Zephanie Tyack

A systematic review of the quality of burn scar rating scales for clinical and research use

INTRODUCTION Scar rating scales have the potential to contribute to better evaluation of scar properties in both research and clinical settings. Despite a large number of scars assessment scales being available, there is limited information regarding the clinimetric properties of many of these scales. The purpose of the review was to inform clinical and research practice by determining the quality and appropriateness of existing scales. This review summarises the available evidence for the clinimetric properties of reliability, validity (including responsiveness), interpretability and feasibility of existing scales. METHODS Electronic searches of MEDLINE, CINAHL, EMBASE and The Cochrane Library databases from 1990 onwards were used to identify English articles related to burn scar assessment scales. Scales were critically reviewed for clinimetric properties that were reported in, but not necessarily the focus of studies. RESULTS A total of 29 studies provided data for 18 different scar rating scales. Most scar rating scales assessed vascularity, pliability, height and thickness. Some scales contained additional items such as itch. Only the Patient and Observer Scar Assessment Scale (POSAS) received a high quality rating but only in the area of reliability for total scores and the subscale vascularity. The Vancouver Scar Scale (VSS) received indeterminate ratings for construct validity, reliability and responsiveness. Where evidence was available, all other criteria for the POSAS, VSS and the remaining 17 scales received an indeterminate rating due to methodological issues, or a low quality rating. Poorly defined hypotheses limited the ability to give a high quality rating to data pertaining to construct validity, responsiveness and interpretability. No scale had empirical testing of content validity and no scale was of sufficient quality to consider criterion validity. CONCLUSIONS The POSAS, with high quality reliability but indeterminate validity, was considered to be superior in performance based on existing evidence. The VSS had the most thorough review of clnimetrics although available data received indeterminate quality ratings. On the basis of the evidence, the use of total scores has not been supported, nor has the measurement of pigmentation using a categorical scale.

Postburn dyspigmentation : Its assessment, management, and relationship to scarring : A review of the literature

Dyspigmentation often arises after deep partial- or full-thickness burns, and assessment of postburn scarring traditionally includes pigmentation. However, the relationship between dyspigmentation and scarring remains unclear. The physiologic basis of dyspigmentation has often been disregarded, and in pathologic states, its origin has been assumed to be in the epidermal melanin. Greater understanding of dyspigmentation among clinicians is required to increase knowledge and accuracy of assessment. This article aims to review the physiologic basis of pigmentation, and address the assessment, preventative management, and treatment options for postburn dyspigmentation.

What influences the functional outcome of children at 6 months post-burn?

The contribution of demographic, injury, pre-morbid, and parent factors to a childs functional outcome at 6 months post-burn injury was examined. Sixty-eight children, aged 5-14 years with percent total body surface area (%TBSA) burns ranging from <1 to 35%, and their primary caregivers participated in the study. It was expected that pre-morbid and parent factors but not injury factors would have a significant impact on the functional outcome of children at 6 months post-burn. Injury factors included the percent of total body surface area burned, number of operative procedures, and source of the burn (i.e. flame burn, scald burn). Pre-morbid child factors included the presence or absence of behaviour problems, psychological or psychiatric problems, learning difficulty or developmental delay. Parent factors included anxiety, depression, coping processes, and social support. Whilst investigating the contribution of these factors to functional outcome, the effect of demographic factors (i.e. age, gender, family socioeconomic status, and the number of previous hospitalizations) was controlled for and investigated. Analyses included two hierarchical multiple regression analyses that supported the expected results. R was significantly different from zero at the end of each step in both hierarchical regression analyses, indicating that each group of factors added significantly to the fit of the model. After step 4 in the final regression model with all independent variables in the equation, R=0.85, F(18,49)=6.89, P<0.001.

Measuring the impact of burn scarring on health-related quality of life: Development and preliminary content validation of the Brisbane Burn Scar Impact Profile (BBSIP) for children and adults.

INTRODUCTION No burn-scar specific, health-related quality of life (HRQOL) measure exists. This study aimed to develop a patient-reported, evaluative HRQOL measure to assess the impact of burn scarring in children and adults. METHOD Semi-structured interviews, content validation surveys, and cognitive interviews were used to develop and test content validity of a new measure - the Brisbane Burn Scar Impact Profile (BBSIP). RESULTS Participants comprised Australian adults (n=23) and children (n=19) with burn scarring; caregivers of children with burn scarring (n=28); and international scar management experts (n=14). Items distinct from other burn scar measures emerged. Four versions of the BBSIP were developed; one for children aged 8-18 years, one for adults, one for caregivers (as proxies for children aged less than 8-years), and one for caregivers of children aged 8-18 years. Preliminary content validity of the BBSIP was supported. Final items covered physical and sensory symptoms; emotional reactions; impact on social functioning and daily activities; impact of treatment; and environmental factors. CONCLUSION The BBSIP was developed to assess burn-scar specific HRQOL and will be available at http://www.coolburns.com.au under a creative commons license. Further testing is underway.

A guide to choosing a burn scar rating scale for clinical or research use

INTRODUCTION A lack of high quality burn scar rating scales underpins the urgent need to introduce a guide for clinicians and researchers to choose the most appropriate scale for their requirements. METHODS An updated electronic search of Medline, CINAHL, and EMBASE databases from 2010 to 2011 of a previous published systematic review were used to identify English articles related to burn scar rating scales. The clinimetric properties, content, purpose, characteristics of the subjects tested and feasibility of each scale were critically reviewed. RESULTS An additional seven papers were identified by the updated search, bringing the total number of papers reviewed to 36. The majority (88%) covered items pertaining to the physical properties of the skin rated by an observer. All of the scales had been tested for the purpose of discriminating between patient groups; however, only preliminary evidence exists for the ability of the scales to measure change in scar properties over time. The majority of testing of scales occurred using Caucasian subjects, males, upper limb sites and adults. CONCLUSIONS This paper provides a guide to selecting the most appropriate burn scar rating scale for research and clinical practice by reviewing the content, purpose, test sample characteristics and feasibility of each scale.

Twelve tips for effective clinical supervision based on a narrative literature review and expert opinion

Background: Clinical supervision has gained wide recognition in recent years as an essential component of a practitioners continuing professional development. However, confusion exists in professional literature regarding the most effective models, styles, processes and methods of clinical supervision. Aim: This article outlines the elements required to establish and sustain an effective clinical supervision arrangement for health professionals, based on current evidence and the authors expert opinion. Conclusion: A set of practical strategies are proposed to assist practitioners to establish an ongoing, effective clinical supervision partnership.

The Functional Outcome of Children After a Burn Injury: A Pilot Study

Assessment of functional outcome can be used as a measure of the effectiveness of intervention during recovery from a burn injury. This pilot study identifies the factors that are likely to be most important for determining standardized functional outcome measures for children after a burn injury; it highlights the contribution of these factors to variations in childrens postburn outcomes. A focus group of 8 parents and a self-report questionnaire administered to 12 children and 13 parents were the means of obtaining information for this exploratory study. Itching was found to be one of the primary impairments that contributed to reduced functional outcome during skin healing after a burn injury. The activities of children who had been burned that were most frequently affected by the injury (as reported by parents) were schoolwork and sports; these were closely followed by sleeping, playing with other children, and unliked activities. Least affected activities were enjoying the family, eating, seeing friends, watching television, and bathing or showering. Eighty-five percent of parents reported at least some level of interference with the listed daily activities. Burn injuries are likely to cause interference with several aspects of a patients daily life. As a result, families require ongoing support and monitoring. Further research should longitudinally compare the performance of children who have been burned with other children and adolescents.

Health professionals' and consumers' opinion: What is considered important when rating burn scars from photographs?

With advances in wound care technology, there is a trend toward patients undertaking specialist burns treatment in an outpatient capacity. Photographic scar evaluation is a part of this trend in some health services because it permits scar assessment by different health professionals, both within and across outpatient services, to assess the impact of scar management strategies. The aim of this study was to explore the parameters considered integral to scar assessment when completing photographic scar evaluation. First, opinions were sought from 38 burn health professionals in 2 tertiary pediatric hospitals who participated in focus groups where in-person and in-photograph scar rating were completed using three burn scar rating scales (modified Vancouver scar scale, Manchester scar scale, and patient and observer scar assessment scale) presented with a standard format and instructions. Second, 36 occupational therapists and physiotherapists from Australia and New Zealand completed questionnaires. Third, 10 healthcare consumers from 1 tertiary pediatric hospital participated in face-to-face or telephone interviews. Parameters believed to be assessed using photographic evaluation of burns scarring were vascularity, surface area, color, contour, height, and overall opinion. However, surface area was considered questionable as an indicator of scar maturity. These parameters mostly differ from those considered important in a burn scar outcome measure when rating scars in-person: height/thickness, vascularity, color, pliability, joint function, and patient/client opinion. A categorical scale with visual descriptors, as well as specific strategies to improve photographic technique, may go some way to addressing the perceived difficulty in rating these parameters using burn scar photographs.

Poor methodological quality and reporting standards of systematic reviews in burn care management

The methodological and reporting quality of burn‐specific systematic reviews has not been established. The aim of this study was to evaluate the methodological quality of systematic reviews in burn care management. Computerised searches were performed in Ovid MEDLINE, Ovid EMBASE and The Cochrane Library through to February 2016 for systematic reviews relevant to burn care using medical subject and free‐text terms such as ‘burn’, ‘systematic review’ or ‘meta‐analysis’. Additional studies were identified by hand‐searching five discipline‐specific journals. Two authors independently screened papers, extracted and evaluated methodological quality using the 11‐item A Measurement Tool to Assess Systematic Reviews (AMSTAR) tool and reporting quality using the 27‐item Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) checklist. Characteristics of systematic reviews associated with methodological and reporting quality were identified. Descriptive statistics and linear regression identified features associated with improved methodological quality. A total of 60 systematic reviews met the inclusion criteria. Six of the 11 AMSTAR items reporting on ‘a priori’ design, duplicate study selection, grey literature, included/excluded studies, publication bias and conflict of interest were reported in less than 50% of the systematic reviews. Of the 27 items listed for PRISMA, 13 items reporting on introduction, methods, results and the discussion were addressed in less than 50% of systematic reviews. Multivariable analyses showed that systematic reviews associated with higher methodological or reporting quality incorporated a meta‐analysis (AMSTAR regression coefficient 2.1; 95% CI: 1.1, 3.1; PRISMA regression coefficient 6·3; 95% CI: 3·8, 8·7) were published in the Cochrane library (AMSTAR regression coefficient 2·9; 95% CI: 1·6, 4·2; PRISMA regression coefficient 6·1; 95% CI: 3·1, 9·2) and included a randomised control trial (AMSTAR regression coefficient 1·4; 95%CI: 0·4, 2·4; PRISMA regression coefficient 3·4; 95% CI: 0·9, 5·8). The methodological and reporting quality of systematic reviews in burn care requires further improvement with stricter adherence by authors to the PRISMA checklist and AMSTAR tool.

Ultrasound is a reproducible and valid tool for measuring scar height in children with burn scars: A cross-sectional study of the psychometric properties and utility of the ultrasound and 3D camera

OBJECTIVE The aim of this study was to investigate the reproducibility and validity of measuring scar height in children using ultrasound and 3D camera. METHOD Using a cross-sectional design, children with discrete burn scars were included. Reproducibility was tested using Intraclass Correlation Coefficient (ICC) for reliability, and percentage agreement within 1mm between test and re-test, standard error of measurement (SEM), smallest detectable change (SDC) and Bland Altman limits of agreement for agreement. Concurrent validity was tested using Spearmans rho for support of pre-specified hypotheses. RESULTS Forty-nine participants (55 scars) were included. For ultrasound, test-retest and inter-rater reproducibility of scar thickness was acceptable for scarred skin (ICC=0.95, SDC=0.06cm and ICC=0.82, SDC=0.14cm). The ultrasound picked up changes of <1mm. Inter-rater reproducibility of maximal scar height using the 3D camera was acceptable (ICC=0.73, SDC=0.55cm). Construct validity of the ultrasound was supported with a strong correlation between the measure of scar thickness and observer ratings of thickness using the POSAS (ρ=0.61). Construct validity of the 3D camera was also supported with a moderate correlation (ρ=0.37) with the same measure using maximal scar height. CONCLUSIONS The ultrasound is capable of detecting smaller changes or differences in scar thickness than the 3D camera, in children with burn scars. However agreement as part of reproducibility was lower than expected between raters for the ultrasound. Improving the accuracy of scar relocation may go some way to address agreement.