JBUR 5899 No.

of Pages 8

burns xxx (2019) xxx –xxx

Available online at www.sciencedirect.com

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journal homepage: www.elsevier.com/locate/burns

Mobilization practices for patients with burn injury

in critical care

Thaís Borgheti de Figueiredo a, *, Key Fujisaki Utsunomiya a,

Amanda Maria Ribas Rosa de Oliveira b , Ruy Camargo Pires-Neto a ,
Clarice Tanaka a
a
Department of Physiotherapy, Communication Science and Disorders, Occupational Therapy, University of São Paulo,
Rua Cipotânea, 51, Cidade Universitária – CEP 05360-000, São Paulo, SP, Brazil
b
Burn ICU, Hospital das Clínicas da Faculdade de Medicina, University of São Paulo, Rua Dr. Ovídio Pires de Campos,
225 – Cerqueira César – CEP 05403-010, São Paulo, SP, Brazil

article info abstract

Article history: Purpose: Patients with burn usually undergo prolonged hospitalization due partially to the
Accepted 27 July 2019 treatment of wounds and scars. Although the benefits of early mobilization are well-known
Available online xxx in critical care patients, there are a lack of studies reporting mobilization practices and
functional status for patients with burn.
Materials: Clinical and physiotherapy data were daily collected, including ICU mobility scale
Keywords:
(IMS) and reported barriers to mobilization therapy during a one-year period. At hospital
Burns
discharge, the 6-min walking test (6MWT), Medical Research Council scale (MRCS) and
ICU
handgrip strength test were applied to evaluate the patients’ functionality.
Physiotherapy
Results: Of the 74 patients admitted, 66% were placed on mechanical ventilation (MV).
Mobilization therapy
Mobilization therapy was administered in 67.2% of physiotherapy sessions, with passive
mobilization being the most prevalent (53.2%) followed by active in-bed exercises (13.6%).
Reported barriers for mobilization included hemodynamic instability followed by limited
time for assistance. At hospital discharge, the 6MWD was 270(136) meters. A positive
correlation was found between handgrip evaluation and 6MWD and a negative correlation
with hospital length of stay.
Conclusions: Mobilization therapy of patients with burns in the ICU was characterized by a low
mobility level during MV with a low functional status at hospital discharge.
© 2019 Elsevier Ltd and ISBI. All rights reserved.

1. Introduction However, most of the studies performed so far have evaluated

clinical, especially respiratory, cardiovascular and neurological
patients [1,2,7–10].
Early mobilization in patients in intensive care units (ICU) is Burn patients present a hypermetabolic syndrome that
feasible, safe and associated with better clinical outcomes [1–6]. causes a deep catabolic state associated not only with the

* Corresponding author at: Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupacional– Faculdade de Medicina da Universidade
de São Paulo, Rua Cipotânea, 51, Cidade Universitária, 05360-000, São Paulo SP Brazil.
E-mail addresses: thaisfigueiredo@usp.br (T.B. de Figueiredo), key.utsu@gmail.com (K.F. Utsunomiya), amandaribasrosa@gmail.com
(A.M.R.R. de Oliveira), pires.ruy@gmail.com (R.C. Pires-Neto), cltanaka@usp.br (C. Tanaka).
https://doi.org/10.1016/j.burns.2019.07.037
0305-4179/© 2019 Elsevier Ltd and ISBI. All rights reserved.

Please cite this article in press as: T.B. de Figueiredo, et al., Mobilization practices for patients with burn injury in critical care, Burns
(2019), https://doi.org/10.1016/j.burns.2019.07.037
JBUR 5899 No. of Pages 8
2 burns xxx (2019) xxx –xxx
breakdown of muscle proteins but also with damage to nearly
all organs, leading to multiple organ dysfunction [11]. The
observed organ changes have the potential to advance to
pathological alterations that can increase morbidity/mortality
[12] and lead to loss of function and a reduced quality of life in
survivors [13,14].
Burns are also among the most costly traumatic injuries
due to the long period of hospitalization for rehabilitation and
the treatment of wounds and scars [15]. When larger areas of
body surface are involved, a longer period of hospitalization is
undertaken including care in specialized intensive therapy
units [16].
Clinical characterization of patients suffering from major
burns with ICU admission in the city of São Paulo, Brazil, was
reported [17]. Thirty-four-year-old patients with an average of
19% of burned body surface and inhalation lesions were
presented in 45% of the cases, with approximately 40% of
mortality [17]. However, in this study, there was no report on
mobilization therapy delivered to the patients in the unit.
Considering the lack of studies of patients with burns in the
ICU and the benefits of early mobilization, the aim of this study
was to report mobilization therapies, barriers and adverse
events related to caring for patients in this unique population,
as well as their functional status at hospital discharge.
2. Methods
This study was approved by the Local Research Ethics
Committee (CAPpesq N 1.015.299). Patients older than 16
years admitted to the burn ICU of the Hospital das Clínicas da
Faculdade de Medicina da Universidade de São Paulo from
April 2014 to March 2015 were included in the present study.
Patients or next of kin signed a written informed consent form
(WICF).
The burn ICU in this hospital is a four-bed unit assisted by a
multidisciplinary team. The staff ratios of professionals to
patients in this unit were 1:4 registered nurses, 1:2 nurse
assistants, 1:4 resident junior physiotherapists and 1:8 senior
physiotherapists. Routine physiotherapy care in this ICU
included both respiratory and mobility therapy. As previously
described elsewhere, respiratory care includes airway clear-
ance maneuvers (including suctioning), lung expansion
techniques, oxygen therapy and noninvasive mechanical
ventilation (NIMV). Additionally, if the patient was intubated
and mechanically ventilated, the physiotherapist was also
responsible for adjusting the ventilator settings, participating
in the weaning process (including extubation) and artificial
airway care [18]. Mobility therapy included patient positioning,
general limb (passive, active or resistive) and trunk exercises,
sitting on the edge of the bed (SOEOB), sitting out of bed (SOOB),
standing up and walking away from the bed. Each mobility
therapy session took around 20 min.
Demographic, clinical and physiotherapy data available
from patient charts were recorded on a daily basis. If a register
was missing from the charts, the physiotherapist or other staff
members were directly contacted for further clarification. The
data collected included age, gender, height, ICU length of stay
(ICU LOS), presence and characterization of comorbidities,
Simplified Acute Physiology Score 3 (SAPS3) [19], Sequential
Please cite this article in press as: T.B. de Figueiredo, et al., Mobilization practices for patients with burn injury in critical care, Burns
(2019), https://doi.org/10.1016/j.burns.2019.07.037
Organ Failure Assessment (SOFA) [20] score, abbreviated burn
severity index (ABSI) [21], total burn surface area (TBSA) [22],
primary area affected by the burn injury, presence or absence
of inhalation lesions, mechanism of injury (flame, electric,
scalding or chemical) and mortality rate during ICU LOS. Data
regarding the duration of mechanical ventilation (MV) and
patients who underwent a tracheostomy (TT) were also
collected. Level of consciousness was assessed using the
Richmond Agitation Sedation Scale (RASS) [23]. Physiotherapy
treatment in the burn ICU was available daily for a 12-h shift
(7:00 a.m. to 7:00 p.m.). However, five months after the
beginning of data collection, physiotherapy assistance was
extended to a 24-h shift.
The highest level of mobility performed with the patient in
each session was recorded using the ICU mobility scale (IMS)
[24,25]. If no mobility activity was performed with the patient,
the reason for not doing so was recorded. During a 12-h shift,
approximately 2 mobility sessions were expected for each
patient and after the 24-h shift implementation, approximate-
ly 3 mobility sessions were expected. Muscle strength was
measured using the Medical Research Council scale (MRCS) at
ICU admission or as soon as the patient experienced an
increased level of consciousness (RASS  1) and twice a week
until ICU discharge. If a patient had a limb amputation or if a
specific limb were unable to be evaluated (skin graft or
dressings), the opposite side score was used to reflect this limb
[26]. ICU-acquired weakness (ICUAW) was considered when
the MRCS score <48 [26].
At hospital discharge, the patient’s functionality was evalu-
ated with a 6-min walking test (6MWT) performed according to
the American Thoracic Society (ATS) guidelines [27], a MRCS
evaluation, and a handgrip strength test using a handheld
dynamometer (Trailite, Germany). For the handgrip test, patients
sat with their arms along the body, with elbows bent at 90 and
the forearms in neutral position. Maximum strength was
assessed on the dominant limb, if possible; otherwise, the other
limb was evaluated. In case of the dominant hand presented a
burn injury, patients were asked if they preferred to perform the
test with the non-dominant hand. Patients were instructed to
squeeze the handle as hard as possible for 3–5 s. Three repetitions
of the test were performed with a resting period of one minute
between measurements [28].
Statistical analyses were performed using the software
“Statistical Package for the Social Sciences” (SPSS) v.20.0 (SPSS,
USA). Descriptive analyses of the categorical and continuous
variables are presented as percentage, number of events, mean
(SD) or median[IQR], when appropriate, after testing for data
distribution (Kolmogorov–Smirnov test). A paired t-test was
performed to compare the MRCS scores at the ICU and hospital
discharge. Pearson’s or Spearman’s correlation tests were
performed according to data distribution to verify associations
between: 6MWD, MRCS score at hospital discharge, handgrip
strength, age, SOFA, TBSA, SAPS3, ABSI, ICU LOS and hospital
LOS. Finally, considering that after five months of data
collection, the number of mobility sessions increased (12-h
shift group– two sessions and 24-h shift group– three sessions),
a comparison was made with these two groups for clinical (ICU
LOS, MV duration and mortality) and functional outcomes
(6MWD, Handgrip strength, maximum mobility level) using
Mann–Whitney test. This research also verified if there was any
JBUR 5899 No. of Pages 8

burns xxx (2019) xxx –xxx 3

association between maximum mobility level achieved and Table 1 – Demographic characterization of the patients
outcomes such as mortality, ICU LOS, MV duration, 6MWD and admitted to the burn ICU (N = 74).
handgrip strength. A regression analysis was performed Variables n
considering clinical and demographic data as appropriate.
Age, years – mean(SD) 42(19)
For all the analyses, we adopted a level of significance of 5%
Gender, male n (%) 58 (78)
(p  0.05).
Height, m – mean(SD) 1.7(0.1)
Comorbidities – n (%)
Drugs/alcohol 22 (30)
3. Results Smoking addiction 14 (19)
Psychiatric disorder 10 (13)
3.1. Subject characteristics Cardiovascular 5 (7)
Diabetes mellitus 4 (5)
Trauma 3 (4)
During the one-year data collection period, 78 patients were Others 4 (5)
admitted to the burn ICU. Four patients were excluded, as
shown in Fig. 1. Detailed data and population characteristics
are provided in Table 1.
Table 2 presents the clinical data of the 74 patients. By 3.2. Mobility practice
observing the SAPS3 of 47 [18] and ABSI of 7 [2] patients, it can
be observed that this was a moderately severe population. The For a total of 3967 registered physiotherapy sessions during the
main mechanism of injury was flame (76%). The prevalence of study period, 3088 sessions were related to mobility practices.
ICUAW evaluated by MRCS scores was 21%, and the ICU and Patients were provided a daily average of 2(1) sessions of
hospital mortality rate were 38%. mobility therapy in the ICU during the study period.

Fig. 1 – Flowchart representing the study population.

Please cite this article in press as: T.B. de Figueiredo, et al., Mobilization practices for patients with burn injury in critical care, Burns
(2019), https://doi.org/10.1016/j.burns.2019.07.037
JBUR 5899 No. of Pages 8

4 burns xxx (2019) xxx –xxx

Table 2 – Clinical characterization of the patients admitted were the most prevalent activities (IMS  3); OOB activities
to the burn ICU. (IMS  4) were rare.
Variable n During MV, mobility therapy was delivered in 1153
sessions, including passive mobilization in 911 (79%) ses-
SAPS3 47 [18]
sions and active exercise (IMS = 1) in 233 (20%) sessions. Only
ABSI 7 [2]
seven patients, two of them in tracheal tube, engaged in OOB
SOFA 2 [4]
TBSA - % 25 [26] activities during MV in a total of nine sessions, i.e., four
Patients with full thickness injury – n (%) 57 (77) patients sat in an armchair with active transfer (IMS = 5) for
% full thickness injury 15 [23] just one session, one patient presented IMS = 4 in two
sessions, another patient presented IMS = 4 and IMS = 6 in
Injury location – n (%) two different sessions, and the last patient presented IMS = 4
Upper body 49 (68)
in one session.
Lower limbs 13 (18)
All 10 (14)
Very few adverse events were reported (n = 5 out of 3088
sessions) and were related to hemodynamic changes, such as
Injury mechanism – n (%) hypotension and tachycardia or vertigo. One fall was reported.
Flame 56 (76) None of these patients were on MV.
Electric 16 (22)
Scalding and chemical 2 (3)
3.3. Barriers
Inhalation injury – n (%) 20 (27)
Barriers were presented in 470 sessions (Table 3). Physiother-
Mechanical ventilation – n (%) 49 (66) apy staff cited the following barriers when mobility therapy
was not provided: hemodynamic instability in 71 events (2% of
Tracheostomy – n (%) 7 (10) sessions) and limited time for assistance in 49 events (1% of
sessions).
Noninvasive mechanical ventilation – n (%) 22 (30)
Deep sedation (RASS  2) was presented in 562 sessions
(out of 1153 mobility sessions during MV); however, this was
Sedation – n (%) 50 (68)
not reported as a barrier by any physiotherapists since it did
Sedation (days) 6 [9] not prevent passive mobilization.

Vasoactive agents – n (%) 34 (45) 3.4. Addition of a mobility session (12-h shift vs 24-h shift)

Readmission to ICU – n (%) 4 (5)

After five months of data collection, physiotherapy assistance
Mortality – n (%) 28 (37)
was extended to a 24-h shift and a mean of one mobility
session was added per day per each patient (two sessions vs
MV duration (days) 5 [13] three sessions). There was no difference founded in any
clinical (ICU LOS, MV duration and mortality) or functional
ICU length of stay (days) 13 [25] outcomes (6MWD, handgrip strength, maximum mobility
level) comparing 12-h shift with 24-h shift.
Hospital length of stay (days) 36 [27]

Data expressed as the mean(SD) or median[IQR] or as stated.
Legend: SAPS3 (Simplified Acute Physiology Score 3), SOFA (Sequential
Organ Failure Assessment), ABSI (Abbreviated Burn Score Index), TBSA
(Total Burn Surface Area).
Physiotherapy care was not provided to three patients due to
the severity of their clinical status. In fact, these patients died
before 48 h ICU LOS.
Out of 3088 mobility therapies, only passive mobilization
(IMS = 0) was provided in 1048 (34%) sessions. There were 1596
sessions (51%) of in-bed exercises (IMS 1 to 3) and 444 sessions
(14%) of out-of-bed (OOB) exercises (IMS > 4). Forty-three
patients (58%) presented an IMS  4, and 27 patients (36%)
walked away from the beds (IMS > 7) at ICU discharge.
Considering only the survivors (n = 46), six patients (13%) did
not perform any activity outside the bed during their ICU stay.
Fig. 2 describes the primary mobility activity provided on a
daily basis for each patient. Although the passive mobilization
(IMS = 0) percentage decreased over time, in-bed exercises
3.5. Mobility level and outcomes
Considering maximum mobility level achieved (IMSmax)
during ICU LOS and clinical and functional outcomes, this
research showed an association between IMSmax and mor-
tality (p < 0.001 OR: 0.5, 95%CI: 0.36–0.68). However, the
association was lost after adjusting for age, TBSA, SAPS3,
MV and sedation duration and ICU LOS in a regression binary
logistic analysis.
3.6. Hospital discharge evaluation
Of the 46 surviving patients, we were able to collect data from
32 patients at hospital discharge. These 32 patients were
characterized by a mean age of 35(12) years, a SAPS3 of 42 [12],
an ABSI of 6 [2] and a TBSA of 12 [23]. ICU LOS was 11 [20] days
and hospital LOS was 36 [25] days. Median length of stay for
hospital discharge evaluations was 19 [20] days after ICU
discharge. Only 15 patients presented full set of assessment
(6MWT, Handgrip strength and MRCS evaluation). For each test
there were: 6MWT, 20 patients; Handgrip strength, 25 patients;

Please cite this article in press as: T.B. de Figueiredo, et al., Mobilization practices for patients with burn injury in critical care, Burns
(2019), https://doi.org/10.1016/j.burns.2019.07.037
JBUR 5899 No. of Pages 8
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Fig. 2 – Primary mobility activity provided on a daily basis for
each patient. Legend: IMS (ICU mobility scale), ICU LO/S (ICU
length of stay). IMS: 0 — Passive; IMS 1 — Active, in bed; 2–3 —
Passive, moved to chair and sitting over edge of bed; IMS 4–6 —
Out-of-bed exercises (standing, transferring bed to chair and
marching in place); 7–10 — Walking exercises (with assistance
of 2 or more people, with assistance of 1 person, with a gait aid
and independently without a gait aid).
Table 3 – Barriers reported by physiotherapists for not
providing mobility therapy during PT sessions in the burn
ICU.
Barriers
Hemodynamic instability
Limited time for assistance
Patient at operating room
Pain
Respiratory instability
Medical orders
Patient’s clinical condition
Missing data
Medical procedure
Patient’s refusal
Nurse procedure
Agitation
Hemodialysis
MRCS, 31 patients. Reasons for not performing the tests are
described in Fig. 1.
At hospital discharge, the average walking distance was 270
(136) meters, which was 62% of the predicted value for their age
and gender [29]. Handgrip strength was 26.5(12.4) kg. Out of 25
patients that performed this test, eight patients presented
burn lesion in their dominant hand. Only one patient out of
this eight complained of pain and uncomfortable feeling and
decided to perform the test with the non-dominant hand.
Additionally, another two patients had their dominant hand
amputated and performed the test with the non-dominant
Please cite this article in press as: T.B. de Figueiredo, et al., Mobilization practices for patients with burn injury in critical care, Burns
(2019), https://doi.org/10.1016/j.burns.2019.07.037
5
test. There was no improvement in the MRCS scores at hospital
discharge compared to the MRCS scores at ICU discharge (57.5
[9] vs 55 [7]; p = 0.368). We also found a positive relationship
between the 6MWD and handgrip strength (r = 0.555; p = 0.04)
and a negative correlation between length of hospital stay and
handgrip strength (r = 0.444; p = 0.03).
4. Discussion
The present study has reported mobilization therapies in burn
ICU patients. Within the level of mobility therapy provided,
therapy was considered safe and presented very few adverse
events. The most reported barriers for not providing mobiliza-
tion therapy were hemodynamic instability and limited time
for assistance with 71 and 49 events, respectively. Deep
sedation was not reported as a barrier, although presented in
49% of the sessions during MV. The ICUAW prevalence was
21%. At hospital discharge, the survivors presented 62% of the
predicted 6MWD for their age and gender and no improvement
in the MRCS scores compared with ICU discharge. Handgrip
strength at hospital discharge was positively correlated with
the 6MWD and negatively correlated with the hospital LOS.
In this study, with the exception of three cases, patients
were provided some type of mobility therapy during their ICU
LOS, whether on MV or not. This is in line with current
knowledge that mobilization therapy is feasible and safe in
mechanically ventilated ICU patients [2,5,18,30]. Considering
burn ICU patients, there is a scarcity of data on the safety and
feasibility of mobilization therapy in this unique population.
Deng et al. [31] showed in a retrospective analysis that mobility
training improves outcomes compared to only passive range of
motion (ROM) therapy; however, they did not explore the type
n and frequency of activities performed during MV or with
spontaneous breathing conditions. Although a high preva-
71
lence of mobilization therapy has been observed, most of the
49
40
therapy provided (85%) was related to in bed exercises and 58%
34 of the patients performed OOB activities at least once before
29 ICU discharge. During MV, only 7 patients (9%) performed OOB
26 activities accounting for 0.7% of all activities provided. This
26 finding is similar to previous studies reporting that OOB
25
exercises in MV patients are not usual ranging from 0 to 16% of
24
all activities [32–34]. Also, the presence of an endotracheal tube
19
11 (ETT) could be a barrier itself for mobilization as OOB exercises
11 were more likely to be provided in non-mechanically ventilat-
4 ed compared to MV patients as also reported [32]. Even though,
the level of activities furnished was low and the high
prevalence of in bed exercises (mostly passive) during MV
could be the reason for the absence of improvement on
outcomes in our study after adding one session of mobility
therapy per day (24-h shift). In fact, the absence of a continuous
progression of the type of exercise and mobilization therapy
has already being reported and reflects the lack of current
standards for care in burn ICU patients, as reported in a recent
survey [35].
Known barriers for mobilization therapy are sedation,
severity of the patient, presence of an endotracheal tube
and limited time for assistance (nursing and physiotherapy)
[36–40]. Even considering a different population, results here
presented are partially in line with previous studies. In fact,
JBUR 5899 No. of Pages 8
6 burns xxx (2019) xxx –xxx
hemodynamic instability was the main reported barrier and
could be related to severity of the patient, percentage of full
thickness injury and presence and need of the EET. Indeed, 70%
of MV patients were on vasopressor agent infusion. However,
so far, there is no consensus for the threshold of vasopressor
dose that is safe for mobilization [36]. Limited time for
assistance was also reported as a barrier. The routine of
nursing care in this unit, consisted of daily prolonged bed
bathing and dressing changes that could expend a couple of
hours or more. This fact associated with other routine care in
the ICU such as medical and surgical procedures leave the
physiotherapists with restricted time to assist patients with
mobility therapy. A daily interprofessional round discussing
the needs of each team and how to better synchronize the
tasks can partially solve this issue. Deep sedation, the most
prevalent barrier, was not reported by the staff. One explana-
tion for this is that passive mobilization was considered a
mobility therapy, therefore, it did not prevent PT staff from
providing it to sedated patients. Grafting prevalence as a
reported barrier was very low (5.5% of the cases). That result
was not expected since a grafted area cannot be mobilized for
at least seven days after the graft. In this case, although not a
reported barrier, it prevented more active and OOB exercises
due to the grafts themselves and limb or thoracic dressing.
Finally, although some barriers were described for mobility
therapy, they did not prevent the physiotherapists from
providing respiratory care to the patients. As described
elsewhere, similar to respiratory therapists in the USA,
physiotherapists in Brazil are more familiar with respiratory
therapy than with mobility therapy [18,41].
ICUAW incidence ranges from 25 to 100% [42] and is
approximately 20% in burn critical care patients [43]. In the
present study, 21% of patients presented ICUAW; however,
these data should be considered with caution. Weakness was
diagnosed using the MRCS score, which was evaluated 2–3
times during the week for each patient according to patient
availability. Nevertheless, this evaluation was not performed
in 22 patients due to the following: patients died before
regaining consciousness (n = 17); patients had short ICU LOSs
(n = 3); and patients had multiple limb dressings and severity
(n = 2). It is also interesting to note that in this specific
population, skin grafts, long-term multiple dressings and pain
are very common, which probably interferes with MRCS
evaluation. Additionally, in some cases, this was not possible
due to amputation or thoracic dressings. Cubitt et al. [43]
reported ICUAW values of 20%, although the method of
diagnosis is not clear.
The 6MWT is used for evaluating functional status at ICU
discharge. Borges et al. [44] reported a functional decrease of
50% at ICU discharge in survivors of sepsis. Waters et al. [45]
reported that after a critical illness or ALI event, 6MWD is
predicted to be only 27% for age and gender. In the present
study, survivors presented 62% functionality for the predicted
age and gender. In this population, patients were approxi-
mately 10 years younger with less comorbidities, although
they presented similar ICU LOSs and MV durations. Addition-
ally, the evaluation here described was performed at hospital
discharge and not at ICU discharge, which could be a bias since
patients could participate in more functional activities after
ICU discharge. Notably, only 20 out of 32 patients performed
Please cite this article in press as: T.B. de Figueiredo, et al., Mobilization practices for patients with burn injury in critical care, Burns
(2019), https://doi.org/10.1016/j.burns.2019.07.037
the 6MWT (Fig. 1). This research found a positive correlation
between the 6MWD and the handgrip strength evaluation and
a negative correlation between handgrip strength and hospital
length of stay. Handgrip strength evaluation has previously
been shown to correlate with 6MWD and VO2 in home-
dwelling patients [46], lower limb strength, calf cross-sectional
area [47] and ICU mortality [48]. Lower handgrip isometric
strength is associated with poor mobility, suggesting that
sarcopenia due to aging is generalized throughout the whole
body [47]. The same pattern could be used to explain our
results, as the ICUAW presented in our patients was
characterized by general, bilateral and similar muscle weak-
ness. Considering the reported barriers to using the MRCS in
our specific population, one possible option could be the
handgrip strength evaluation for screening ICUAW, although
the present study was not designed to support this suggestion.
Furthermore, one should note that 40% of the handgrip
measure was not performed in the best scenario considering
that eight patients presented burn lesions on the dominant
hand and another two performed the test with the non-
dominant hand. Consequently, this result should also be
considered with caution.
Some limitations of our study should be addressed. (1)
During data collection (after 5 months), physiotherapy
treatment was extended to a 24-h shift instead of a regular
12-h shift due to an administrative change in the hospital.
Indeed, an extra mobility session (12-h shift vs 24-h shift) was
not translated into a better functional outcome, although our
study was not originally design to address this question,
probably due to the low mobility level delivered and deep
sedation; (2) Data collection was performed using clinical
charts and daily interviews with the staff, and patient
treatment was not supervised by the investigators, which
could lead to a bias in reported events and missing data.
Nevertheless, it was a four-bed ICU, and all the staff, including
nurses and physicians, and charts were evaluated daily. It is
not expected that a high level of mobility therapy had been
performed unseen. (3) Although not reported by the staff,
sedation was the most prevalent barrier for providing active
mobility therapy during MV; (4) Unfortunately, we do not have
handgrip strength evaluation data for patients during their ICU
stay. Indeed, the benefits of handgrip strength to evaluate
muscle strength were known, but its use was not routine in
that ICU. Additionally, the MRCS is one of the most common
tests studied and clinically performed in the ICU; (5) Finally,
not all the patients agreed on performing hospital discharge
evaluation and this could be a source of potential response bias
in our findings, however no clinical or demographic character-
istics difference comparing those performing and not per-
forming the tests were found.
In conclusion, it was observed that mobilization therapy in
a burn ICU is also feasible and safe, although it has been
characterized by a low level of mobility during mechanical
ventilation. This scenario may be related to the dynamics of
this ICU, where sedation, although not reported, is the most
prevalent barrier and prevented more active exercises. Also,
related to this, the lack of stablished standards for care of ICU
patients with burns can hinder their evolution to more active
and functional activities during their ICU stay. Survivors
presented low functional status at hospital discharge, which
JBUR 5899 No. of Pages 8
burns xxx (2019) xxx –xxx
may be related to the inherent difficulties of this population
(due to injuries and dressings) and even the low prevalence of
OOB exercises during the period of hospital internment.
Conflict of interest
None
REFERENCES
[1] Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L,
et al. Early activity is feasible and safe in respiratory failure
patients. Crit Care Med 2007;35(January (1)):139–45.
[2] Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L,
et al. Early intensive care unit mobility therapy in the
treatment of acute respiratory failure. Crit Care Med 2008;36
(August (8)):2238–43.
[3] Needham DM, Korupolu R. Rehabilitation quality
improvement in an intensive care unit setting:
implementation of a quality improvement model. Top Stroke
Rehabil 2010;17(July–August (4)):271–81.
[4] Perme C, Nalty T, Winkelman C, Kenji Nawa R, Masud F. Safety
and efficacy of mobility interventions in patients with femoral
catheters in the ICU: a prospective observational study.
Cardiopulm Phys Ther J 2013;24(June (2)):12–7.
[5] Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik
AJ, Esbrook CL, et al. Early physical and occupational therapy
in mechanically ventilated, critically ill patients: a randomised
controlled trial. Lancet 2009;373(May (9678)):1874–82.
[6] Sricharoenchai T, Parker AM, Zanni JM, Nelliot A, Dinglas VD,
Needham DM. Safety of physical therapy interventions in
critically ill patients: a single-center prospective evaluation of
1110 intensive care unit admissions. J Crit Care 2014;29(June
(3)):395–400.
[7] Bartolo M, Bargellesi S, Castioni CA, Bonaiuti D, Antenucci R,
Benedetti A, et al. Early rehabilitation for severe acquired brain
injury in intensive care unit: multicenter observational study.
Eur J Phys Rehabil Med 2016;52(February (1)):90–100.
[8] Bartolo M, Bargellesi S, Castioni CA, Intiso D, Fontana A,
Copetti M, et al. Mobilization in early rehabilitation in
intensive care unit patients with severe acquired brain injury:
an observational study. J Rehabil Med 2017;49(November
(9)):715–22.
[9] Olkowski BF, Shah SO. Early mobilization in the Neuro-ICU:
how far can we go? Neurocrit Care 2017;27(August (1)):141–50.
[10] Ramos Dos Santos PM, Aquaroni Ricci N, Aparecida Bordignon
Suster E, de Moraes Paisani D, Dias Chiavegato L. Effects of
early mobilisation in patients after cardiac surgery: a
systematic review. Physiotherapy 2017;103(March (1)):1–12.
[11] Jeschke MG. Postburn hypermetabolism: past, present, and
future. J Burn Care Res 2016;37(March–April (2)):86–96.
[12] Duke JM, Randall SM, Fear MW, Boyd JH, Rea S, Wood FM.
Understanding the long-term impacts of burn on the
cardiovascular system. Burns 2015;42(March (2)):366–74.
[13] Grisbrook TL, Reid SL, Edgar DW, Wallman KE, Wood FM, Elliott
CM. Exercise training to improve health related quality of life
in long term survivors of major burn injury: a matched
controlled study. Burns 2012;38(December (8)):1165–73.
[14] Willis CE, Grisbrook TL, Elliott CM, Wood FM, Wallman KE, Reid
SL. Pulmonary function, exercise capacity and physical
activity participation in adults following burn. Burns 2011;37
(December (8)):1326–33.
[15] Brusselaers N, Monstrey S, Vogelaers D, Hoste E, Blot S. Severe
burn injury in Europe: a systematic review of the incidence,
etiology, morbidity, and mortality. Crit Care 2010;14(5):R188.
Please cite this article in press as: T.B. de Figueiredo, et al., Mobilization practices for patients with burn injury in critical care, Burns
(2019), https://doi.org/10.1016/j.burns.2019.07.037
7
[16] DeKoning EP, Hakenewerth A, Platts-Mills TF, Tintinalli JE.
Epidemiology of burn injuries presenting to North Carolina
emergency departments in 2006–2007. Burns 2009;35
(September (6)):776–82.
[17] de Campos EV, Park M, Gomez DS, Ferreira MC, Azevedo LC.
Characterization of critically ill adult burn patients admitted
to a Brazilian intensive care unit. Burns 2014;40(December
(8)):1770–9.
[18] Pires-Neto RC, Lima NP, Cardim GM, Park M, Denehy L. Early
mobilization practice in a single Brazilian intensive care unit. J
Crit Care 2015;30(October (5)):896–900.
[19] Metnitz PG, Metnitz B, Moreno RP, Bauer P, Del Sorbo L,
Hoermann C, et al. Epidemiology of mechanical ventilation:
analysis of the SAPS 3 database. Intensive Care Med 2009;35
(May (5)):816–25.
[20] Jones AE, Trzeciak S, Kline JA. The sequential organ failure
assessment score for predicting outcome in patients with
severe sepsis and evidence of hypoperfusion at the time of
emergency department presentation. Crit Care Med 2009;37
(May (5)):1649–54.
[21] Tobiasen J, Hiebert JM, Edlich RF. The abbreviated burn
severity index. Ann Emerg Med 1982;11(May (5)):260–2.
[22] Giretzlehner M, Dirnberger J, Owen R, Haller HL, Lumenta DB,
Kamolz LP. The determination of total burn surface area: how
much difference? Burns 2013;39(September (6))1107–13, doi:
http://dx.doi.org/10.1016/j.burns.2013.01.021 Epub 2013 Apr 6.
2013.
[23] Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O’Neal PV, Keane
KA, et al. The Richmond Agitation-Sedation Scale: validity and
reliability in adult intensive care unit patients. Am J Respir Crit
Care Med 2002;166(November (10)):1338–44.
[24] Hodgson C, Needham D, Haines K, Bailey M, Ward A, Harrold
M, et al. Feasibility and inter-rater reliability of the ICU
mobility scale. Heart Lung 2014;43(January–February (1)):19–24.
[25] Kawaguchi YMF, Nawa RK, Figueiredo TB, Martins L, Pires-
Neto RC. Perme intensive care unit mobility score and ICU
mobility scale: translation into portuguese and cross-
cultural adaptation for use in Brazil. J Bras Pneumol
2017;42:429–34.
[26] Hermans G, Clerckx B, Vanhullebusch T, Segers J, Vanpee G,
Robbeets C, et al. Interobserver agreement of Medical Research
Council sum-score and handgrip strength in the intensive care
unit. Muscle Nerve 2012;45(January (1)):18–25.
[27] Committee A. ATS statement: guidelines for the six-minute
walk test. Am J Respir Crit Care Med 2002;166(July (1)):111–7.
[28] Dourado VZ, Antunes LC, Tanni SE, de Paiva SA, Padovani CR,
Godoy I. Relationship of upper-limb and thoracic muscle
strength to 6-min walk distance in COPD patients. Chest
2006;129(March (3)):551–7.
[29] Enright PL, Sherrill DL. Reference equations for the six-minute
walk in healthy adults. Am J Respir Crit Care Med 1998;158
(November (5 Pt 1)):1384–7.
[30] Denehy L, Skinner EH, Edbrooke L, Haines K, Warrillow S,
Hawthorne G, et al. Exercise rehabilitation for patients with
critical illness: a randomized controlled trial with 12 months of
follow-up. Crit Care 2013;17(July (4)):R156.
[31] Deng H, Chen J, Li F, Li-Tsang CW, Liu Q, Ma X, et al. Effects
of mobility training on severe burn patients in the BICU:
a retrospective cohort study. Burns 2016;42(November
(7)):1404–12.
[32] Jolley SE, Moss M, Needham DM, Caldwell E, Morris PE, Miller
RR, et al. Point prevalence study of mobilization practices for
acute respiratory failure patients in the United States. Crit
Care Med 2017;45(February (2))205–15, doi:http://dx.doi.org/
10.1097/CCM.0000000000002058 2016.
[33] Nydahl P, Ruhl AP, Bartoszek G, Dubb R, Filipovic S, Flohr HJ,
et al. Early mobilization of mechanically ventilated patients: a
1-day point-prevalence study in Germany. Crit Care Med
2014;42(May (5)):1178–86.
JBUR 5899 No. of Pages 8
8 burns xxx (2019) xxx –xxx
[34] Berney SC, Harrold M, Webb SA, Seppelt I, Patman S, Thomas
PJ, et al. Intensive care unit mobility practices in Australia and
New Zealand: a point prevalence study. Crit Care Resusc
2013;15(December (4)):260–5.
[35] Cambiaso-Daniel J, Parry I, Rivas E, Kemp-Offenberg J, Sen S,
Rizzo JA, et al. Strength and cardiorespiratory exercise
rehabilitation for severely burned patients during intensive
care units: a survey of practice. J Burn Care Res 2018(March).
[36] Dubb R, Nydahl P, Hermes C, Schwabbauer N, Toonstra A,
Parker AM, et al. Barriers and strategies for early mobilization
of patients in intensive care units. Ann Am Thorac Soc 2016;13
(May (5)):724–30.
[37] Jolley SE, Regan-Baggs J, Dickson RP, Hough CL. Medical
intensive care unit clinician attitudes and perceived barriers
towards early mobilization of critically ill patients: a cross-
sectional survey study. BMC Anesthesiol 2014;14:84.
[38] Leditschke IA, Green M, Irvine J, Bissett B, Mitchell IA. What are
the barriers to mobilizing intensive care patients? Cardiopulm
Phys Ther J 2012;23(March (1)):26–9.
[39] Mendez-Tellez PA, Dinglas VD, Colantuoni E, Ciesla N,
Sevransky JE, Shanholtz C, et al. Factors associated with
timing of initiation of physical therapy in patients with acute
lung injury. J Crit Care 2013;28(December (6)):980–4.
[40] Morris PE. Moving our critically ill patients: mobility barriers
and benefits. Crit Care Clin 2007;23(January (1)):1–20.
[41] Kollef MH. Evaluating the value of the respiratory therapist:
where is the evidence? Focus on the barnes-jewish hospital
experience. Respir Care 2017;62(December (12)):1602–10.
Please cite this article in press as: T.B. de Figueiredo, et al., Mobilization practices for patients with burn injury in critical care, Burns
(2019), https://doi.org/10.1016/j.burns.2019.07.037
[42] Kress JP, Hall JB. ICU-acquired weakness and recovery from
critical illness. N Engl J Med 2014;371(July (3)):287–8.
[43] Cubitt JJ, Davies M, Lye G, Evans J, Combellack T, Dickson W,
et al. Intensive care unit-acquired weakness in the burn
population. J Plast Reconstr Aesthet Surg 2015;69(May (5)):
e105–9.
[44] Borges RC, Carvalho CR, Colombo AS, da Silva Borges MP,
Soriano FG. Physical activity, muscle strength, and exercise
capacity 3 months after severe sepsis and septic shock.
Intensive Care Med 2015;41(August (8)):1433–44.
[45] Waters A, Hill K, Jenkins S, Johnston C, Mackney J. Discordance
between distance ambulated as part of usual care and
functional exercise capacity in survivors of critical illness
upon intensive care discharge: observational study. Phys Ther
2015;95(September (9)):1254–63.
[46] Zhang Q, Lu H, Pan S, Lin Y, Zhou K, Wang L. 6MWT
performance and its correlations with VO(2) and handgrip
strength in home-dwelling mid-aged and older chinese. Int J
Environ Res Public Health 201714(May (5)).
[47] Lauretani F, Russo CR, Bandinelli S, Bartali B, Cavazzini C,
Di Iorio A, et al. Age-associated changes in skeletal muscles
and their effect on mobility: an operational diagnosis
of sarcopenia. J Appl Physiol (1985) 2003;95(November
(5)):1851–60.
[48] Ali NA, O’Brien Jr JM, Hoffmann SP, Phillips G, Garland A, Finley
JC, et al. Acquired weakness, handgrip strength, and mortality
in critically ill patients. Am J Respir Crit Care Med 2008;178
(August (3)):261–8.