| | Physical and Psychologic Rehabilitation Outcomes for Young Adults Burned as ChildrenAbstract Baker CP, Russell WJ, Meyer W III, Blakeney P. Physical and psychologic rehabilitation outcomes for young adults burned as children. ObjectiveTo report physical and psychologic outcomes for young adult survivors of pediatric burns. DesignProspective, correlational study. SettingAcute and rehabilitation pediatric burn care facility. ParticipantsEighty-three young adult survivors of pediatric burns, who were 18 to 28 years of age, with total body surface area (TBSA) burns of 30% or greater, and were at least 2 years postburn. InterventionsNot applicable. Main Outcome MeasuresPhysical outcomes were assessed by muscle strength tests, grip and pinch measurements, mobility levels, and self-care (activities of daily living) skills. Psychologic outcomes included behavioral problems, personality disorder, and incidence of psychiatric illness. An individually administered Structured Clinical Interview for Diagnosis, based on the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, for psychiatric diagnosis, was used to assess mental health, and behavioral problems were assessed with the Young Adult Self-Report. Participants reported educational achievement, employment status, state of transition from family of origin (home) to independent living, and pair bonding. The Short-Form 36-Item Health Survey and the Quality of Life Questionnaire were used to assess each participant’s self-reported general health and quality of life. ResultsThe majority of subjects had physical and psychologic outcomes that were within the normal range when compared with age-mates who had not experienced burns. The areas that were most likely to be impaired involved peripheral strength (wrist and grip). These deficits affected some self-care skills and correlated with TBSA. Standardized diagnostic interviews showed that greater than 50% of subjects qualified for a psychiatric diagnosis, with anxiety disorders as the most frequently occurring diagnosis. There were few significant correlations of the physical measurements or self-care skills with the burn size, psychologic problems, or social outcomes, and none appeared to be clinically important. ConclusionsMost of the people in this sample were functioning physically and psychosocially within normal limits as they reached adulthood. Although they appeared to function well as measured by standardized assessments, there were indications of private suffering that suggested they may not be functioning at an optimal level. The findings suggest that rehabilitation professionals could improve outcomes by including programs to develop overall muscle strength in severely burned children and by addressing concerns related to anxiety and other symptoms of psychologic distress. THE QUESTION OF rehabilitation outcomes for pediatric burn survivors has become more prominent over the past 2 decades as medical science and surgical techniques have advanced so that most burned children survive. Each year 40,000 to 50,000 people are admitted to hospitals for severe burn injuries in the United States; approximately 25% of these are under 18 years of age.1, 2, 3 Whereas 40 years ago, only half of the children with total body surface area (TBSA) burns of 50% could be expected to survive, now half of those with TBSA burns of 85% can be expected to survive.1 In fact, those children who reach a burn center with burns of greater than 70% of TBSA now routinely survive.1 Of note, 1 burn center reported that in 2006, there was a 50% survival rate of children ages 0 to 14 years with burns of 99% of TBSA.4 In contrast to advances in acute care, relatively little is known about the long-term outcomes of children with burn injuries and even less is known about their functioning when they enter adulthood. Most outcomes assessments of pediatric burn survivors focus on the immediate burn period through the first 2 years postburn and use standardized assessment tools designed for general populations rather than tools to identify specific difficulties of burned children. In these reports, the majority of young survivors seem to have reasonably good outcomes; only about 30% have significant psychosocial problems,5, 6, 7, 8, 9, 10 and even those with massive injuries and amputations are usually reported to achieve appropriate physical independence.10, 11, 12 There are no true longitudinal studies that involve more than 1 time-point of evaluation for pediatric burn survivors. Although the study by Sheridan et al10 included young adults (mean age, 24y), only 2 published studies13, 14 have evaluated aspects of long-term adjustment specifically at the time when survivors of childhood burns are making the transition from dependent adolescents to independent adults. In 1988, investigators at the University of Texas Medical Branch and Shriners Hospital for Children, Shriners Burns Hospital in Galveston, TX, examined 38 young adults who had experienced a burn covering at least 40% of TBSA. These investigators found that most subjects were in school or employed and were within normative limits on measures of psychologic adjustment. Those who had significant psychologic disturbance were different from their well-adjusted peers in their perceptions of their family cohesiveness and independence.13 A decade later, a similar group of investigators14 from the same institutions reported the long-term psychologic functioning of more than 40 children who survived burns of at least 80% of TBSA. Using a number of objective measures such as the Child Behavior Checklist and the Parenting Stress Index, they found that the survivors and their parents scored within normative limits on the tests, indicating positive psychosocial adjustment of these children with massive burns.14 Despite the optimistic reports of outcomes reported in these and other studies, clinical experience tells us that even those children who appear to do well experience great difficulties in the process, and those difficulties are not reflected in the outcomes reports. It is possible that standardized instruments do not capture the full effect of adjustment issues among this population of patients. The current study presents physical disability data in the context of an overview of the psychologic and psychiatric data previously reported for the same sample.15, 16, 17, 18, 19, 20, 21, 22, 23 This article synthesizes a wide array of physical and psychologic data for 1 cohort of subjects into a coherent summary to highlight rehabilitative needs of pediatric burn survivors becoming adults. Methods  Participants This study was part of a comprehensive investigation conducted at Shriners Hospital for Children, Shriners Burns Hospital in Galveston, TX, and was supported by the National Institute of Disability and Rehabilitation Research and National Center for Research Resources, National Institutes of Health. Patients who sustained a thermal injury by flame, scald, or heat were eligible for participation. Those who sustained chemical or electrical burns or had preexisting conditions that could contribute to the effects of burn injury were excluded. Those patients who primarily reside outside of the United States were also excluded. In addition, participants were required to understand English sufficiently well to follow directions and respond to questionnaire items. Eighty-three young adult survivors of pediatric burn injuries (52 men, 31 women) participated in this study. Subjects were 18 to 28 years old and were burned at least 2 years before the time of their assessments, before the age of 18 years, with at least 30% of TBSA burned. The mean age of participants was 21±2.5 years (range, 18–28y), TBSA burned was 52%±20% (range, 30%–99%), and years postburn was 14±5. All of the participants were originally treated at this acute burn care facility. The usual length of hospital stay 15 years ago for these people with 30% or more TBSA burned was 1 day per percent burn for the acute phase (first 2y postburn), with an average of 7 to 8 days for each reconstructive procedure. Approximately 70% of the participants were white, 15% African American, and 15% Hispanic. Participants came predominantly from the southern United States and west of the Mississippi River. Self-report was used to assess current level of education, employment, and pair bonding; the last term was used to indicate a relationship with a significant other. Educational status was assessed by asking how many years of education each had completed, and the following data were obtained: 28% high school dropouts, 33% high school graduation only, 34% some college, and 5% completed college. Seventy-seven percent either worked or attended school. Twenty-seven percent reported that they had established a long-term partner. The details of this relationship were explored in an open-ended interview. In addition, living arrangement and financial dependence were assessed in like manner. Instruments Physical assessment instruments The physical assessment results were reflected by a variety of measures. Muscle strength was assessed using standard and widely accepted strength testing procedures by Kendall et al.24 A Jamar hand dynamometera assessed hand grip strength, and a B&L pinch gaugeb was also used. Hand grip and pinch strengths were assessed with standard procedures for subject position and instructions, and the greatest of 3 trials was reported for each grip and pinch strength measure. Mobility evaluation examined each subject’s ability to assume various positions, such as side-to-side rolling, sitting, quadruped, kneeling, and standing. Stability was assessed by requiring subjects to hold positions against an externally applied force. Ratings were I (independent) or A (requires assistance); these were then transcribed to numeric ratings for the data analysis. Each participant demonstrated or reported his or her ability to perform activities of daily living (ADLs). ADLs were assessed with a self-report form developed at this facility (appendix 1). The instrument examines areas of mobility, hygiene, dressing, feeding, and home management. Each item was rated as 1 (independent), 2 (independent but not performed normally), 3 (required equipment), 4 (required supervision), 5 (required assistance), or 6 (unable to perform). When appropriate, subjects demonstrated their abilities to perform the activity. An unpublished study (C.P. Baker, A. Hantz, L. Hillman, M. Shepherd, unpublished data, Feb 2003) examined the validity of this instrument, comparing the results with those of the motor section of the FIM instrument. Scores on the facility-generated instrument correlated with FIM scores at .92 or higher. Spearman rank correlation coefficients for the combined sections of this instrument and the FIM averaged .96. No reliability data are available. Psychologic assessment instruments A battery of psychologic assessments was administered to each participant. Behavioral problems were assessed with the Young Adult Self-Report (YASR) for ages 18 to 30 years by Achenbach.25 The YASR contains a 119-item list of problem behaviors. Each behavioral item is rated as 0 for not true, 1 for somewhat or sometimes true, and 2 for very true or often true. The report can be interpreted by grouping the problem items into externalizing, internalizing, and total problems and/or by viewing the syndrome subscales—that is, anxious or depressed, withdrawn, somatic complaints, thought problems, attention problems, intrusive thoughts, aggressive behavior, and delinquent behavior. In addition to the problem scores, the YASR contains items about friends, education, job, family, spouse or other, illnesses or disability, concerns or worries, and the best things the people perceive about themselves; these items are scored to yield adaptive functioning subscales. Psychometric information for the YASR has been reported in the manual for the YASR and the Young Adult Behavior Checklist.25 Achenbach25 reports that test-retest reliability across the problem scales yielded a mean r of .84. In a matched sample of referred (for treatment of a clinical problem) and nonreferred subjects, the Total Problems Scale was highly predictive of referred subjects. When T scores were above 64 (clinical range for the instrument), the probability that a referred subject was being identified ranged between .74 and .79 for men and .79 and .82 for women.25 Individually administered structured diagnostic interviews (Structured Clinical Interview for Diagnosis [SCID]) assessed mental health.26 This fully structured, clinical interview allows operationally defined, consistent, and accurate Axis I psychiatric diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, the official manual of the American Psychiatric Association. Health-related quality of life (QOL) was measured by the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36).27, 28 The SF-36 is designed for those 14 years of age and older and consists of 8 scales, including physical functioning, physical role, bodily pain, general health, vitality, social functioning, emotional role, and mental health. Two summary scores, physical health and mental health, are derived from the 8 scales. The SF-36 is age-normed to the general population and has excellent psychometric properties for both the general population29 and those with specific medical conditions.30, 31, 32 High internal consistency (Cronbach α range, .65–.94)29, 30, 31, 32 and excellent test-retest stability (interclass correlation coefficient range, .73–.97)29, 30 have been reported. Many studies have investigated the relationships found between the SF-36 and other accepted health measures; correlations have ranged from .42 to .78.29 Further evidence of construct validity is reported by Brazier et al.33 Although used in a study of patients with burn injuries,10 the instrument’s specific reliability coefficients and validity have not been reported for this population. The Quality of Life Questionnaire (QLQ) by Evans and Cope34 was used to assess long-term psychosocial adjustment. It is a multidimensional tool that examines various aspects of daily living with the assumption that certain behaviors are indicative of adaptive psychosocial functioning.34, 35 It includes 192 true-false questions categorized into 5 major domains and 15 subdomains. The 5 major domains are general well-being, interpersonal relations, organizational activity, occupational activity, and leisure and recreational activity. The subdomains include material well-being, physical well-being, personal growth, marital relations, parent-child relations, extended family relations, extramarital relations (social support), altruistic behavior, political behavior, job characteristics, occupational relations, job satisfiers, creative/aesthetic behavior, sports activity, and vacation behavior. The QLQ has well-established psychometric properties, including construct validity. For example, internal consistency is reported as stable, with reliability coefficients ranging from .61 to .98, and test-retest reliability coefficients of .77 to .89.34 Procedure Participants were contacted by mail or telephone and invited to travel to the Shriners Burns Hospital in Galveston, TX to be assessed for psychosocial and physical well-being and difficulties. Data collection occurred between spring 2000 and fall 2002. A university institutional review board approved the study, participation in the study was voluntary, and written consent was obtained before participation. All potential subjects were contacted by telephone, and notes were taken to document reasons for nonparticipation and burn demographics. People who refused to participate in the study did not have significantly different demographics related to age, sex, ethnicity, or TBSA, but the nonparticipants were younger at the time of burn than those who participated.15 In the Shriners Hospital system, all patients are routinely followed up for health needs and are provided with needed medical intervention until they reach the age of 21 years. The typical physical rehabilitation interventions for subjects in our study included positioning, splinting, scar massage and management to affected areas, pressure dressings and compression garments, active and passive exercise, facilitation of normal physical development, strength and endurance training, ambulation, participation in functional and self-care activities, and caregiver education. During participants’ inpatient and outpatient care, a coordinated team approach was used and included physicians, nursing personnel, psychologists, psychiatrists, social workers, occupational and physical therapists, music therapists and child-life specialists, plastic and reconstructive professionals, prosthetic and orthotic personnel, and dieticians; there was frequent communication among members of this rehabilitation and medical team. In short, this report documents outcomes for what might be considered an ideal continuum of care.36, 37 For this study, a licensed physical therapist performed extensive assessments on each participant, averaging 80 to 90 minutes to complete. Included in these assessments and reported for this study were (1) comprehensive manual muscle strength measurements, (2) hand grip and pinch measurements, (3) a mobility and stability evaluation, and (4) ADL assessment. In addition, each participant completed the battery of psychologic assessments administered by licensed psychologists. Data Analysis Means, standard deviations, and percentages were calculated for each physical assessment measurement. Relationships between physical assessments and psychologic instruments were determined by Pearson correlation coefficients. An α level of .05 was used. Results Physical Assessment Data Muscle strength, hand and pinch strengths, and mobility A thorough manual muscle test examined the strength of each subject’s neck, shoulders, elbows, wrists, hips, knees, ankles, and toes. Sixty-five percent of our subjects had all strength values in normal ranges (scored 5/5); another 19% had 1 or more areas assessed as “good” (4/5). Approximately 94% of subjects had normal strength in neck movements, 92% had normal strength in the elbow, and 84% had normal strength in the ankle. The region most likely to show impaired strength was the wrist, where 26% of subjects showed some decreased strength, most often in wrist flexion. Approximately 20% of subjects had decreased strength in the toes or hip, most often in hip extension. Not surprisingly, subjects with higher TBSA burns had significantly lower mean strength (r=−.43, P<.001) overall, and considerably fewer had normal strength in the various body regions. Of those with burns of greater than 50% of TBSA, 42% had less than normal strength in wrist movements, and 39% had less than normal strength in toes. All participants had complete physical assessments examining all areas of the body, both burned and nonburned areas. For this study, data were not gathered in a manner that allowed comparison of strength of burned versus nonburned extremities or areas. Table 1 provides information regarding average handgrip, lateral (key grip) pinch, tip-to-tip pinch, and tripod pinch for all subjects. Subjects had little variability between mean right and left hand grip or pinch strength values; the average difference was approximately 2.22N (.50lb) (range of mean differences, 2.27–2.85N [.51–.64lb]). Sex differences are reflected in table 1, as is impact from size of burn. Subjects with TBSA burns of 50% or more had lower average grip and pinch strengths than did those with burn sizes less than 50% of TBSA. There was a significant relationship between tripod pinch and TBSA (r=.259, P=.02). Table 2 provides normative values from other sources for comparison. | | |  | Measurement | Men (n=49) | Women (n=31) | <50% TBSA (n=47) | >50% TBSA (n=33) | All Subjects (N=80) | |
|---|
| Handgrip | 473.29 (106.4) | 236.56(53.18) | 396.34(89.10) | 361.53(81.05) | 381.57(85.78) | | | Lateral (key) | 100.98(22.70) | 69.39(15.60) | 90.61(20.37) | 86.47(19.44) | 88.88(19.98) | | | Tip-to-tip | 76.51(17.20) | 54.89(12.34) | 70.02(15.74) | 65.75(14.78) | 68.24(15.34) | | | Tripod | 95.55(21.48) | 72.11(16.21) | 91.68(20.61) | 79.53(17.88) | 86.56(19.46) | | | | |
| | | | Subject | Hand Grip | Key Grip | Tip-to-Tip | Tripod (palmar) | |
|---|
| Men right | 538.24(121.00) | 115.65/112.99(26.00/25.40) | 80.07/69.57(18.00/15.64) | 118.32/88.74(26.60/19.95) | | | Men left | 464.84(104.50) | 110.32/105.07(24.80/23.62) | 5.62/66.28(17.00/14.90) | 9114.32/85.76(25.70/19.28) | | | Women right | 313.16(70.40) | 78.29/78.33(17.60/17.61) | 49.38/48.39(11.10/10.86) | 76.51/70.59(17.20/15.87) | | | Women left | 271.34(61.00) | 72.06/73.040(16.20/16.42) | 46.71/46.22(10.50/10.39) | 72.51/65.39(16.30/14.70) | | | | |
Ninety-three percent of subjects had normal mobility, and 50% had normal stability. The activity most likely to be physically challenging was “walking on an unlevel surface”; 6% of subjects reported difficulty with this. No significant correlations were found between mean mobility and TBSA or mean stability and TBSA. ADL skills Twenty-six self-care skills were assessed by demonstration or responses to questions. A majority (83%) of the young adults were able to address their own self-care needs without any modifications or assistive devices. Ninety-nine percent of subjects reported being independent in the areas of hygiene (toileting, bathing) and home management skills (ie, making a sandwich, opening a soda can, using a telephone). In dressing activities (eg, putting on pants), 98% of the subjects were independent. Feeding skills were the most varied of those examined; 88% were independent. Generally, people with more TBSA burned were more likely to have limitations in self-care abilities. This finding was significant for mobility (r=−.298, P=.006) and dressing (r=−.251, P=.022). However, these relationships, although statistically significant, represent fair or no clinical importance. Relationships Between Physical and Psychologic Measures No significant relationships were found between mobility and stability scores and the YASR problem subdomains; P values ranged from .059 to .999, with the highest r value of −.218 found with the delinquent behaviors subscale. Few significant correlations were found with strength scores and the YASR problem subdomains. The only significant correlation between strength and YASR was found in mean shoulder strength and aggression subscale (r=.228, P=.048). Hand grip strength correlated significantly with the internalizing scale (r=−.308, P=.008), anxious-dependent scale (r=−.294, P=.012), and withdrawn scale (r=−.276, P=.018); tip-to-tip pinch strength correlated significantly with the internalizing scale (r=−.245, P=.036) and withdrawn scale (r=−.238, P=.043). These correlations indicate a relationship between poor hand function and increased behavioral problems. Feeding was the only ADL area to have a significant relationship to any areas of the YASR; both total problems (r=.267, P=.02) and the attention scale (r=.227, P=.049) had significant correlations. The SCID results are reported in detail elsewhere.23 They showed that 45.5% received 1 or more current Axis I psychiatric diagnoses; anxiety disorders occurred with the highest prevalence (31%). Lifetime mental health diagnoses were more common; 59.4% had 1 or more lifetime Axis I diagnoses. Again, the anxiety disorders had a high prevalence (38%), but in this time frame affective disorders were also very common (44.4%). The prevalence of current and lifetime psychiatric diagnoses are twice the national prevalence. The presence of any current Axis I diagnosis, any current affect diagnosis and any current anxiety diagnosis were compared with the mobility, stability, strength, and ADL scores. None of the physical measures had significant relationships with the current SCID findings. The strongest, yet still nonsignificant, relationship was between physical stability and any current affective disorder with an r value of .175 (P=.12). On the SF-36, mean values for the survivors on the physical component scale (PCS) and mental component scale (MCS) were 50.30 for men and 50.11 for women, similar to published norms (50.00 for each scale) for the U.S. population.29 The results suggest that these young adults perceive the impact of health on their lives in ways that are similar to those of the general population. Overall muscle strength correlated significantly to SF-36 PCS score (r=.438, P<.001). All hand and grip strength values correlated significantly with the physical functioning subscale of the SF-36 (r range, .24–.31) but not with the overall PCS. However, handgrip and key (lateral) pinch strength correlated significantly with the MCS (r=.289, P=.017; r=.309, P=.01, respectively). Mobility (r=−.419, P<.001) and stability (r=−.464, P<.001) correlated with the SF-36 PCS values. None of the ADL scores correlated with PCS or MCS scores. The QLQ showed that burn survivors as a group rated their overall QOL (mean, 103.4±22.3) significantly lower (P<.001) than the normative reference group reported by Evans and Cope34 (113.2±20.4). None of the physical measures had significant relationships with the QLQ total score; the strongest, yet still nonsignificant, relationship was between the total QLQ and physical stability (r=−.200, P=.081). Discussion A large majority (93%) of our subjects with significant burns performed well physically. There were a few notable differences in overall strength and handgrip. Sixty-five percent of our subjects had normal muscle strength in all areas of the body, with another 19% having “good” strength as their lowest obtained strength value. Only 35% of our subjects had any long-term strength deficits in any area of the body. Distal areas of the body (wrists, toes) were more likely to have impaired strength. It may be that these areas of the body were more likely to have surgical intervention, muscle loss, nerve damage, or partial or complete amputations, which could have affected the strength in these areas and the surrounding joints. For example, a person might have experienced an amputation of a finger or distal part of finger; this would not impair the ability to grasp the hand dynamometer but would result in decreased grip strength because not all fingers were able to exert force. Our findings are somewhat surprising, because published literature suggests that people with burns often have marked muscle weakness in spite of standard occupational and physical therapy rehabilitation programs.38 Prolonged hospitalization may account for the loss of muscle mass and diminished cardiovascular endurance. The child who has been burned tends to move rigidly and slowly, which can result in limited activity and impaired strength.39, 40, 41 Children with larger burns may tire easily and may require strengthening and cardiovascular exercises appropriate to the age of the child, the specific area burned, and the strengthening and cardiovascular training devices available.36 There was a sizable difference between postural mobility and stability (93% had normal postural mobility, but only 50% had postural stability rated as normal when assessed). We postulate that this is related to the diminished toe strength in 20% of the subjects; lack of a stable base would impair standing balance and the ability to walk on unlevel surfaces. People flex their toes to grasp the ground or their shoes to gain stability during stance and gait.42 Further, toe muscle weakness decreases a person’s ability to invert and evert the foot and ankles, influencing the ability to adjust to perturbations.43 This relationship is speculative from the findings in this study and warrants future investigation. Not surprisingly, when compared with age-mates who had not experienced burn injury, our subjects had lower grip and pinch strength values, as shown in Table 1, Table 2. The findings by Mathiowetz et al44 for fifty-five 20- to 24-year-olds are reported in table 2; Jansen et al45 also examined mean pinch values, and those for subjects aged 20 to 39 years (n=13) are reported in italics in these columns. In 2 instances (tip and tripod pinch) our subjects’ mean values were comparable to or exceeded those reported by either Mathiowetz44 or Jansen.45 This may have been due to differences in finger positions allowed between our subjects and those in the other 2 studies. Specifically, subjects in the later 2 studies were not allowed to “recruit” other fingers when trying for the maximum tip pinch. Although we tried to watch for this occurrence, it may be that we were not as vigilant as the examiners in the Mathiowetz44 or Jansen45 studies. Regarding ADL skills, our data are similar to those of other researchers who found that most burned children were appropriate for their ages in self-care skills 1 year postinjury. Measures used by other researchers to assess children’s self-care skills include the Vineland Adaptive Behaviors Scales personal subdomain or observational assessments as used in the current study.12, 46 Our finding that feeding skills were more often affected is likely due to the decreased wrist, hand grip, and pinch strengths seen for some subjects. Total or partial finger amputations may also have played a role in this. Not surprisingly, Meyers-Paal et al12 found that pediatric patients with fingers amputated because of massive burns were significantly more dependent in self-care skills than those without amputations. Our data within the psychosocial domain suggest that these young burn survivors function satisfactorily in most areas of their lives. When survivors’ scores on the YASR scale were compared with those of the published reference group, men with burn injuries reported only more somatic complaints, but the women conveyed significantly more externalizing and total problems. Although subjects apparently function satisfactorily, analysis of the structured psychiatric interviews showed that many of these participants suffer serious anxieties. Such anxieties are usually not easily observable by others and can be kept private, secrets to all but the subject and close confidantes. Such serious anxieties must impact QOL for those who suffer them. These psychologic and psychiatric findings were not related to the physical data collected; they seem to be reflected on the QLQ but not on the SF-36. Four studies have used the SF-36 to assess QOL in people with burns.10, 47, 48, 49 In our study, as in the others,10, 47 QOL for burn survivors as measured by the SF-36 did not differ significantly from that of age-matched normative data for the general population. The differences between the SF-36 and the QLQ are the subject for another study. Few significant correlations (other than those that are obviously related) were found between the physical measures and psychologic or health assessments. The relationship between the PCS of the SF-36 and muscle strength is obvious, because the ability to perform physical tasks such as carrying groceries and walking up stairs (as reflected on the SF-36) would be directly related to available muscle strength. Most of the correlations, however, were not statistically significant or were of little clinical importance, suggesting that the long-term QOL for these burn survivors may not be related to their physical abilities. Study Limitations The reader is cautioned not to generalize our findings to other burn populations. All subjects in our study had extensive and prolonged medical intervention and therapy, with annual follow-up until age 21 years or until they no longer needed burn care. Not all burn survivors will have such an extensive, multidisciplinary team. All of our subjects were English-speaking residents of the United States, so these results may not be applicable to people in other cultures. Furthermore, the subjects self-selected to the extent that they were willing, for whatever reasons, to travel to Galveston and invest their time in this study. Another concern is that, as of this writing, information about the location and extent of scarring and amputations is not entered into the database, so we can only hypothesize the relationship between our dependent measures and those aspects that would obviously contribute to impairment, either psychologic or physical. In addition, all subjects in the study had comprehensive physical assessments, and our database does not delineate the body area burned to enable us to correlate this to strength values obtained for extremities or trunk musculature. Conclusions These results suggest that a vast majority of children experiencing moderate to severe burns will be able to address their own self-care and mobility needs as young adults. Intensive exercise programs recently described in the literature might have resulted in a higher percentage of our subjects achieving normal muscle strength.38, 40, 41 However, the high rate of anxieties and diminished QOL reported indicate a degree of distress that we must attempt to address, and interventions to address the psychosocial needs are just beginning to be tested.50 For the burn survivors in this study, the greatest apparent need during this transition is for psychosocial assistance. None of the young adults in this study, however, were receiving professional help for their difficulties. Most burn survivors who suffer psychologic symptoms of distress after discharge from a burn center and who desire treatment must rely on mental health professionals in the community. However, it may be difficult for them to find helpful resources, because such treatment is expensive and often not affordable by the patient, at least in the United States, without insurance or other financial assistance. Future research is warranted to determine what continued resources are needed to assist young survivors during this transition to optimally function as adults achieving to their greatest potentials. Supplier Acknowledgments We thank the Departments of Rehabilitation Services and Medical Records at Shriners Hospital for Children, Shriners Burns Hospital, Galveston, TX, for their collaboration and advice for this article. We also thank Mary Ellen Spellman, PT, Jennifer Ellison, PhD, PT, and Caroline Jansen, PhD, PT for their assistance with data collection. References 1. 1Pruitt B, Wolf S, Mason A. Epidemiological, demographic and outcome characteristics of burn injury. In: Herndon D editors. Total burn care. 3rd ed.. Philadelphia: WB Saunders; 2007;p. 14–32. 2. 2American Burn Association. Burn incidence and treatment in the US 2007 fact sheet. Available at: http://www.ameriburn.org/resources_factsheet.php. Accessed June 13, 2007. 3. 3Agency for Healthcare Research and Quality. Welcome to HCUPnet. Available at: http://hcupnet.ahrq.gov/HCUPnet.jsp. Accessed June 13, 2007. 4. 4Pereira CT, Barrow RE, Sterns AM, et al. Age-dependent differences in survival after severe burns: a unicentric review of 1,674 patients and 179 autopsies over 15 years. J Am Coll Surg. 2006;202:536–548. Full Text |
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50. 50Meyer WJ, Blakeney P. Psychosocial support. In: Barrett J editors. Principles and practice of burn surgery. New York: Marcel Dekker; 2005;p. 365–394. a Department of Physical Therapy, School of Allied Health Sciences, University of Texas Medical Branch, Galveston, TX b Department of Psychiatry and Behavioral Sciences, University of Texas Medical Branch, Galveston, TX c Department of Surgery, University of Texas Medical Branch, Galveston, TX d Shriners Hospital for Children, Shriners Burns Hospital, Galveston, TX.  Reprint requests to Christine P. Baker, EdD, PT, School of Allied Health Sciences, Dept of Physical Therapy, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-1144.
Supported by the National Institute of Disability and Rehabilitation Research (grant no. H133G990052) and the National Center for Research Resources, National Institutes of Health (grant no. M01RR00073). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated. PII: S0003-9993(07)01565-1 doi:10.1016/j.apmr.2007.09.014 © 2007 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved. |
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