained for 3 months. There was no significant difference in elbow extension, supination, pronation, grip strength and FIM score. CONCLUSION: As a result, intra-articular injection of hyaluronic acid is effective for the treatment of post-burn contracture of the elbow.

The effects of electrical shock on the expressions of aquaporin subunits in the rat spinal cords / 대한해부학회지

We analyzed aquaporin (AQP) expression in the rat spinal cord following an electrical shock (ES) to elucidate the roles of AQP in spinal cord injury (SCI) induced by an electrical burn. In control animals, AQP1 immunoreactivity was observed in the small diameter dorsal horn fibers of laminae I and II and in astrocytes and neurons in the spinal cord. Both AQP4 and AQP9 immunoreactivity were detected in astrocytes. One week after the ES, AQP1 immunoreactivity in dorsal horn fibers was downregulated to 83, 61, and 33% of control levels following a 1-, 4-, or 6-second ES, respectively. However, AQP1 immunoreactivity in ventral horn neurons increased to 1.3-, 1.5-, and 2.4-fold of control levels following a 1-, 4-, or 6-second ES, respectively. AQP4 immunoreactivity was upregulated after an ES in laminae I and II astrocytes in a stimulus-intensity independent manner. Unlike AQP1 and AQP4, AQP9 immunoreactivity was unaffected by the ES. These findings indicate that altered AQP immunoreactivity may be involved in SCI following an ES.

Effects of Modified Dynamic Metacarpophalangeal Joint Flexion Orthoses after Hand Burn

OBJECTIVE: To assess the effectiveness of modified dynamic metacarpophalangeal joint flexion orthoses for treatment of post-burn hand contractures. METHOD: We enrolled 42 hand burn patients with limited range of motion at the metacarpophalangeal joints in this study. The patients were randomly assigned into either a control or an orthotic group. Both groups received the standard rehabilitation therapy focused on hand therapy; 21 subjects in the orthotic group wore a splint for 3 hours per day for 8 weeks. Hand function was measured by active range of motion, grip strength and other assessment tools. All parameters were estimated using the Mann-Whitney U test at the beginning and the end of the treatment after 8 weeks. RESULTS: The 21 subjects that had an orthotic intervention showed significant improvement in the range of motion at 2nd, 3rd, 4th and 5th metacarpophalangeal joints (p0.05). There was a significant difference in the hand function scales between the 2 groups (p<0.05). CONCLUSION: The modified dynamic metacarpophalangeal joint flexion orthoses provide continuous flexion to metacarpophalangeal joint that is needed for the restoration of range of motion in post-burn hand contractures. For the clinical application of hand orthoses in patients with hand disorders, additional research into its affects are required.