Bernadette Nedelec

Burn rehabilitation and research: proceedings of a consensus summit.

Burn rehabilitation is an essential component of successful patient care. In May 2008, a group of burn rehabilitation clinicians met to discuss the status and future needs of burn rehabilitation. Fifteen topic areas pertinent to clinical burn rehabilitation were addressed. Consensus positions and suggested future research directions regarding the physical aspects of burn rehabilitation are shared.

Quantitative measurement of hypertrophic scar: interrater reliability and concurrent validity.

Research into the pathophysiology and treatment of hypertrophic scar (HSc) remains limited by the heterogeneity of scar and the imprecision with which its severity is measured. The objective of this study was to test the interrater reliability and concurrent validity of the Cutometer® measurement of elasticity, the Mexameter® measurement of erythema and pigmentation, and total thickness measure of the DermaScan C® relative to the modified Vancouver Scar Scale (mVSS) in patient-matched normal skin, normal scar, and HSc. Three independent investigators evaluated 128 sites (severe HSc, moderate or mild HSc, donor site, and normal skin) on 32 burn survivors using all of the above measurement tools. The intraclass correlation coefficient, which was used to measure interrater reliability, reflects the inherent amount of error in the measure and is considered acceptable when it is >0.75. Interrater reliability of the totals of the height, pliability, and vascularity subscales of the mVSS fell below the acceptable limit (≅0.50). The individual subscales of the mVSS fell well below the acceptable level (≤0.3). The Cutometer reading of elasticity provided acceptable reliability (>0.89) for each study site with the exception of severe scar. Mexameter and DermaScan C reliability measurements were acceptable for all sites (>0.82). Concurrent validity correlations with the mVSS were significant except for the comparison of the mVSS pliability subscale and the Cutometer maximum deformation measure comparison in severe scar. In conclusion, the Mexameter and DermaScan C measurements of scar color and thickness of all sites, as well as the Cutometer measurement of elasticity in all but the most severe scars shows high interrater reliability. Their significant concurrent validity with the mVSS confirms that these tools are measuring the same traits as the mVSS, and in a more objective way.

Quantitative measurement of hypertrophic scar: intrarater reliability, sensitivity, and specificity.

The comparison of scar evaluation over time requires measurement tools with acceptable intrarater reliability and the ability to discriminate skin characteristics of interest. The objective of this study was to evaluate the intrarater reliability and sensitivity and specificity of the Cutometer®, the Mexameter®, and the DermaScan C® relative to the modified Vancouver Scar Scale (mVSS) in patient-matched normal skin, normal scar (donor sites), and hypertrophic scar (HSc). A single investigator evaluated four tissue types (severe HSc, less severe HSc, donor site, and normal skin) in 30 burn survivors with all four measurement tools. The intraclass correlation coefficient (ICC) for the Cutometer was acceptable (≥0.75) for the maximum deformation measure for the donor site and normal skin (>0.78) but was below the acceptable range for the HSc sites and all other parameters. The ICC for the Mexameter erythema (>0.75) and melanin index (>0.89) and the DermaScan C total thickness measurement (>0.82) were acceptable for all sites. The ICC for the total of the height, pliability, and vascularity subscales of the mVSS was acceptable (0.81) for normal scar but below the acceptable range for the scar sites. The DermaScan C was clearly able to discriminate HSc from normal scar and normal skin based on the total thickness measure. The Cutometer was less discriminating but was still able to discriminate HSc from normal scar and normal skin. The Mexameter erythema index was not a good discriminator of HSc and normal scar. Receiver operating characteristic curves were generated to establish the best cutoff point for the DermaScan C total thickness and the Cutometer maximum deformation, which were 2.034 and 0.387 mm, respectively. This study showed that although the Cutometer, the DermaScan C, and the Mexameter have measurement properties that make them attractive substitutes for the mVSS, caution must be used when interpreting results since the Cutometer has a ceiling effect when measuring rigid tissue such as HSc and the Mexameter erythema index does not discriminate normal scar from HSc.

Assessment of pruritus characteristics and impact on burn survivors.

The goal of this cross-sectional study was to characterize and describe persistent postburn pruritus. Cause and treatment of postburn itch is elusive. It has been suggested that burn survivors with persistent pruritus should be divided into acute itch (⩽6 months postinjury) and chronic itch (>6 months postinjury) because the cause of itch may be different. Cross-sectional data of itch characteristics reported here are from the baseline data of a prospective, randomized, double-blind, controlled pilot study of 23 subjects with frequent and bothersome postburn pruritus. Subjects self-completed validated scales for variables of itch sensation, affect of itch, and severity. Variables of quality of life, frequency, pain and itch intensity, skin condition, scar, and medication were also recorded. Itch frequency revealed that 87% of subjects experienced itching daily, 96% experienced three or more episodes a day, and 52% had episode durations lasting 5 to 30 minutes per incidence. Itch was reported as unbearable by 94% of subjects with chronic itch and by 86% of subjects with acute itch, whereas bothersome was 88 and 100%, respectively. Itch sensation dimension of stinging was 74% in both acute and chronic itch subjects. Crawling and burning sensations were often severe. Potential itch triggers and relief activities were identified. Differences in sensory and affective itch components were detected between acute and chronic itch subjects. Combinations of itch mechanisms probably contribute to the development of and changes in pruritus. Characterizing the sensation and affective itch dimensions in conjunction with inflammation, burn injury, recovery, scar maturation, medication, and psychological status should better elucidate postburn itch.

Burn Therapists' Opinion on the Application and Essential Characteristics of a Burn Scar Outcome Measure

Comprehensive burn rehabilitation requires the use of an appropriate burn scar outcome measure (BSOM). The literature reports many BSOMs; however, an objective, practical, inexpensive, valid, reliable, and responsive instrument eludes us. A problem in the development of such a measure is disagreement in which scar properties to include. The objective of this study was to determine the burn scar variables that therapists believe should be included in a BSOM. An Internet survey was administered to burn occupational and physical therapists. The response rate was 38.6% (105 surveys). Of the respondents, 38.1% use a BSOM; of those, 75% use the Vancouver Scar Scale. Reasons why respondents do not use a BSOM (61.9%) are because they are not familiar with available measures, have not found one that is clinically practical, or need more training. The majority (95%) believes that using a BSOM is important, and the following BSOM characteristics were reported as important: reliable, valid, quick, easy, and noninvasive. Respondents indicated that the following properties should be included in a BSOM: pliability (96.2%), vascularity (92.4%), height (87.6%), appearance (75.2%), skin breakdown (74.3%), itch (73.3%), surface texture (70.5%), pigmentation (68.6%), and pain (67.6%). This study suggests that using a BSOM is important despite its inconsistent use, and BSOM education may be valuable. The top three agreed-upon properties for inclusion are already incorporated into the most commonly used BSOM—the Vancouver Scar Scale—suggesting that modifications may be reasonable.

Skin characteristics: normative data for elasticity, erythema, melanin, and thickness at 16 different anatomical locations

The clinical use of non‐invasive instrumentation to evaluate skin characteristics for diagnostic purposes and to evaluate treatment outcomes has become more prevalent. The purpose of this study was to generate normative data for skin elasticity, erythema (vascularity), melanin (pigmentation), and thickness across a broad age range at a wide variety of anatomical locations using the Cutometer® (6 mm probe), Mexameter®, and high‐frequency ultrasound in a healthy adult sample.

Longitudinal burn scar quantification

Quantitative studies of the clinical recovery of burn scars are currently lacking. Previous reports validate the objective, precise, diagnostic capabilities of high-frequency ultrasound to measure thickness, the Cutometer(®) to measure pliability and the Mexameter(®) to measure erythema and pigmentation of scars. Thus, we prospectively quantified clinical characteristics of patient-matched, after burn hypertrophic scar (HSc), donor site scar (D) and normal skin (N) using these instruments. One investigator measured 3 sites (HSc, D, N) in 46 burn survivors at 3, 6, and 12 months after-burn. A mixed model regression analysis, adjusting p-values for multiplicity of testing, was used to compare means among sites and time points. Participants were 41.2±13.5 years old, 87% males, predominantly Caucasian, with an average of 19.5% body surface area burned. HSc thickness decreased significantly between 3 and 6, 6 and 12, and 3 and 12 months (all p<0.0001), but remained thicker than D and N skin (all p<0.0001). Pliability differed significantly between HSc, D and N sites at all time points (all p<0.0001), with HSc and D increasing between 3 and 12 months (p<0.05) but not reaching normal. HSc and D sites were significantly more erythematous than normal skin (p<0.05) at 3 and 6 months but D sites approached normal by 12 months. The only time points at which pigmentation significantly differed were the HSc and D sites at 6 months. Thickness, pliability, erythema and pigmentation of N skin remained similar over the 12 months. We found that post-burn HSc thickness, pliability and erythema differed significantly from D and N skin at 3, 6, and 12 months and does not return to normal by 12 months after-injury; however, significant improvements towards normal can be expected. Donor sites are redder than normal skin at 3 and 6 months but can be expected to return to normal by 12 months. Although the color of HSc and D sites change markedly with time these color changes are primarily due to changes in redness of the site, not melanin in this primarily Caucasian population.

Practice guidelines for early ambulation of burn survivors after lower extremity grafts.

The objective of this review was to systematically evaluate the available clinical evidence for early ambulation of burn survivors after lower extremity skin grafting procedures so that practice guidelines could be proposed. It provides evidence-based recommendations, specifically for the rehabilitation interventions required for early ambulation of burn survivors. These guidelines are designed to assist all healthcare providers who are responsible for initiating and supporting the ambulation and rehabilitation of burn survivors after lower extremity grafting. Summary recommendations were made after the literature, retrieved by systematic review, was critically appraised and the level of evidence determined according to Oxford Centre for Evidence-Based Medicine criteria. A formal consensus exercise was performed to address some of the identified gaps in the literature which were believed to be critical building blocks of clinical practice.

Practice guidelines for the application of nonsilicone or silicone gels and gel sheets after burn injury.

The objective of this review was to systematically evaluate available clinical evidence for the application of nonsilicone or silicone gels and gel sheets on hypertrophic scars and keloids after a burn injury so that practice guidelines could be proposed. This review provides evidence based recommendations, specifically for the rehabilitation interventions required for the treatment of aberrant wound healing after burn injury with gels or gel sheets. These guidelines are designed to assist all healthcare providers who are responsible for initiating and supporting scar management interventions prescribed for burn survivors. Summary recommendations were made after the literature, retrieved by systematic review, was critically appraised and the level of evidence determined according to Oxford Centre for Evidence-based Medicine criteria.1

Acute phase modulation of systemic insulin-like growth factor-1 and its binding proteins after major burn injuries

OBJECTIVES To provide a detailed, sequential analysis of insulin-like growth factor-1 and its binding proteins in adults during the acute phase after a major burn injury. DESIGN Descriptive, repeated measurements for quantitation and characterization of insulin-like growth factor-1 and its binding proteins in adult burn survivors. SETTING Burn center in a university hospital. PATIENTS A total of 17 severely burned (>15% total body-surface area burned) adult patients. INTERVENTIONS Venous blood was collected twice a day for 10 days and centrifuged, and the sera were stored at -80 degrees C until analysis. A series of 340 serum samples were analyzed by radioimmunoassay to determine the circulating concentration of insulin-like growth factor-1 and its major binding proteins (insulin-like growth factor-binding protein), by Western ligand blotting. To better understand the changes seen in systemic insulin-like growth factor-binding protein-3 levels by Western ligand blotting, a proteolysis assay was performed. MEASUREMENTS AND MAIN RESULTS Insulin-like growth factor-1 levels were reduced from day 0 and correlated with insulin-like growth factor-binding protein-1 and -2 (p <.01), but not insulin-like growth factor-binding protein-3 and -4. Insulin-like growth factor-binding protein-3 was decreased relative to normal on day 0, declined further until day 3, and began recovering by day 6, but returned to only 35% of normal by day 10. Insulin-like growth factor-binding protein-1 and -2 were increased relative to normal and remained increased throughout the 10-day period. Insulin-like growth factor-binding protein-4 concentrations, however, were similar to normal at day 1 but gradually increased over time. Burn serum incubated with recombinant human glycosylated iodine-125 insulin-like growth factor-binding protein-3 did not demonstrate any proteolysis, although proteolysis of nonglycosylated iodine-125 insulin-like growth factor-binding protein-3 reached levels of approximately 40%. CONCLUSIONS Insulin-like growth factor-binding protein-3 proteolysis does not seem to be the mechanism by which systemic insulin-like growth factor-1 levels are reduced in major burn survivors. In vitro proteolysis of recombinant human glycosylated and nonglycosylated iodine-125 insulin-like growth factor-binding protein-3 does not reflect the in vivo situation in major burn survivors.