Dale W. Edgar

Core outcomes for adult burn survivors: A clinical overview

Burn trauma ranges from the minor burn to the devastating injury, which can impact on all aspects of a persons life including aesthetic appearance, relationships with others and psychological, social and physical functioning. Measurement of outcome in burns patients is therefore complex and multi-faceted. The increasing numbers of major burn survivors implies that understanding health outcomes in these patients has assumed high priority. This paper sets out a conceptual framework for unifying outcome measurement, which may be useful to all members of the multidisciplinary team who are contemplating outcome assessment in their burn patients. It outlines seven core domains of assessment which are (i) skin; (ii) neuromuscular function; (iii) sensory and pain; (iv) psychological function; (v) physical role function; (vi) community participation; and (vii) perceived quality of life. Within each domain, we present a brief clinical review of the most commonly administered measurement tools that have been, or potentially could be, used to assess aspects of these core domains. Where possible, the psychometric properties and clinical utility of these tools are presented. A concise discussion of key methodological issues which should be addressed in this assessment process is then provided, together with suggestions for future research.

Demonstration of the validity of the SF-36 for measurement of the temporal recovery of quality of life outcomes in burns survivors

OBJECTIVE Outcome assessment after burn is complex. Determination of quality of life is often measured using the Burns Specific Health Scale (BSHS), a validated tool in the burn population. The SF-36 is a generic quality of life questionnaire that is validated for numerous populations, but not in burns. The aim of the study was to examine the validity of SF-36, using the BSHS as a reference. METHODS 280 burn patients were recruited at Royal Perth Hospital. Each completed SF-36 and BSHS-B at regular intervals to 2 years after burn. Regression modelling was used to assess the temporal validity and the relative sensitivity of the measures. RESULTS SF-36 domains and BSHS-B demonstrated significant associations at all time points (r=0.37-0.76, p<0.002). In the months after burn, SF-36 domains: role physical; bodily pain; social function and role emotional outperformed BSHS-B total score and domain scores. Greater measurement sensitivity was demonstrated in all SF-36 summary and subscales measures (except General Health) when compared to BSHS-B and sub-domains. CONCLUSION This study demonstrated SF-36 as a valid measure of recovery of quality of life in the burn patient population. The data suggests that SF-36 components were more sensitive to change than the BSHS-B from ∼1 month after injury.

A 26-Year Population-Based Study of Burn Injury Hospital Admissions in Western Australia

The aim of the study was to use state-wide health administrative data to assess the incidence, temporal trends, and external cause of burn injury-related hospital admissions and mortality in Western Australia from 1983 to 2008. Linked hospital morbidity and death data for all persons hospitalized with an index burn injury in Western Australia for the period 1983–2008 were identified. Annual age-specific incidence and age standardized rates were estimated. Poisson regression analyses were used to estimate temporal trends in hospital admissions and mortality. Zero-truncated negative binomial regression analysis was used to identify factors associated with hospital length of stay. From 1983 to 2008, there were 23,450 hospitalizations for an index burn injury. Hospital admission rates declined by an average annual rate of 2% (incidence rate ratio [IRR], 95% confidence interval [CI] = 0.983, 0.981–0.984), and burn-related mortality declined by an average annual rate of 2% (IRR, 95% CI = 0.98, 0.96–1.01). Aboriginal people while having significantly higher hospitalization rates than non-Aboriginal people experienced a greater 26-year decline in hospitalizations of 58% (IRR, 95% CI = 0.42, 0.37–0.48) compared with 32% (IRR, 95% CI = 0.68, 0.65–0.71) for non-Aboriginal people. Children younger than 5 years, 20- to 24-year-old men, and adults older than 65 years remain at high risk for burn injury, and males continue to be hospitalized twice as frequently as females. The results demonstrate declines in burn injury hospitalizations and mortality in both Aboriginal and non-Aboriginal populations. Continued research is required of the impacts of medical interventions and the burn pathway of identified high-risk populations.

Goniometry and linear assessments to monitor movement outcomes: are they reliable tools in burn survivors?

BACKGROUND Despite common use and theoretical construct validity, goniometry is not reported to be reliable for the measurement of burn-affected joint range of motion. Similarly, a number of simple objective measures commonly used to document hand mobility have eluded this rigour. This study aimed to examine the within sessions of intra-rater and inter-rater reliability of active joint range of motion measurement in patients with burns. METHODS Intra-rater reliability: One physical therapist (PT) recorded duplicate measurements on each burn-affected joint after a 5-min interval in a subset of patients (n=21). Inter-rater reliability: Four qualified PTs took part in repeated measures testing of 45 patients on the same day. RESULTS Intra-rater reliability was excellent with intraclass correlation coefficients (ICCs>.99) and 95% confidence intervals (CIs)=.99-1.0. Inter-rater reliability was also excellent with ICCs>.94 (95% CIs=.90-.99). The minimum detectable change using goniometry at the ankle was > or =5 degrees and for all other joints tested was > or =9 degrees. For linear hand measures a change of >1cm and thumb opposition > or =1/2 of one scale point indicated measurable difference. CONCLUSION This study demonstrated excellent intra-rater and inter-rater reliability and measurement of clinically relevant change for all measurements when applied with a standardised protocol. Therefore, assessing joint range of motion (ROM) with a goniometer or hand movement with linear or scale measurements can provide accurate, objective measures in the burns population.

Using the Burn Specific Health Scale-brief as a measure of quality of life after a burn-what score should clinicians expect?

BACKGROUND How do clinicians determine the acceptable level of recovery of quality of life (QoL) after a burn? Many use the Burn Specific Health Scale (BSHS). The aim of this study was to examine normative values of the BSHS-Brief (BSHS-B) questionnaire in the general population. METHODS Two random samples of the non-burned public were taken. Each individual completed either the physical or the generic questions adapted from the BSHS-B questionnaire. RESULTS Of the 124 subjects who completed the physical questions, > 73% rated themselves 36/36. Group mean (SD) = 34.8 (2.9), median (IQR) = 36 (35-36), range 16-36. Advancing age was associated with reduced physical capability (p = 0.016). In contrast, 7.6% of the 105 subjects who answered the generic questions recorded a full score (84/84). Group mean (SD) = 71.3 (13.8), median (IQR) = 76 (66-80), range 10-84. CONCLUSION The study showed the non-burned population do not respond with full scores to all questions in the BSHS-B. The result was more notable in the non-physical questions related to the psychological and environmental factors. The data presented prompts clinicians to collect and define acceptable recovery of quality of life after a burn as measured by the BSHS-B for their local burn population.

Exercise training to improve health related quality of life in long term survivors of major burn injury: A matched controlled study

OBJECTIVE Patients often experience reduced health-related quality of life (HRQOL) following burn injury. Exercise training has been demonstrated to improve HRQOL in a number of clinical populations, yet it is unknown whether exercise can improve HRQOL in burns patients. PROCEDURES Nine burn-injured participants (42±18.38%TBSA: 6.56±3.68 years after injury) and 9 matched controls participated in a 12-week exercise programme. HRQOL was assessed via the Burn Specific Health Scale-Brief (BSHS-B) and the Medical Outcomes Study 36-Item Short Form (SF-36). Activity limitation was measured using the quick Disabilities of the Arm, Shoulder and Hand (QuickDASH). RESULTS The burns group had decreased HRQOL compared to the controls at baseline, as reported by the BSHS-B (t (16)=3.51, p=0.003) and some domains of the SF-36 including role physical (t (16)=3.79, p=0.002). Burned participants reported decreased activity levels compared to the controls as measured by the QuickDASH (t (16)=2.19, p=0.044). Exercise training improved SF-36 scores in both burn (t (8)=3.77, p=0.005) and control groups (t (8)=2.71, p=0.027). Following training there was no difference between the groups on the SF-36 or QuickDASH. CONCLUSION Exercise training improves HRQOL and activity limitations in burn-injured patients to a level that is equivalent to that of their uninjured counterparts.

Local and systemic treatments for acute edema after burn injury: a systematic review of the literature.

Burn injury is a complex trauma that results in local and generalized edema. Edema fluid limits the exchange of vital nutrients in healing the burn wound and will compromise vulnerable tissues. Although the importance of edema control in tissue salvage is recognized, treatments targeted at edema control have not been critically reviewed. Thus, the objective was to assess the evidence for the effectiveness of local and systemic treatments for edema management immediately after burn injury. Searches for randomized controlled trials were conducted of online databases, research and thesis registers, and grey literature repositories. Handsearches included journals, bibliographies, and proceedings. Authors were contacted to clarify and submit extra study details. Eight studies were included. Management of acute major burn resuscitation including colloid increases lung edema (mean difference [MD], 0.04 ml/ml alv vol; 95% confidence interval [CI], 0.03–0.04; P < .00001) and mortality (risk ratio, 3.67; 95% CI, 1.16–11.58; P = .03). Continuous administration of vitamin C in acute burn resuscitation reduces local wound edema (MD, −3.50 ml/g; 95% CI, −4.63 to −2.37; P < .00001) and systemic fluid retention (MD, −8.60 kg; 95% CI, −13.47 to −3.73; P = .0005). Local acute hand burn edema is reduced (MD, −29.00 ml; 95% CI, −53.14 to −4.86; P = .02), and active hand motion increased (MD, 10.00°; 95% CI, 4.58–15.42; P = .0003), using electrical stimulation with usual physiotherapy. Each review outcome was based on a small single-facility study. Thus, future research in intervention for acute burn edema must focus on multicentre trials and validation of outcome measures in the burn population.

The effect of exercise training on pulmonary function and aerobic capacity in adults with burn

PURPOSE Pulmonary function (PF) is compromised in some individuals following burn, which may result in impaired aerobic capacity. Exercise training improves PF and exercise capacity in children recovering from burns, yet it is unknown if adults will demonstrate the same response. PROCEDURES 9 burn injured participants (%TBSA 42 ±18.38, 6.56 years ±3.68 post injury) and 9 matched controls participated in a 12-week goal directed interval training and resistance exercise programme. PF was measured using spirometry, and a graded exercise test quantified peak oxygen consumption (Vo(2peak)), both prior to and following the exercise training. The Canadian Occupational Performance Measure assessed the participants goal attainment. RESULTS Burn injured participants had significantly lower PF (FEV(1)/FVC ratio) than the healthy controls both prior to and following the exercise intervention (F(1,16)=8.93, p=0.009). Exercise training did not improve PF in either group, however both groups had a significant improvement in their Vo(2peak), maximal minute ventilation, and work achieved on a graded exercise test (F(1,16)=19.325, p<0.001), (F(1,16)=51.417, p<0.001) and (F(1,16)=36.938, p<0.001), respectively, following the exercise training. All participants achieved their occupational performance goals. CONCLUSION Although the exercise training did not alter PF, both aerobic capacity and occupational performance were improved.

Developing a burn injury severity score (BISS): Adding age and total body surface area burned to the injury severity score (ISS) improves mortality concordance

BACKGROUND There is limited research validating the injury severity score (ISS) in burns. We examined the concordance of ISS with burn mortality. We hypothesized that combining age and total body surface area (TBSA) burned to the ISS gives a more accurate mortality risk estimate. METHODS Data from the Royal Perth Hospital Trauma Registry and the Royal Perth Hospital Burns Minimum Data Set were linked. Area under the receiver operating characteristic curve (AUC) measured concordance of ISS with mortality. Using logistic regression models with death as the dependent variable we developed a burn-specific injury severity score (BISS). RESULTS There were 1344 burns with 24 (1.8%) deaths, median TBSA 5% (IQR 2-10), and median age 36 years (IQR 23-50). The results show ISS is a good predictor of death for burns when ISS≤15 (OR 1.29, p=0.02), but not for ISS>15 (ISS 16-24: OR 1.09, p=0.81; ISS 25-49: OR 0.81, p=0.19). Comparing the AUCs adjusted for age, gender and cause, ISS of 84% (95% CI 82-85%) and BISS of 95% (95% CI 92-98%), demonstrated superior performance of BISS as a mortality predictor for burns. CONCLUSION ISS is a poor predictor of death in severe burns. The BISS combines ISS with age and TBSA and performs significantly better than the ISS.

A reliable and valid outcome battery for measuring recovery of lower limb function and balance after burn injury

INTRODUCTION The measurement of recovery after burns to the lower limbs is hampered by an absence validated injury specific tools. This research aimed to select and validate a battery of outcome measures of recovery after lower limb burn injury (LLBI). METHOD Reliability study: Reliability of the single leg stance (SLS), the Timed Up and Go (TUG) and the tandem walk (TW) tests were measured using a test-retest trial involving 28 patients with LLBI. Validity study: Clinical data from 172 patients with LLBI were used to compare changes in each LL outcome measure with changes in the Burn Specific Health Scale-Brief (BSHS-B). RESULTS All tests, except the SLS test with eyes closed, demonstrated excellent inter-rater reliability (ICCs=0.81-0.93). The TUG and the TW-forwards tests were shown to be valid and to provide additional information to the BSHS-B when combined as a battery. The TW-backwards test was redundant while the SLS and ankle DF measures did not correlate highly with the BSHS-B. CONCLUSION This study shows that the TUG test and the TWF are reliable and valid in the burns population and along with the BSHS-B form a useful test battery for measuring recovery from LLBI.