Longitudinal Evaluation of Pressure Applied by Custom Fabricated Garments Worn by Adult Burn Survivors.

Custom fabricated pressure garments (PGs) are commonly used to prevent or treat hypertrophic scars (HSc) after burn injury. However, there is minimal scientific evidence quantifying pressure after standard measurement and fitting techniques. Adult burn survivors whose HSc was treated with PGs were recruited. Trained fitters, blinded to study locations and results, took the garment measures. Once the PGs arrived and were fitted, baseline pressure measures at HSc and normal skin (NS) sites were determined using the Pliance X® System. Pressure readings were repeated at 1, 2, and 3 months. The mean baseline pressure was 15.3 (SD 10.4) at HSc and 13.4 (SD 11.9) at NS sites. There was a significant reduction during the first month at both sites (P = .0002 HSc; P = .0002 NS). A multivariable linear regression mixed model, adjusting for garment type, baseline pressure, and repeated measures, revealed further reduction at HSc sites between 1 and 2 months (P = .03). By 3 months, the mean pressure reduced to 9.9 (SD 6.7) and 9.15 (SD 7.2) mm Hg at HSc and NS sites, respectively. At each time point, the pressure was higher at HSc compared with NS but was significantly different only at 1 month (P = .01). PGs were worn ≥12 hr/d 7 d/wk. PGs that apply 15 to 25 mm Hg pressure significantly improve HSc; however, immediately after fitting newly fabricated PGs, the average pressure was at the bottom of the recommended range and by 1 month was significantly below. Clinicians are likely underestimating the dosage required and the significant pressure loss within the first 2 months.

Perceived Value of a Knowledge Translation Intervention Designed to Facilitate Burn Survivors' Work Reintegration.

Returning to work can be challenging for burn survivors. Approximately 28% never return to any form of employment, resulting in lower health-related quality of life. Open communication has been identified as a facilitator for return to work (RTW). To ease the RTW process and promote communication with coworkers and employers a knowledge translation (KT) intervention was developed for burn survivors. Following its implementation, the impact on the RTW process was evaluated. This study was a cross-sectional, mixed methods study where burn survivors included in the KT intervention were compared with a control group. Control group participants were selectively invited so that the two groups' mean age, sex, and percent total body surface area burned were similar. Semistructured interviews gathered information about their RTW process and outcomes. Qualitative data were analyzed through thematic analysis and quantitative data were summarized and compared using Mann-Whitney tests. Overall, both groups were satisfied with their RTW process. Participants from the control group identified more barriers related to support received, particularly at work, and reported more psychological symptoms such as posttraumatic stress disorder, self-consciousness, and discomfort with questions. Many participants from the KT group indicated the KT intervention gave them tools and information to provide others with a better understanding of their lived experience. It is possible that the KT intervention facilitated more open communication by empowering burn survivors to explain their situation on their own, thus reducing the prevalence of social and psychological barriers by allowing them to self-advocate for more support.

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.

Development and clinimetric evaluation of the mouth impairment and disability assessment (MIDA).

INTRODUCTION: Burns of the face and mouth region have a profound impact on function. Currently the outcome measure that is most commonly used in the burn care literature is horizontal and vertical opening. Impairment-based outcomes such as this do not capture the functional implications of these injuries in spite of the devastating impact they can have on burn survivor's lives. PURPOSE OF THE STUDY: To generate an assessment that evaluates the impairments, activity limitations, and participation restrictions associated with mouth injuries and prospectively collect data to examine the clinimetric properties. METHODS: A multistep assessment development process was undertaken including a comprehensive literature search and review, burn care expert and burn survivor interviews, generation of a preliminary version and field-testing, modifications based on field testing and updated literature review, and further field testing with data collection of 23 burn survivors. Clinimetric properties were examined by evaluating: whether there was a ceiling or floor effect, the internal consistency, construct validity, and responsiveness. RESULTS: The mouth impairment and disability assessment (MIDA) has a 28 item self-report portion, divided into four subscales, completed by the patient and an impairment-based section completed by the burn therapist. Two items demonstrated a ceiling effect, one was removed the other retained. There was strong and statistically significant (p<0.0001) correlation of the symptoms subscale as well as vertical opening with the functional activities subscale of the MIDA. The functional activities subscale demonstrated good internal consistency and the symptoms subscale was adequate. Re-evaluation approximately seven and a half months after the baseline evaluation demonstrated a statistically significant change with time and treatment. CONCLUSIONS: The MIDA now offers clinicians the ability to assess mouth impairment and disability of burn survivors who have sustained burn injuries to their face and mouth region.

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.