Archives of Physical Medicine and Rehabilitation
Volume 88, Issue 12, Supplement 2 , Pages S1-S2, December 2007

The NIDRR Burn Injury Rehabilitation Model System Program: Selected Findings

  • David R. Patterson, PhD

      Affiliations

    • Corresponding Author InformationCorrespondence to David R. Patterson, PhD, University of Washington, Harborview Medical Center, Box 359740, 325 Ninth Ave, Seattle, WA 98104-2499

Burn Center, University of Washington, Harborview Medical Center, Seattle, WA.

Article Outline

Abstract 

Patterson DR. The NIDRR burn injury rehabilitation model system program: selected findings.

The quality of burn care has improved over the past few decades, and consequently many more survivors with large-area burn injuries have long-term rehabilitation needs. The National Institute on Disability Rehabilitation Research recognized that the rehabilitation of people with burn injuries has been underaddressed and established model systems of care for this population in 1994. This special supplement to the Archives of Physical Medicine and Rehabilitation reports on some of the research that has been generated by the Burn Rehabilitation Model Systems over the past 13 years.

Key Words: Burns, Rehabilitation

 

BURN INJURIES HAVE LARGELY been neglected as etiologies for disability in the literature. However, several developments have raised awareness of burn trauma as a source of acquired disability that often requires rehabilitation. A primary trend is the increase in survival rates for people with severe burn injuries. The percentage of people who survive with very large burn injuries has increased dramatically over the past few decades.1, 2, 3 Another development is the increased recognition that rehabilitation for burn-related disability should extend beyond strengthening and mobility to address the cosmetic disfigurement often experienced by burn survivors, as well as related pain and stress disorders. A further important step was recognition by the National Institute on Disability and Rehabilitation Research (NIDRR) that the rehabilitation issues faced by burn survivors were significant enough to warrant creation of a model system worthy of research funding. NIDRR’s action was undoubtedly a reaction to a growing recognition for rehabilitation efforts needed for burn injuries, but their designation also propelled recognition and improvement of burn rehabilitation in the community.

NIDRR is one of the 3 components of the Office of Special Education and Rehabilitative Services within the U.S. Department of Education and is dedicated to examining the long-term effects of various injuries. For a number of years, NIDRR has supported rehabilitation model systems, first for spinal cord injury (SCI) and, more recently, for traumatic brain injury (TBI). The model system program has led to common databases that have yielded data on thousands of patients with SCI and TBI for epidemiologic studies. They have also produced hundreds of descriptive and treatment studies on rehabilitation for these types of disabilities.

The Burn Model Systems (BMS) of Care were established in 1994. Three burn treatment centers received awards of 36 months in duration to provide leadership in rehabilitation as a key component of exemplary burn care and to advance the research base of rehabilitation services for burn survivors. The 3 funded centers were tasked with establishing and carrying out projects that provide a coordinated system of care including emergency care, acute care management, comprehensive inpatient rehabilitation, and long-term interdisciplinary follow-up services. The BMS centers were also expected to carry out innovative projects for the delivery, demonstration, and evaluation of comprehensive medical, vocational, and other rehabilitation services to meet the wide range of needs of people with burn injuries. In the late 1990s, a fourth center was funded, and the BMS target population was expanded to include children. The 4 centers have developed a longitudinal database that contains information on over 2708 adults and more than 1390 children (BMS Database). Separate funding of the Burn Model Systems Database Coordinating Center (BMS/DCC) was established in 1998. The BMS/DCC may be viewed online at http://bms-dcc.uchsc.edu.

This supplement focuses on some recent findings generated by site-specific and multisite data collection. Each of the 4 centers is represented, as is the DCC. In selecting the studies, we attempted to give readers a sample of the range of rehabilitation issues faced by people who survive large and/or serious burn injuries. Some topics, such as the need for strengthening, are expected areas of focus, whereas others, such as the effects of poor pain control, might be less common in a discussion of rehabilitation.

We begin with an overview of the types of rehabilitation issues faced by patients with severe burn injuries. Much of this summary is based on a review of the burn rehabilitation literature published by Esselman et al.4 What is apparent from this overview is that burn rehabilitation involves certain topics that would be immediately evident to specialists in this area, such as treatment of contractures, heterotopic ossification, neuropathies, and difficulty returning to work. However, there are many complications of burn injuries that are not so apparent, such as sensitivity to temperature extremes, sleep difficulty, pruritus (itching), and the impact of societal reactions to burn-related cosmetic disfigurement. The overview by Esselman5 is followed by an article describing practical issues related to managing a 4-center database. The 4 centers that participate in the BMS submit their data to a database coordinating center. In their discussion, Lezotte et al6 discuss not only how the integrity of such data is insured but also how potential pitfalls and threats to validity are anticipated and managed.

We next turn to the effects of exercise on burn rehabilitation. Severe burn injuries can result in marked skeletal muscle catabolism and weakness, as well as in diminished aerobic capacity. The article by de Lateur et al7 focuses on a 12-week, 36-session treadmill aerobic exercise program, based on preset quotas and work-to-tolerance guidelines. Their randomized, controlled study found improvements in aerobic capacity in the treatment group relative to controls. Suman and Herndon8 focus on children with particularly large surface-area burn injuries (greater than 40% total body surface area [TBSA]). From their randomized controlled study, the authors concluded that 12-week exercise programs completed either in a rehabilitation center or at home result in improvements in lean body mass and muscle strength relative to no-exercise control. Further, there is evidence that these beneficial effects may persist for at least 3 months after treatment.

A very deep burn in a joint area creates a number of rehabilitation challenges, but little has been published on this topic. Holavalahalli et al9 began to remedy this deficit in the literature by studying hand function after deep (full-thickness) hand burns in 32 survivors using total active motion, the Jebsen-Taylor Hand Function Test, and the Michigan Hand Questionnaire. Their discussion provides useful information about how functional deficits are manifested with such burn injuries and how preventative and therapeutic rehabilitation can be designed accordingly.

The next 2 studies focus on the effects of burn pain or on efforts to attempt to control it. Edwards et al10 determined how pain at discharge was associated with risk for suicidal ideation at 6-month and 1-year follow-ups. Pain was a predictor of suicidal ideation, providing more and particularly compelling evidence for the need to control pain effectively after a burn injury. We now know that pain medication frequently falls short of controlling burn pain and that nonpharmacologic interventions are highly desirable. Sharar et al11 report on 3 ongoing studies that use immersive virtual reality, a novel form of distraction, to reduce pain during burn physical therapy.

Our final area of focus is on long-term outcome after burn injuries. The area of vocational return after burn injuries has received little attention in the literature and yet is one that can represent high costs to a patient and society. Esselman et al12 identify several of the barriers that prevent timely return to work in 88 patients, using scheduled phone interviews. Baker et al13 report a rare study on young adults who were burned as children (83 subjects who received burn injuries of at least 30% of TBSA). Their finding that the majority of patients have physical and psychologic outcomes in the normative range (when compared with nonburned age-mates) is another important lesson from a rehabilitation perspective. These results remind us that it is not helpful to people with disability to “overpathologize” or make broad negative assumptions about outcome. It is more important to focus on the unique areas of rehabilitation that some burn survivors will require.

This supplement provides a number of articles on the wide variety of rehabilitation issues that burn survivors must face. Several investigators in this supplement report on randomized controlled studies on topics where such designs have been largely nonexistent until now. Overall, the numbers of patients with injuries and the size of these injuries are greater than those typically seen in the literature. We hope that this series of articles show that the NIDRR-sponsored model systems are advancing the state of the science with burn injuries, as they have long done with TBI and SCI.

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References 

  1. Thomas S, Barrow RE, Herndon DN. History of the treatment of burns. In:  Herndon DN editors. Total burn care. 2nd ed.. New York: WB Saunders; 2002;p. 1–10
  2. Saffle JR, Davis B, Williams P. Recent outcomes in the treatment of burn injury in the United States: a report from the American Burn Association Patient Registry. J Burn Care Rehabil. 1995;16(3 Pt 1):219–232discussion 288-9
  3. Pruitt BA, Goodwin CW, Mason AD. Epidemiological, demographic, and outcome characteristics of burn injury. In:  Herndon DN editors. Total burn care. 2nd ed.. New York: WB Saunders; 2002;p. 16–30
  4. Esselman PC, Thombs BD, Magyar-Russel G, Fauerbach JA. Medical and psychological aspects of rehabilitation from burn injury. Am J Phys Med Rehabil. 2006;85:383–413
  5. Esselman PC. Burn rehabilitation: an overview. Arch Phys Med Rehabil. 2007;88(12 Suppl 2):S3–S6
  6. Lezotte DC, Hills RA, Heltshe SL, et al. Assets and liabilities of the Burn Model System data model: a comparison with the National Burn Registry. Arch Phys Med Rehabil. 2007;88(12 Suppl 2):S7–S17
  7. de Lateur BJ, Magyar-Russell G, Bresnick MG, et al. Augmented exercise in the treatment of deconditioning from major burn injury. Arch Phys Med Rehabil. 2007;88(12 Suppl 2):S18–S23
  8. Suman OE, Herndon DN. Effects of cessation of a structured and supervised exercise conditioning program on lean mass and muscle strength in severely burned children. Arch Phys Med Rehabil. 2007;88(12 Suppl 2):S24–S29
  9. Holavanahalli RK, Helm PA, Gorman AR, Kowalske KJ. Outcomes after deep full-thickness hand burns. Arch Phys Med Rehabil. 2007;88(12 Suppl 2):S30–S35
  10. Edwards RR, Magyar-Russell G, Thombs B, et al. Acute pain at discharge from hospitalization is a prospective predictor of long-term suicidal ideation following burn injury. Arch Phys Med Rehabil. 2007;88(12 Suppl 2):S36–S42
  11. Sharar SR, Carrougher GJ, Nakamura D, Hoffman HG, Blough DK, Patterson DR. Factors influencing the efficacy of virtual reality distraction analgesia during postburn physical therapy: preliminary results from 3 ongoing studies. Arch Phys Med Rehabil. 2007;88(12 Suppl 2):S43–S49
  12. Esselman PC, Wiechman Askay S, Carrougher GJ, et al. Barriers to return to work after burn injuries. Arch Phys Med Rehabil. 2007;88(12 Suppl 2):S50–S56
  13. Baker CP, Russell WJ, Meyer W, Blakeney P. Physical and psychologic rehabilitation outcomes for young adults burned as children. Arch Phys Med Rehabil. 2007;88(12 Suppl 2):S57–S64

 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.

 Reprints are not available from the author.

PII: S0003-9993(07)01648-6

doi:10.1016/j.apmr.2007.10.001

Archives of Physical Medicine and Rehabilitation
Volume 88, Issue 12, Supplement 2 , Pages S1-S2, December 2007

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