Pain, depression, and physical functioning following burn injury.

OBJECTIVE: Little is known about how pain and depression after burn injury may influence long-term outcomes such as physical functioning. This prospective study examined associations between pain, depression, and physical functioning in a sample of burn injury survivors. DESIGN AND PARTICIPANTS: Questionnaires assessing pain, depression, and physical functioning were completed by 64 (52% of original sample) adult burn survivors shortly after discharge from burn care and at 1- and 2-year follow-ups. RESULTS: Pain and physical functioning improved over the 2 years of the study, whereas depression levels were stable. Pain and depression were associated with poorer physical functioning over time, but associations varied according to the time span under consideration. Also, the association between pain and physical functioning was strongest among persons with higher depression scores. CONCLUSIONS: Pain and depression may contribute independently to compromises in physical functioning. The co-occurrence of pain and depression represents even greater risk for reduced physical functioning over time among burn survivors.

Effect of acute and chronic alcohol abuse on pain management in a trauma center.

The proper management of acute pain has been identified as a primary indicator of quality assurance in US trauma centers. Nearly half of all trauma patients are injured while intoxicated and 75% of these patients have chronic alcohol problems. The management of pain caused by injuries in patients with alcohol problems poses unique challenges. Biases exist regarding the crosstolerance effects of ethanol and opioids and the pain thresholds of patients with substance abuse histories. The purpose of this review is to examine some of the factors that inform our decisions of how to manage acute pain in this population and to review the empirical evidence that exists.

Using QMethodology to identify reasons for distress in burn survivors postdischarge.

Reasons for distress after burn injuries have not been codified based on any type of acceptable empirical or statistical technique. The unique design methodology proposed in this study can identify the most common reasons cited for causing distress in burn survivors after discharge. A Q-sort task was developed with the assistance of our burn advisory group. After identifying 50 possible reasons for distress after discharge, each reason was placed on a laminated game card. In compliance with Qmethodology, a game board was developed that allowed patients to rank order each reason from "not causing distress" to "causing significant distress." A total of 69 burn survivors were enrolled in the study at four different time points: 1 month, 6 months, 1 year and 2 years postdischarge. After factor analysis, four factors accounted for all of the participants across time points. This indicates that at least four distinct groups of people can be categorized according to themes raised in rating reasons for distress. This Q-sort technique allowed us to capture the complexity of conceptualizing human distress by categorizing clusters of reported problems into similar groups. This methodology shows great promise for developing interventions that target unique needs of burn survivors.

VIRTUAL REALITY HYPNOSIS.

Scientific evidence for the viability of hypnosis as a treatment for pain has flourished over the past two decades (Rainville, Duncan, Price, Carrier and Bushnell, 1997; Montgomery, DuHamel and Redd, 2000; Lang and Rosen, 2002; Patterson and Jensen, 2003). However its widespread use has been limited by factors such as the advanced expertise, time and effort required by clinicians to provide hypnosis, and the cognitive effort required by patients to engage in hypnosis.The theory in developing virtual reality hypnosis was to apply three-dimensional, immersive, virtual reality technology to guide the patient through the same steps used when hypnosis is induced through an interpersonal process. Virtual reality replaces many of the stimuli that the patients have to struggle to imagine via verbal cueing from the therapist. The purpose of this paper is to explore how virtual reality may be useful in delivering hypnosis, and to summarize the scientific literature to date. We will also explore various theoretical and methodological issues that can guide future research.In spite of the encouraging scientific and clinical findings, hypnosis for analgesia is not universally used in medical centres. One reason for the slow acceptance is the extensive provider training required in order for hypnosis to be an effective pain management modality. Training in hypnosis is not commonly offered in medical schools or even psychology graduate curricula. Another reason is that hypnosis requires far more time and effort to administer than an analgesic pill or injection. Hypnosis requires training, skill and patience to deliver in medical centres that are often fast-paced and highly demanding of clinician time. Finally, the attention and cognitive effort required for hypnosis may be more than patients in an acute care setting, who may be under the influence of opiates and benzodiazepines, are able to impart. It is a challenge to make hypnosis a standard part of care in this environment.Over the past 25 years, researchers have been investigating ways to make hypnosis more standardized and accessible. There have been a handful of studies that have looked at the efficacy of using audiotapes to provide the hypnotic intervention (Johnson and Wiese, 1979; Hart, 1980; Block, Ghoneim, Sum Ping and Ali, 1991; Enqvist, Bjorklund, Engman and Jakobsson, 1997; Eberhart, Doring, Holzrichter, Roscher and Seeling, 1998; Perugini, Kirsch, Allen, et al., 1998; Forbes, MacAuley, Chiotakakou-Faliakou, 2000; Ghoneim, Block, Sarasin, Davis and Marchman, 2000). These studies have yielded mixed results. Generally, we can conclude that audio-taped hypnosis is more effective than no treatment at all, but less effective than the presence of a live hypnotherapist. Grant and Nash (1995) were the first to use computer-assisted hypnosis as a behavioural measure to assess hypnotizability. They used a digitized voice that guided subjects through a procedure and tailored software according to the subject's unique responses and reactions. However, it utilized conventional two-dimensional screen technology that required patients to focus their attention on a computer screen, making them vulnerable to any type of distraction that might enter the environment. Further, the two-dimensional technology did not present compelling visual stimuli for capturing the user's attention.

Barriers to return to work after burn injuries.

OBJECTIVE: To identify barriers to return to work after burn injury as identified by the patient. DESIGN: A cohort study with telephone interview up to 1 year. SETTING: Hospital-based burn centers at 3 national sites. PARTICIPANTS: Hospitalized patients (N=154) meeting the American Burn Association criteria for major burn injury, employed at least 20 hours a week at the time of injury, and with access to a telephone after discharge. INTERVENTION: Patients were contacted via telephone every 2 weeks up to 4 months, then monthly up to 1 year after discharge. MAIN OUTCOME MEASURES: A return to work survey was used to identify barriers that prevented patients from returning to work. A graphic rating scale determined the impact of each barrier. RESULTS: By 1 year, 79.7% of patients returned to work. Physical and wound issues were barriers early after discharge. Although physical abilities continued to be a significant barrier up to 1 year, working conditions (temperature, humidity, safety) and psychosocial factors (nightmares, flashbacks, appearance concerns) became important issues in those with long-term disability. CONCLUSIONS: The majority of patients return to work after a burn injury. Although physical and work conditions are important barriers, psychosocial issues need to be evaluated and treated to optimize return to work.