R. Scott Ward

Pressure Therapy for the Control of Hypertrophic Scar Formation after Burn Injury: A History and Review

Devastating functional problems can result from the formation of hypertrophic scar tissue after burn injury. Although a patient with burns may have several medical problems to contend with because of the injury, most ongoing rehabilitation difficulties are a consequence of the continual wound contraction that occurs in immature burn scars. Treatment of hypertrophic burn scar consists of several surgical options and of pressure therapy, which traditionally involves wearing garments made from elasticized fabric. This article reviews the treatment of hypertrophic scar tissue, with emphasis on its history and on nonsurgical methods of managing the burn scar.

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.

Sensory loss over grafted areas in patients with burns.

We studied loss of cutaneous sensibility after grafting in 60 patients with burns who had applied for impairment assessment. Fifty-eight patients (97%) demonstrated markedly diminished or absent responses to sharp/dull, hot/cold, and light touch stimuli over grafted areas. However, all but one patient had intact perception over donor areas and over areas of healed (ungrafted) partial-thickness burns. Deep touch sensation was intact over both grafted and ungrafted areas in all patients. Loss of sensation was not related to patient age, burn size, or type of burn; nor did sensory loss correlate with the impairment rating received. Depth of burn injury appears to be the best predictor of altered sensation, and some abnormalities in patients appear inevitable after skin grafting. Patients should be counseled about possible outcomes. However, the decrease in sensation that was observed rarely contributed significantly to the long-term impairment rating of these burn victims.

Substance P axons and sensory threshold increase in burn-graft human skin

BACKGROUND Our knowledge of afferent nerve fiber reinnervation of grafted skin following third-degree burn is limited by a lack of quantitative histological and psychophysical assessment from the same cutaneous area. The current study compares fiber profile and functional recovery measurements in injured and control skin from the same subject. MATERIALS AND METHODS Nerve regeneration and modality-specific sensory thresholds were compared using immunocytochemical labeling with protein gene product 9.5 antibody to stain all axons and anti-substance P to label substance P axons (which are predominantly unmyelinated), as well as computerized instrumentation to obtain psychophysical estimates. RESULTS Compared to control skin, threshold measures of pinprick (P < 0.001), warming (P < 0.001), touch (P < 0.001), and vibration (P < 0.01) were significantly elevated in burn-graft skin and correlated with histological analysis of skin biopsies obtained from the same site. Immunohistochemical staining of all axons innervating the dermis and epidermis revealed a significant reduction in burn-graft relative to control skin (54% decrease, P < 0.0001). In contrast, the incidence of substance P nerve fibers was significantly elevated in burn-graft (177% increase, P < 0.05) and appeared to correlate with patient reports of pruritus and pain. CONCLUSIONS Observations support the hypothesis that sensory regeneration is fiber-size-dependent in burn-graft skin. The findings that substance P fiber growth increased while total fiber count decreased and that thermal threshold showed the greatest degree of functional recovery suggest that unmyelinated neurons have the greater ability to transverse scar tissue and reinnervate grafted skin following third-degree burn injury.

A clarion to recommit and reaffirm burn rehabilitation.

Burn rehabilitation has been a part of burn care and treatment for many years. Yet, despite of its longevity, the rehabilitation outcome of patients with severe burns is less than optimal and appears to have leveled off. Patient survival from burn injury is at an all-time high. Burn rehabilitation must progress to the point where physical outcomes parallel survival statistics in terms of improved patient well-being. This position article is a treatise on burn rehabilitation and the state of burn rehabilitation patient outcomes. It describes burn rehabilitation interventions in brief and why a need is felt to bring this issue to the forefront. The article discusses areas for change and the challenges facing burn rehabilitation. Finally, the relegation and acceptance of this responsibility are addressed.

Home treadmill friction injuries: A five-year review

Treadmills are popular home fitness machines in American homes. Young children are at risk for friction injuries if they contact moving treadmills. The purpose of this study was to determine the impact of treatment of treadmill friction injuries in children. A review of 1,211 pediatric patients younger than 6 years treated at the Intermountain Burn Center between July 1997 and June 2002 was conducted. Forty-eight of these cases (4%) were treadmill friction injuries. The mean TBSA of these burns was 0.5%. The volar surface of the hand was the most common site of injury. Twenty-two (46%) of the 48 identified patients had full-thickness injuries that were treated surgically. Medical costs associated with treadmill friction injuries averaged US 2,385 dollars. The number of treadmill friction accidents resulting in friction injuries to children less than 6 years of age deserves serious attention and increased public awareness.

Understanding and Eliminating Disparities in Health Care: Development and Assessment of Cultural Competence for Interdisciplinary Health Professionals at The University of Utah—A 3-Year Investigation

Background and Purpose. In 2003, The University of Utah initiated the Cultural Competency and Mutual Respect (CCMR) educational program for the Interdisciplinary Health Sciences Students (IHSS), professionals in medicine (MED), pharmacy (PHARM), nursing (NSG), physical therapy (PT), and others. This 3‐year study assessed the pre/post learning outcomes of the CCMR program through Campinha‐Bacotes Inventory for Assessing the Process of Cultural Competence‐Revised (IAPCC‐R©).1‐4 Subjects. A total of 2,124 IHSS students, participating in CCMR learning modules, completed the Inventory for Assessing the Process of Cultural Competence‐Revised (IAPCC‐R©), with 114 PT and MED subjects as controls. Methods. This study was approved by The University of Utah Health Sciences Center Institutional Review Board. Verbal and written permission was received for use of the IAPCC‐R©. Following informed consent procedures, IAPCC‐R© pre/post data was collected each semester from fall 2003 through spring 2006. Paired and nonpaired analyses were performed, comparing Cultural Competence (CC) scores and constructs, P < .05, for each discipline, along with demographics. Results. Study outcomes resulted in 1,974 usable, completed inventories, with overall IAPCC‐R© pre/post scores demonstrating gains in progression towards cultural competence. In year 2, the curriculum was adjusted based upon student feedback and facilitator input; however, overall CC was not necessarily further enhanced. In terms of CC—Asian, Hispanic, and Other demographic IHSS subject categories outpaced Caucasians. Discussion. Overall CC was improved for all disciplines. In terms of the 5 constructs of CC, results indicated that PT, MED, PHARM, and NSG disciplines attained significant scores for the cultural constructs of “attitudes,” “knowledge,” and “skills” but not “encounters” and “desires.” Although posttest scores indicated marked progressions, approaching CC, IHSS did not yet demonstrate Cultural Proficiency. The constructs of cultural “desires” and “encounters” warrant further curricular enhancement and examination for progression towards attainment of Cultural Proficiency. Conclusion. Results of this 3‐year investigation indicate that the IHSS are becoming more Culturally Aware as a result of CCMR program participation and are significantly progressing towards Cultural Competence. However, overall, these interdisciplinary health science student subjects have not achieved the level of Cultural Proficiency. Ongoing support is needed to assist facilitators in teaching matters of Cultural Competence, in a way that is sensitive to the core values, beliefs, and attitudes of health care professionals. Further investigation, in both academic and clinical education, is warranted to examine culturally competent practice opportunities within interprofessional health care interactions and to reduce health care disparities and medical errors for the patients/clients served.

Influence of pressure supports on joint range of motion.

Burn patients often complain of restricted mobility following application of elasticized nylon anti-burn-scar supports. This study was designed to analyse the influence of this type of pressure garment on joint range of motion (ROM). Data were compiled from 80 burn-affected joints of 17 burn patients placed in a support for the first time. Joint ROM was measured directly prior to, and again immediately following, the donning of the pressure support. ROM was measured using standard goniometric techniques. Range of motion increased in 26 joints (32.5 per cent), decreased in 26 joints (32.5 per cent) and showed no change in 28 joints (35 per cent) after application of the pressure garment. There were no correlations between ROM results and age, time postburn and per cent TBSA in this population. Patients were also asked if movement felt any different after the support was applied. Their varied comments, such as movement felt easier or more difficult, were consistent with the actual ROM data. It appears that there is no predictably detrimental change in joint ROM due to the application of pressure garments.

Functional outcomes following ankle arthrodesis in males with haemophilia: analyses using the CDC’s Universal Data Collection surveillance project

In persons with haemophilia (PWH), repeated ankle haemarthroses lead to pain, loss of joint range of motion (ROM), and limitations in activity and participation in society. PWH are offered ankle arthrodesis (AA) to eliminate pain. In our experience, PWH are hesitant to proceed to AA due to concerns regarding gait anomalies, functional decline and complete loss of ROM. The aim of this study was to report outcomes in ROM, assistive device (AD)/wheelchair use, activity scale and work/school absenteeism for participants in the CDCs Universal Data Collection surveillance project (UDC) pre‐ and post‐ AA. Males with haemophilia enrolled in the UDC with first report of AA (1998–2010) were selected. Descriptive statistics were calculated using data from the annual study visit pre‐AA and the follow‐up visit (~12–24 months) post‐AA. The 68 subjects who fulfilled the criteria were: mean age 36.9 years (SD = 12.9); 85.3% white; 85.3% haemophilia A; 72% severe, 20.6% moderate; and 10.3% with inhibitor once during the study period. Mean loss in total arc of ankle motion was 17.02° (SD = 21.8, P ≤ 0.01) pre‐ compared to post‐AA. For 61.8%, there was no change in use of AD for ambulation/mobility. For 85.3%, there was no change in use of a wheelchair. On a self‐reported activity scale, 11.8% improved, 8.8% worsened and 79.4% did not change. Work/school absenteeism averaged 2.7 (SD = 6.4) pre‐ and 1.5 (SD = 6.4, P = 0.26) days per year post‐AA. While ankle ROM was significantly reduced post‐AA, for most subjects, there was no change in use of AD/wheelchair for ambulation/mobility. Physical activity was maintained and work/school absenteeism remained stable.

Our Great Opportunity

Seventy-nine years ago, Elsie MacGill was on the exciting verge of becoming the first woman from Canada to receive a bachelors degree in electrical engineering, when, after experiencing flu-like symptoms for a few days, she woke up one morning to discover that she was completely paralyzed from the waist down.1 She was eventually diagnosed with acute infectious myelitis and was told she would never walk again. We have heard those words before. In 1929, times were tough enough for a woman who wanted to become an engineer … the addition of a disability such as this would seem to be too much to overcome. Well, MacGill finished her university tests from her hospital bed and received her degree. She was determined to not be bedridden and eventually used canes for mobility. During her recovery, while writing a magazine article titled Women on the Wing , she learned that it took very little strength to pilot a plane, and she developed an interest in aeronautics. She ended up pursuing further study at MIT and became a well-respected aircraft designer during the Second World War. She insisted on being a passenger on the test flights of each of the aircraft she helped design. Personally, I prefer my planes to be tested long before I ride in them! Although Elsie MacGill did not have the help of formal physical therapy, her story represents the kind of inspiring experiences we are privileged to witness on a regular basis in this great profession. Her story—and many others like it—remind me that opportunity is in the challenge, hope is in the desire, and value is in the effort (Figure). The profession of physical therapy is anchored in myriad opportunities that are rooted in the challenges we face, whether in the preparation of new colleagues, …