Systematic Review and Expert Consensus on the Use of Orthoses (Splints and Casts) with Adults and Children after Burn Injury to Determine Practice Guidelines.

The objective of this review was to systematically evaluate the available literature addressing the use of orthoses (splints and casts) with adult and pediatric burn survivors and determine whether practice guidelines could be proposed. This review provides evidence-based recommendations specifically for rehabilitation professionals who are responsible for burn survivor rehabilitation. A summary recommendation was made after the literature was retrieved using a systematic review and critical appraisal by multiple authors. The level of evidence of the literature was determined in accordance with the Oxford Centre for Evidence-based Medicine criteria. Due to the low level of evidence in the available literature, only one practice guideline could be recommended: orthotic use should be considered as a treatment choice for improving range of motion or reducing contracture in adults who have sustained a burn injury. To address the rehabilitation-specific gaps found in the literature regarding orthotic use in burn rehabilitation and provide guidance to clinicians, a formal expert consensus exercise was conducted as a final step to the project. The resultant manuscript provides a summary of the literature regarding orthotic use with burn patients, one practice guideline, proposed orthotic terminology and additional practice recommendations based on expert opinion. The limitations in the current literature are also discussed, and suggestions are made for future studies in the area of orthotic use after burn injury.

Randomized controlled trial of the immediate and long-term effect of massage on adult postburn scar.

BACKGROUND: One objective of massage therapy applied to hypertrophic scar (HSc), is to improve the structural properties so skin possesses the strength and elasticity required for normal mobility. However, research supporting this effect is lacking. The objective of this study was to characterize the changes in scar elasticity, erythema, melanin, and thickness immediately after a massage therapy session and after a 12-week course of treatment compared to intra-individual matched control scars. METHODS: We conducted a prospective, randomized, single-blinded, pragmatic, controlled, clinical trial evaluating the impact of a 12-week course of massage therapy. Seventy burn survivors consented to participate and 60 completed the study. Two homogeneous, intra-individual scars were randomized to usual care control or massage therapy plus usual care. Massage, occupational or physical therapists provided massage treatment 3x/week for 12 weeks. Scar site characteristics were evaluated weekly immediately before and after massage treatment including elasticity (Cutometer), erythema and melanin (Mexameter), and thickness (high-frequency ultrasound). Analysis of covariance (ANCOVAs) were performed to test for immediate and long-term treatment effects. A mixed-model approach was used to account for the intra-individual scars. RESULTS: Scar evaluation immediately before and after massage therapy at each time point revealed changes for all scar characteristics, but the group differences were predominantly present during the early weeks of treatment. The within group long-term analysis revealed a significant increase in elasticity, and a reduction in thickness, during the 12-week treatment period for both the control scar (CS) and massage scar (MS). The increase in elasticity reached significance at week 8 for the MS and week 10 for the CS and the reduction in thickness at week 5 for the CS and week 7 for the MS. There was no significant within group long-term differences for either erythema or melanin. There were group differences in erythema at week 8 and 11 where the CS was less erythematous than the MS. CONCLUSIONS: The immediate impact of forces applied during massage therapy may lead patients and therapists to believe that there are long-term changes in elasticity, erythema, and pigmentation, however, once baseline measures, the control scar, and time were incorporated in the analysis there was no evidence of long-term benefit. Massage therapy applied with the objective of increasing scar elasticity or reducing erythema or thickness over the long-term should be reconsidered.

Burn Rehabilitation Therapists Competency Tool-Version 2: An Expansion to Include Long-Term Rehabilitation and Outpatient Care.

The Burn Rehabilitation Therapist Competency Tool (BRTCT) was developed in 2011 to define core knowledge and skill sets that are central to the job performance of occupational and physical therapists working with burn patients during acute hospitalization and initial rehabilitation. It was the first national effort to provide standards that burn centers could use for the training and evaluation of a BRT performance. The American Burn Association Rehabilitation Committee recently expanded the tool to include long-term rehabilitation and outpatient care in order to more fully represent all of the stages of care in which patients with burn injury receive therapy. Thirty-six burn centers contributed competencies, 17 rehabilitation experts participated in a systematic Delphi questionnaire process, and eight representatives from seven additional burn centers validated the tool. The revised BRTCT, called the BRTCT-2, includes four new practice domains and 28 new competency statements. The expanded tool provides a common framework of standards for performance for occupational and physical therapists working with patients throughout the full spectrum of burn care.

Somatosensory Rehabilitation for Neuropathic Pain in Burn Survivors: A Case Series.

Neuropathic pain is an enormous rehabilitation challenge that has a substantial negative effect on patient function and quality of life. Somatosensory rehabilitation is a novel, nonpharmacological intervention described by Spicher based on the neuroplasticity of the somatosensory system. The rationale for somatosensory rehabilitation is that treating hypoesthesia will decrease neuropathic pain. Particularly for those with established neuropathic pain, the hypoesthesia may be masked by mechanical allodynia, which must be treated before treating the underlying hyposensitive zone. This case series describes the outcome of 17 burn survivors treated with somatosensory rehabilitation for their neuropathic pain. Before initiating treatment a modified version of the McGill Pain Questionnaire-short form (Questionnaire de la douleur St. Antoine, QDSA) was completed with the patients. The total score (×/64) was converted to percentage. The mechanical allodynia was assessed with the Rainbow Pain Scale that uses touch with the 15-g Semmes Weinstein Monofilaments (SWMs) and that was rated as painful on the visual analog scale (3/10 or resting pain + 1/10), as the criteria for mechanical allodynia. The severity level was assessed using seven predetermined SWMs to identify the smallest that elicited pain. The treatment consisted of avoiding all touch in the allodynic zone while concurrently providing proximal sensory and vibratory counter stimulation. Once the mechanical allodynia was eliminated, the underlying hypoesthesia was treated. Hypoesthesia was evaluated with the SWMs, and the percent improvement from baseline was calculated. The sensory reeducation treatment for hypoesthesia consisted of touch discrimination, texture perception, and vibratory stimulation. Seventeen patients (71/29% male/female, 21 ± 25% TBSA burned, 486 ± 596 days postburn) were evaluated and treated. Of these 15 initially presented with mechanical allodynia. The SWM scores had improved by 27 ± 21% (n = 14) and 29 ± 26% (n = 12) at 2 and 3 months posttreatment, respectively. The QDSA scores had improved by 9 ± 14% (n = 8) and 23 ± 23% (n = 6) at 2 and 3 months posttreatment, respectively. There were two patients who initially presented with hypoesthesia and six who had their zone of hypoesthesia treated after the mechanical allodynia had resolved. For these eight patients, their ability to perceive light touch improved by 27 ± 17% (n = 8) and 35 ± 25% (n = 6) at 2 and 3 months postsensory reeducation treatment initiation, respectively. The QDSA improved by 9 and 50% for the two patients who initially presented with hypoesthesia. In this case series, the majority of patients (13/17 or 76%) showed substantial improvements after somatosensory rehabilitation suggesting this is a treatment approach that should be considered with burn survivors experiencing neuropathic pain. There is a need, however, for future controlled studies to further investigate this approach and to determine if there is a subpopulation of burn survivors that are more likely than others to benefit from this approach.

Practice Guidelines for Cardiovascular Fitness and Strengthening Exercise Prescription After Burn Injury.

The objective of this review was to systematically evaluate the available clinical evidence for the prescription of strength training and cardiovascular endurance exercise programs for pediatric and adult burn survivors so that practice guidelines could be proposed. This review provides evidence-based recommendations specifically for rehabilitation professionals who are responsible for burn survivor rehabilitation. Summary recommendations were made after the literature was retrieved by systematic review, was critically appraised by multiple authors and the level of evidence determined in accordance with the Oxford Centre for Evidence-based Medicine criteria. Although gaps in the literature persist and should be addressed in future research projects, currently, strong research evidence supports the prescription of strength training and aerobic conditioning exercise programs for both adult and pediatric burn survivors when in the presence of strength limitations and/or decreased cardiovascular endurance after evaluation.