burns46(2020)1193 1200

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Assessing the effects of 6 weeks of intermittent aerobic

exercise on aerobic capacity, muscle fatigability, and quality
of life in diabetic burned patients: Randomized control
study
a,b, a,c
Walid Kamal Abdelbasset *, Nermeen Mohamed Abdelhalim
a Department of Physical Therapy and Health Rehabilitation, College of Applied Medical Sciences, Prince Sattam Bin Abdulaziz University, Alkharj,
Saudi Arabia
b Department of Physical Therapy, Kasr Al-Aini Hospital, Cairo University, Giza, Egypt
c Department of Physical Therapy, New Kasr El-Aini Teaching Hospital, Faculty of Medicine, Cairo University, Egypt

articleinfo abstract

Article history: Background: Both burn and diabetes mellitus (DM) cause functional and psychosocial disabilities. A low-cost
Accepted 22 December 2019 and safe approach is greatly required to reduce these disabilities and the effects of aerobic exercise have
generated varied evidence to date. The aim of the study was to explore the effects of 6 weeks of intermittent
aerobic exercise (IAE) on aerobic capacity, muscle fatigability, and quality of life (QoL) in diabetic burned
patients (DBPs).
Keywords: Methods: The study design was a prospective, single-blind, randomized controlled trial. Between March2018
Burn and July2019 thirty-six(22malesand16 females)diabetic burnedpatients were included in the study, their age
Diabetes mellitus ranged 35 55 years. They were clinically diagnosed with type 2 DM and total body surface area (TBSA) was
Intermittent aerobic exercise 15 30%. The participants were randomly assigned to theIAE group (n=18)and controls (n=18). Aerobic
Aerobic capacity capacity,muscle fatigability,and QoL were assessed initially and repeated after 6 weeks of intervention.
Muscle fatigability
Quality of life Results: Initial data demonstrated non-significant differences between the IAE and control groups (p > 0.05).
Comparing pre- and post-intervention outcomes showed significant improvement of VO 2max, muscle
fatigability, QoL domains in the IAE group after 6 weeks intervention (p < 0.05) and non-significant changes
in the control group (p > 0.05). The IAE group showed statistically significant improvement more than the
control group in all outcome measures (p < 0.05).
Conclusions: 6 weeks of intermittent aerobic exercise is an effective alternative modality to improve aerobic
capacity, muscle fatigability, and QoL in DBPs. Adherence to intermittent aerobic
exerciseshouldbepracticable intomainstreamclinical interventionforthosepatients. © 2019 Elsevier Ltd and
ISBI. All rights reserved.

Abbreviations: DM, diabetes mellitus; IAE, intermittent aerobic exercise; QoL, quality of life; DBPs, diabetic burned patients; TBSA, total body surface area;
ADL, activity daily living; BP, blood pressure; ICU, intensive care unit; BMI, body mass index; HbA1c, glycosylated haemoglobin; WHO, World Health
Organization; VO2max, maximum oxygen uptake; EMG, electromyography; MVC, maximum voluntary contraction; B-BSHS, brief burns specific health scale.

* Corresponding author at: Department of Physical Therapy and Health Rehabilitation, college of Applied Medical Science, Prince Sattam Bin Abdulaziz
University, Alkharj, Saudi Arabia.
E-mail address: walidkamal.wr@gmail.com (W.K. Abdelbasset).
https://doi.org/10.1016/j.burns.2019.12.013
0305-4179/© 2019 Elsevier Ltd and ISBI. All rights reserved.

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1194 burns46(2020)1193
1. Introduction
Globally, burn injuries are accompanied by numerous com-plications of
different organs influence healthy persons. Subsequently, the patients
suffered from diabetes mellitus, vascular disorders, peripheral
neuropathies, and immune deficiency may be subjected to great
destructive effects on their health [1].
In the past burns increased mortality rate and many burned patients’
loss their activity of daily life (ADL) [2]. Currently, advancement in
management and care of burned patients leads to increase survival rates,
reduce complications, and improve quality of life (QoL) [3]. Also, the
improvement of physical therapy rehabilitation plays a vital role in
reducing physical and functional deficits [4]. Diabetes mellitus (DM) is
the commonest metabolic disease which identified by high glucose level
in the blood as a result of insulin secretion dysfunction, abnormal insulin
effect, or both [5]. DM is similar to burn injuries that impact negatively on
different organs like cardiovascular complications, peripheral
neuropathies, and impairments of immune system [6].
Diabetic burned patients (DBPs) may predispose to more
deteriorations and complications as diabetic angiopathy result from
damaged perfusion, diabetic immunodeficiency attends to infection, the
spread of sepsis, urinary tract infection [7], cellulitis, renal failure [8],
increased time spent in the hospital, and many admissions to burn
intensive care unit (ICU) [9].
Burns may also diminish lung function and reduce aerobic capacity
lasting for long times [10]. Also, burns have negative effects on the
cardiovascular system with more cardiac output, less ventilation, and
increase heart rate until two years after burn injury [11]. There is an
indirect relationship between the onset of DM and aerobic capacity. Both
physical activity and aerobic capacity are independently accompanied by
the hazard of developing type 2 DM [12].
Burn injuries increasethe basalmetabolic rate with minimal clinical
effects and have been manifested for a long period with large burns,
probably lead to persistence of fatigue [13]. Fatigue is intensely related to
minor QoL and major work-related disability, and the danger of acquiring
moderate to severe fatigue after burn injuries [14]. In diabetic patients,
fatigue is common with orwithout detectivepathological disordersand is
correlated to decreaseADL [15]. Fatigue inDM maybe because of
physiological factors such as hypo- or hyperglycemia, psycho-logical
factors such as depression or anxiety, or lifestyle problems such as
decreased physical activity or obesity [16].
Contribution in organized resisted or aerobic exercises program has
different effects, such as the decreased tendency for surgical procedures to
release hypertrophic scar, increased muscle power and muscle bulk [17].
The definitive purpose of physical therapy rehabilitation with burned
patients is to aid in returning functional capability [18]. Furthermore,
exercises can aid diabetic patientsto improveaerobic
capacity,increasemuscle power, enhance blood-glucose level, reduce
insulin resistance, decrease cholesterol level, and decrease blood pressure
(BP) [19]. Prior studies have identified the efficacy of aerobic exercise on
aerobic capacity [20], ventilatory markers [21], psychological conditions
[22], and metabolic disorders [23] but particularly, no previous studies
examined its effects on the DBPs.
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1200
It would appear instinctive that diabetic patients who suffer from
burns would have worse prognosis than non-diabetic patients. Despite a
lack of experimental studies struggling to evaluate the impacts of resisted
and aerobic exercises programs on DBPs, to the best of our knowledge,
there have been no studies to date assessing aerobic capacity, muscle
fatigability, and QoL in DBPs. It is a great challenge to physical therapists
who handling with DBPs to find appropri-ate exercises program to restore
functional abilities and to improve QoL. The aim of this study was to
explore the effects of 6 weeks intermittent aerobic exercises on aerobic
capacity, muscle fatigability, and QoL in DBPs.
2. Material and methods
2.1. Subjects
The study design was a prospective, single-blind, randomized controlled
trial. Between March 2018 and July 2019, thirty-six DBPs were included
in the study in the tertiary hospital of Cairo University, their age ranged
35 55 years. They were clinically diagnosed with type 2 DM
(glycosylated haemoglobin (HbA1c) 6.5%) based on the
recommendations of world health organization (WHO) [24] and total
body surface area (TBSA) was 15 30% measured by rule of nines, depth
of burn (partial to full-thickness burn), causes of burn (flame, scald,
chemical), surgical procedures (none, split-thickness skin graft, full-
thickness skin graft), and with a minimum of 4 months after burn injuries
with traditional physical therapy program until complete recovery.
Avoiding type II error, the patients were randomly allocated to two equal
groups, 18 in each group. Any patient who suffered from burns in head,
neck, perineum, hands, and feet, inhalation injury, psychiatric disorders,
paralysis, and congenital anomalies was excluded. Before initiating the
study, each patient was well-versed about the study procedures and signed
an inscribed informed consent. The proposal of the study was approved by
the localized research ethical committee of the Cairo University Hospitals
(number PT-018-029) complying with the Helsinki Declaration.
2.2. Sample size and randomization
This present study decided a sample size of thirty-one patients using G*
power 3.0.10 software (University Dusseldorf, Dus-seldorf, Germany)
with 80% power, 0.05 margin of error, and 0.5 effect size. Hence, this
study comprised thirty-six patients to account for a 20% drop-out. The
thirty-six patients were assigned into two groups. The allocation was
performed before intervention by a blinded physiotherapist who was not
aware of the study procedure using a random number generating table.
The first group (n = 18) received intermittent aerobic exercise (IAE) while
the second group (n = 18) did not conduct the IAE program as a control.
2.3. Assessment
2.3.1. Initial assessment
Demographic and clinical features of the study participants including age,
gender, body mass index (BMI), glycosylated
 burns46(2020)1193 1200
haemoglobin (HbA1c), TBSA, depth of burn, causes of burn, surgical
intervention and the period after burn injuries were recorded before
initiating the study. Aerobic capacity, muscle fatigability, and QoL were
initially assessed and repeated after 6 weeks at the end of the study
intervention.
2.3.2. Aerobic capacity
All patients conducted a progressive exercise test on the treadmill
(COSMED, Rome, Italy) in accordance with the Bruce protocol treadmill
stress test to collect the maximum oxygen uptake (VO 2max) using the
proper VO2max formula for non-athletes [25]. Each patient was
encouraged to provide maximal effort throughout the test.
2.3.3. Muscle fatigability
Quadriceps intermittent fatigue test was performed using
Electromyography (EMG) (Dantec Keypoint Focus 6 chan-nels, Natus
medical incorporated, Pleasanton, USA). The position of the patient was
straighter back with hip flexion of 90 and knee flexion of 60 . Normal
values had been previously developed [26]. Before initiating the
assessment, patients instructed to perform 5 s quadriceps sub maximum
isometric contractions (warming-up) to be acquainted with soundtrack
commendations and visual feedback. After warming-up, patients were
instructed to perform 3 maxi-mum voluntary contractions (MVC) 30 s
separately. Then the neuromuscular assessment was executed initiating
with 5 s MVCs overlaid with one hundred Hz (Db 100) and ten Hz (Db10)
doublet and tracked after 2 s (relaxation) by two potential doublets
transmitted 4 s separately. The second MVC was performed after 15 s rest
with overlaid doublet tracked after 2 s by 1 potential doublet in the muscle
during relaxation. After this initial neuromuscular assessment, the patients
were instructed to conduct the fatigue assignment which com-prised ten
intermittent sets of submaximal isometric contraction (5 on/5 off)
initiating first set with 10% MVC and elevated each set with 10% MVC
until failing to perform the task. When the patient impotent to sustain the
reached force >2.5 s for five sec after ending the set 10-contraction post-
ten minutes of recovery, the same neuromuscular assessment was
repeated.
2.3.4. Quality of life
The validated brief burns specific health scale (B-BSHS) was used to
assess QoL in the DBPs. B-BSHS is 40-item generic questionnaire that
assesses QoL in 9 dimensions (simple abilities, hand function, heat
sensitivity, interpersonal rela-tionships, work, treatment of regimens,
affect, sexuality, and body image)regarding the physical and psychosocial
difficul-ties.The B-BSHS is consisted of 5 points of severity ranged from
0 (extreme) to 4 (none) at all items [27,28]. The mean value of domain
score was recorded and the higher scores regard a better health condition.
2.4. Intervention
All participants of the study groups were commended to regularly
undergo home exercise for 6 weeks. The quantifiable obligation of
frequently and properly undergoing the home exercise was clearly
detailed to each participant.
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1195
2.4.1. Exercise program
The aerobic exercise group conducted 6 weeks intermittent aerobic
exercise (IAE) at moderate intensity, according to the guidelines of
cardiovascular prevention [29]. The program was comprised of three
weekly sessions for 6 weeks; each session was continued for nearly 40
min. The exercise intensity was organized by distance and time covered.
Each session was commenced with 5 10 min warm-up at 50 60% of
maximum heart rate (maxHR). IAE comprised of 30 min of training/
relaxation. Each participant was instructed to run for two minutes at a
workload intensity of 70% of the velocity at maximum oxygen uptake,
followed by one-minute relaxation. This process was iterated during the
session period for almost 30 min. Over the period of the study program,
the intensity of exercise was gently elevated every two weeks in
accordance with the patient’s ability under supervision of an experienced
and specialized physiotherapist.
2.5. Statistical analysis
All data were collected and analyzed using SPSS software version 25
(IBM Corp, Armonk, NY, USA). Descriptive statistics were used to
examine the demographic and clinical character-istics of the study
participants. The Kolmogorov Smirnov test was utilized to assess the
normally distribution of the collected data. The student's t-test was used to
assess the changes of the normal distributed data (unpaired t-test for
intergroup and paired t-test for intragroup) while the Wilcoxon test was
used to assess the changes of the non-normal distributed data. Data were
analyzed as a mean standard deviation. The significant level was accepted
at a p-value <0.05.
3. Results
The present study screened 44 consecutive patients for eligibility in this
randomized control study. Eight of these patients were not assigned for
allocation (5 did not encounter the inclusive criteria and 3 denied to
conduct the study program). Fig. 1 detailed the flow chart of the study.
The mean values of the initial data were analyzed and demonstrated non-
significant differences between the IAE and control groups (p > 0.05) as
detailed in Table 1.
Comparing between pre- and post-intervention outcomes showed
significant improvement of the mean values of VO 2max, muscle
fatigability, B-BSHS domains in the IAE group after a 6-wee intervention
(p < 0.05) whereas non-significant changes for any outcome were
demonstrated in the control group (p > 0.05) as detailed in Table 2.
Comparison between the IAE and control groups at the end of the study
intervention, the IAE group showed statistically significant improvement
more than the control group in all outcome measures (p < 0.05) as detailed
in Table 3.
4. Discussion
The aim of the study was to investigate the effects of 6 weeks of IAE on
aerobic capacity, muscle fatigability, and QoL in DBPs hypothesizing that
IAE could improve those measures in DBPs.
1196 burns46(2020)1193 1200

Fig. 1 – The flow chart of the study.

The results of the current study showed that aerobic capacity, muscle
fatigability, and functional & psychosocial domains of B-BSHS were
significantly improved in DBPs when compared with that of a matched
control group.
The combination of burns with DM leads to a high morbidity rate. DM
has considered a risk factor affecting burns trauma because of disturbed
sensation as polyneurop-athy and decreased acuity of vision as
retinopathy. These issues may denote that diabetic patients may not
distinguish and/or stay away from sources of burns. Therefore, they are
more vulnerable to critical burn injuries with various compli-cations that
require special management with intensive rehabilitation programs [30].
The dissipation of thermal energy through different skin layers
depends on the thermal conductivity and vasodilatation of the affected
tissues [31]. Previous studies established that DM is characterized by
decreasing transmissions of thermal energy to the adjacent skin tissues
besides little hyperaemic reactions [32]. The reduction of the thermal
conductivity with diabetic patients results from the thin dermis, thick
hypoder-mis, and impairment of the heat-regulating center [33].
joined the IAE program are more likely to get QoL advantages such as
improved physical and psychosocial difficulties that are critical in
restoring ADL. Additionally, IAE has various possible impacts, such as
increased heat sensitivity, interper-sonal relationships, and work
capability.
The preceding studies assessed the influences of aerobic exercises on
burned patients [34] and diabetic patients [35] separately. In agreements
with our results, one of the previous studies within burned patients
reported that decreasing in exercise capabilities characterized by lowering
Vo2max than normal before the treatment intervention [36]. Suman et al.,
showed that burned patients after thermal injury suffered from
disturbances in cardiopulmonary system and reported an enhancement in
exercise performance, treadmill training time, balance, and stability of
burned patients after 12 weeks of aerobic training and conventional
exercises. The improve-ment of Vo2max and Berg Balance Scale (BBs) in
the study group paralleled to the sham group that may result from more
blood supply to muscles owing to maximum cardiac output, increased
vascularization and activity of the oxidative enzyme [37].

The present study demonstrated that aerobic exercises play a vital role Earlier studies have indicated the critical association between aerobic
in physical therapy rehabilitation for DBPs. By contributing in 6 weeks of capacity and the occurrence of type 2 DM independent of physical fitness
IAE at moderate intensity, there was improvement of Vo 2max, MVC, and rates [12,38]. Numerous of underlying mechanisms may be implicated by
B-BSHS. Hence, DBPs who the

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 burns46(2020)1193 1200 1197

Table 1 – Initial data of the study.

Variables IAE group (n = 18) CG (n = 18) p-Value

Gender (M/F) 12/6 14/4 0.46

Age (years) 47.8 6.2 46.3 6.7 0.49
2
BMI (kg/m ) 27.3 2.5 26.8 2.3 0.54
HbA1c (%) 6.8 1.2 7.1 1.3 0.48
Medications od DM n(%)
Metformin 11(61) 12(67) 0.72
Gliptins 8(44) 5(28)
Statins 7(39) 8(44)
Total burn area (TBSA%) 26.4 3.5 25.7 4.1 0.58
Causes of injury n (%)
Flame 7(39) 5(28) 0.83
Scald 8(45) 9(50)
Chemical 3(16) 4(22)
Depth of burn n (%)
Partial thickness 5(28) 4(22) 0.84
Full thickness 7(39) 6(33)
Partial and full thickness 6(33) 8(45)
Skin graft (yes/no n (%)) 11(61)/7(39) 13(72)/5(28) 0.48
Time since burn (months) 5.7 1.4 6.2 1.7 0.34
1 1
VO2max (mL/kg /min ) 27.46 3.32 25.82 3.26 0.14
Quadriceps muscle MVC (Nm) 167.6 43.14 178.3 47.52 0.48
B-BSHS
Simple abilities 3.04 0.81 3.15 0.83 0.69
Hand function 3.19 0.65 3.21 0.71 0.93
Heat sensitivity 1.62 0.92 1.59 0.88 0.92
Interpersonal relationship 3.21 0.71 3.32 0.67 0.64
Work 2.41 0.87 2.45 0.94 0.89
Treatment regimens 3.14 0.83 3.11 0.84 0.91
Affect 3.19 0.57 3.13 0.52 0.74
Sexuality 3.32 0.64 3.35 0.62 0.89
Body image 2.23 1.41 2.25 1.37 0.99
IAE: intermittent aerobic exercise; CG: control group; BMI: body mass index; HbA1c: glycosylated haemoglobin; DM: diabetes mellitus; TBSA:
total body surface area; VO2max: maximum oxygen uptake; MVC: maximum voluntary contraction; B-BSHS: brief-burn specific health scale.

Table 2 – The differences of mean values pre- and post- intervention for IAE and control groups.

Variables IAE group (n = 18) CG (n = 18)

Pre- Post- p-Value Pre- Post- p-Value

HbA1c (%) 7.6 1.2 5.0 0.4 0.04 7.1 1.3 6.9 1.2 0.63
VO2max (mL/kg 1/min 1) 27.46 3.32 38.71 4.1 <0.001 25.82 3.26 27.2 3.33 0.22
Quadriceps muscle MVC (Nm) 167.6 43.14 232.4 51.2 0.002 178.3 47.52 189 45.6 0.49
B-BSHS
Simple abilities 3.04 0.81 3.72 0.99 0.03 3.15 0.83 3.09 0.81 0.83
Hand function 3.19 0.65 3.67 0.23 0.006 3.21 0.71 3.24 0.69 0.89
Heat sensitivity 1.62 0.92 3.12 0.65 <0.001 1.59 0.88 1.63 0.91 0.89
Interpersonal relationship 3.21 0.71 3.77 0.32 0.004 3.32 0.67 3.29 0.64 0.89
Work 2.41 0.87 3.23 0.52 0.002 2.45 0.94 2.51 0.97 0.85
Treatment regimens 3.14 0.83 3.84 0.45 0.003 3.11 0.84 3.08 0.81 0.91
Affect 3.19 0.57 3.71 0.33 0.002 3.13 0.52 3.11 0.55 0.91
Sexuality 3.32 0.64 3.82 0.35 0.006 3.35 0.62 3.41 0.64 0.77
Body image 2.23 1.41 3.24 0.71 0.011 2.25 1.37 2.33 1.4 0.86
IAE: intermittent aerobic exercise; CG: control group; HbA1c: glycosylated haemoglobin; VO2max: maximum oxygen uptake; MVC: maximum
voluntary contraction; B-BSHS: brief-burn specific health scale.
 advantageous impact of high peak VO 2 on controlling blood glucose
levels. Prior studies have demonstrated that there was a reduced amount
of type I muscle fiber and the density of capillaries [39], high level of fat
constituent in muscle fibers [40], and increased ratio of glycolytic and
oxidative
enzyme that combined with low insulin tolerance [41]. Additionally, there
is a proof that the aerobic exercise program improves the density of
skeletal muscle capillaries and consequently increases muscular oxidative
capability [42].

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1198 burns46(2020)1193 1200

Table 3 – Post-intervention differences between IAE and control groups.

Variables IAE group (n = 18) CG (n = 18) p-Value

HbA1c (%) 5.0 0.4 6.9 1.2 0.04

1 1
VO2max (mL/kg /min ) 38.71 4.1 27.2 3.33 <0.001
Quadriceps muscle MVC (Nm) 232.4 51.2 189 45.6 0.01
B-BSHS
Simple abilities 3.72 0.99 3.09 0.81 0.04
Hand function 3.67 0.23 3.24 0.69 0.02
Heat sensitivity 3.12 0.65 1.63 0.91 <0.001
Interpersonal relationship 3.77 0.32 3.29 0.64 0.01
Work 3.23 0.52 2.51 0.97 0.01
Treatment regimens 3.84 0.45 3.08 0.81 0.01
Affect 3.71 0.33 3.11 0.55 0.01
Sexuality 3.82 0.35 3.41 0.64 0.02
Body image 3.24 0.71 2.33 1.4 0.02
IAE: intermittent aerobic exercise; CG: control group; HbA1c: glycosylated haemoglobin; VO2max: maximum oxygen uptake; MVC: maximum
voluntary contraction; B-BSHS: brief-burn specific health scale.

It is widely known that exercise at high-intensity is a common reason
for muscular fatigability for the sake of metabolic and neuronal issues.
Intermittent exercise program allows high-intensity exercise for a
prolonged time more than continuous exercise training, as oxygen is
returned, phospho-creatine is refilled moderately and metabolites of the
muscle are expelled during the recovery stages [43]. Bogdanis et al.
reported that retrieving of maximum output and muscular production of
phosphocreatine after 30 s fast running looks to happen similarly.
Conversely, no one was fully regained after 6 min of exercise training
sessions [44]. Finally, because of physiological regaining during recovery
stages between the intervals, intermittent exercise training helps to do the
greater capacity of training with least muscular fatigability than
continuous exercise training which continually increased central stress
and peripheral structures [45].
capacity in DBPs. Other limitations, the present study missed long term
follow-up and home exercise of was not supervised. Further studies are
required to assess neuromuscular functions and muscle fatigue related to
functional activities not related to MVCs with a view to explain the effects
of neuromuscular dysfunction on the usual activities of the patient.
5. Conclusions
The present study findings revealed that 6 weeks of IAE is an effective
alternative modality that improves aerobic capacity, muscle fatigability,
and QoL in DBPs. Adherence to IAE should be practicable into
mainstream clinical intervention for those patients.

Paratz and colleagues reported that, after wound recovery, subjects

who contributed in aerobic exercise training involving three times per Funding
week for an hour session suggestively improves their muscle power and
exercise functioning (shuttle test) compared to pre-treatment and No agency granted funding for this study.
compared to a control group of patients. A new feature of this trial was
that aerobic exercise training was also correlated to enhanced QoL, as
well as, the benefits of diminished muscular fatigue and improved the Conflicts of interest
muscular endurance [46].
The authors declare that no competing interests concern the publishing of
It is important to highlight that T2DM was assessed in the present the study.
study using HbA1c test because of its high sensitivity and specificity to
diagnose T2DM compared to oral glucose tolerance test (OGTT) which
used to diagnose gestational diabetes [24,47,48]. Acknowledgement

Our study have some strengths. Firstly, the six weeks of IAE appear to The authors gratefully acknowledge all patients for their involvement and
be acceptable and feasible for DBPs. Secondly, objective measurements obligation throughout the study. The authors also would like to thank the
were used to assess aerobic capacity and muscle fatigability. Finally, this deanship of scientific research, Prince Sattam bin Abdulaziz University.
study demonstrated a high response rateofthestudyparticipants. On the
other hand,ithas some limitations. The main limitation of the study is the
quadriceps intermittent isometric fatigue test which does not exactly REFERENCES
regard the usualpatients' activity. Whereas,the present study approved that
the recorded VO2max is accompanying with endurance and force of
quadriceps muscle. Therefore, the role of peripheral muscles may
[1] McCampbell B, Wasif N, Rabbitts A, Staiano-Coico L, Yurt RW, Suzanne
illustrate the lowered aerobic
Schwartz S. Diabetes and burns: retrospective Cohort study. J Burn Care Rehabil
2002;3:157 66.
Downloaded for Universitas Muhammadiyah Semarang (akun.mhs5@gmail.com) at Muhammadiyah University Semarang from ClinicalKey.com by Elsevier on October 07, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
 burns46(2020)1193 1200 1199

[2] Pruitt BA, Mason AD, Goodwin CW. Epidemiology of burn injury and [22] Abdelbasset WK, Alqahtani BA. A randomized controlled trial on the
demography of burn care facilities. Probl Gen Surg 2010;7:235 51. impact of moderate-intensity continuous aerobic

[3] Bloemsma GC, Dokter J, Boxma H, Oen IM. Mortality and causes of
death in a burn centre. Burns 2008;34:1103 7.
[4] van Baar ME, Essink-Bot ML, Oen IM, Dokter J, Boxma H, van Beeck
EF. Functional outcome after burns: a review. Burns 2006;32(1):1 9.

[5] American Diabetes Association. Diagnosis and classification of diabetes

mellitus. Diabetes Care 2012;35:S64 71.
[6] Morain WD, Colen LB. Wound healing in diabetes mellitus. Clin Plast
Surg 1990;17:493 501.
[7] Hobizal KB, Wukich DK. Diabetic foot infections: current concept
review. Diab Foot Ankle 2012;3:1 8.
[8] Memmel H, Kowal-Vern A, Latenser BA. Infections in burn patients.
Diabetes Care 2004;27:229 33.
[9] Kimball Z, Patil S, Mansour H, Marano MA, Petrone SJ, Chamberlain
RS. Clinical outcomes of isolated lower extremity or foot burns in diabetic versus
non-diabetic patients: a 10-year retrospective analysis. Burns 2013;39:279 84.
[10] Grisbook TL, Wallman KE, Elliott CM, Wood FM, Edgar DW, Reid SL.
The effect of exercise training on pulmonary function and aerobic capacity in
adults with burns. Burns 2012;38(4):607 13.

[11] Jeschke MG, Chinkes DL, Finnerty CC, Kulp G, Suman OE, Norbury
WB, et al. Pathophysiologic response to severe burn injury. Ann Surg
2008;248(3):387 401.
[12] Katzmarzyk PT, Craig CL, Gauvin L. Adiposity, physical fitness and
incident diabetes: the physical activity longitudinal study. Diabetologia
2007;50(3):538 44.
[13] Porter C, Tompkins RG, Finnerty CC, Sidossis LS, Suman OE, Herndon
DN. The metabolic stress response to burn trauma: current understanding and
therapies. Lancet 2016;388 (10052):1417 26.

[14] Gabbe BJ, Cleland H, Watterson D, Schrale R, McRae S, Taggart S, et al.

Predictors of moderate to severe fatigue 12 months following admission to
hospital for burn: results from the Burns Registry of Australia and New Zealand
(BRANZ) long term outcomes project. Burns 2016;42(8):1652 61.
[15] Weijman I, Ros WJ, Rutten GE, Schaufeli WB, Schabracq MJ, Winnubst
JA, et al. Fatigue in employees with diabetes: its relation with work
characteristics and diabetes related burden. Occup Environ Med 2003;60(Suppl.
1):i93 8.
[16] Fritschi C, Quinn L. Fatigue in patients with diabetes: a review. J
Psychosom Res 2010;69:33 41.
[17] Suman OE, Spies RJ, Celis MM, Mlcak RP, Herndon DN. Effects of a
12-wk resistance exercise program on skeletal muscle strength in children with
burn injuries. J Appl Physiol (1985) 2001;91(3):1168 75.

[18] Celis MM, Suman OE, Huang TT, Yen P. Effect of a supervised exercise
and physiotherapy program on surgical interventions in children with thermal
injury. J Burn Care Rehabil 2003;24:57 61.

[19] Colberg SR, Sigal RJ, Yardley JE, Riddell MC, Dunstan DW, Dempsey
PC, et al. Physical activity/exercise and diabetes: a position statement of the
American Diabetes Association. Diabetes Care 2016;39(11):2065 79.

[20] Ahmed AS, Ahmed MS, Mahmoud WS, Abdelbasset WK, Elnaggar RK.
Effect of high intensity interval training on heart rate variability and aerobic
capacity in obese adults with type 2 diabetes mellitus. Biosci Res 2019;(3):2450
8.
[21] Abdelbasset WK, Abo Elyazid TI, Elsayed SH. Comparison of high
intensity interval to moderate intensity continuous aerobic exercise on ventilatory
markers in coronary heart disease patients: a randomized controlled study. Int J
Physiother Res 2017;5(3):2013 8.

exercise on the depression status of middle-aged patients with congestive
heart failure. Medicine 2019;98(17):e15344.
[23] Abdelbasset WK, Tantawy SA, Kamel DM, Alqahtani BA, Soliman
GS. A randomized controlled trial on the effectiveness of 8-week high intensity
interval exercise on intrahepatic triglycerides, visceral lipids, and health-related
quality of life in diabetic obese patients with nonalcoholic fatty liver disease.
Medicine 2019;98(12):e14918.
[24] World Health Organization (WHO). Use of Glycated Haemoglobin
(HbA1c) in the Diagnosis of Diabetes Mellitus. Abbreviated Report of a WHO
Consultation. Geneva: WHO; 2011.
[25] Bruce RA, Kusumi F, Hosmer D. Maximal oxygen intake and
nomographic assessment of functional aerobic impairment in cardiovascular
disease. Am Heart J 1973;85(4):546 62.
[26] Decramer M, de Bock V, Dom R. Functional and histologic picture
of steroid-induced myopathy in chronic obstructive pulmonary disease. Am J
Respir Crit Care Med 1996;153:1958 64.
[27] Kildal M, Andersson G, Fugl-Meyer A, Lannerstam K, Gerdin B.
Development of a brief version of the burn specific health scale (BSHS-B). J
Trauma 2001;51(4):740 6.
[28] Samhan AF, Abdelhalim NM. Impacts of low-energy extracorporeal
shockwave therapy on pain, pruritus, and health-related quality of life in patients
with burn: a randomized placebo-controlled study. Burns 2019;45(5):1094 101.
[29] Eckel RH, Jakicic JM, Ard JD, de Jesus JM, Houston Miller N,
Hubbard VS, et al. AHA/ACC guideline on lifestyle management to reduce
cardiovascular risk: a report of the American College of Cardiology/American
Heart Association Task Force on practice guidelines. Circulation 2014
2013;129(25 Suppl 2):S76 99.
Downloaded for Universitas Muhammadiyah Semarang (akun.mhs5@gmail.com) at Muhammadiyah University Semarang from ClinicalKey.com by Elsevier on October 07, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
[30] Petrofsky JS, McLellan K, Bains GS, Prowse M, Ethiraju G, Lee S,
et al. Skin heat dissipation: the influence of diabetes, skin thickness, and
subcutaneous fat thickness. Diabetes Technol Ther 2008;10(6):487 93.
[31] Petrofsky JS, Lee H, Trivedi M, Hudlikar AN, Yang CH, Goraksh
N, et al. The influence of aging and diabetes on heat transfer characteristics of
the skin to a rapidly applied heat source.
Diabetes Technol Ther 2010;12(12):1003 10.
[32] McLellan K, Petrofsky JS, Bains G, Zimmerman G, Prowse M, Lee
S. The effects of skin moisture and subcutaneous fat thickness on the ability of
the skin to dissipate heat in young and old subjects, with and without diabetes,
at three environmental room temperatures. Med Eng Phys 2009;31 (March
(2)):165 72.
[33] Holowatz LA, Thompson-Torgerson C, Kenney WL. Aging and the
control of human skin blood flow. Front Biosci (Landmark Ed) 2010;15:718 39.
[34] Grisbrook TL, Wallman KE, Elliott CM, Wood FM, Edgar DW,
Reid SL. The effect of exercise training on pulmonary function and aerobic
capacity in adults with burn. Burns 2012;38(4):607 13.
[35] Colberg SR, Sigal RJ, Fernhall B, Regensteiner JG, Blissmer BJ,
Rubin RR, et al. Exercise and type 2 diabetes: the American College of Sports
Medicine and the American Diabetes Association: joint position statement
executive summary. Diabetes Care 2010;33(12):2692 6.
[36] Ali ZM, El-refay BH, Ali RR. Aerobic exercise training in
modulation of aerobic physical fitness and balance of burned patients. J Phys
Ther Sci 2015;27:585 9.
[37] Suman OE, Mlcak RP, Herndon DN. Effect of exercise training on
pulmonary function in children with thermal injury. J Burn Care Rehabil
2002;23:288 93.
[38] Lynch J, Helmrich SP, Lakka TA, Kaplan GA, Cohen RD, Salonen
R, et al. Moderately intense physical activities and high levels of
cardiorespiratory fitness reduce the risk of non-insulin-
1200 burns46(2020)1193
dependent diabetes mellitus in middle-aged men. Arch Intern Med
1996;156(12):1307 14.
[39]Lillioja S, Young AA, Culter CL, Ivy JL, Abbott WG, Zawadzki JK, et al.
Skeletal muscle capillary density and fiber type are possible determinants of in
vivo insulin resistance in man. J Clin Investig 1987;80(2):415 24.
[40]He J, Watkins S, Kelley DE. Skeletal muscle lipid content and oxidative
enzyme activity in relation to muscle fiber type in type 2 diabetes and obesity.
Diabetes 2001;50(4):817 23.
[41]Simoneau JA, Kelley DE. Altered glycolytic and oxidative capacities of
skeletal muscle contribute to insulin resistance in NIDDM. J Appl Physiol
1997;83(1):166 71.
[42]Allenberg K, Johansen K, Saltin B. Skeletal muscle adaptations to
physical training in type II (non-insulin-dependent) diabetes mellitus. Acta Med
Scand 1988;223(4):365 73.
[43]Ratel S, Lazaar N, Williams CA, Bedu M, Duche P. Age-differences in
human skeletal muscle fatigue during high-intensity intermittent exercise. Acta
Padiatric 2003;92 (11):1248 54.
1200
[44] Bogdanis GC, Nevill ME, Boobis LH, Lakomy HK, Nevill AM.
Recovery of power output and muscle metabolites following 30 s of maximal
sprint cycling in man. J Physiol 1995;482(Pt 2):467 80.
[45] Ben Abderrahman A, Zouhal H, Chamari K, Thevenet D, de
Mullenheim PY, Gastinger S, et al. Effects of recovery mode (active vs. passive)
on performance during a short high-intensity interval training program: a
longotudinal study. Eur J Appl Physiol 2013;113(6):1373 83.
[46] Paratz JD, Stockton K, Plaza A, Muller M, Boots RJ. Intensive
exercise after thermal injury improves physical, functional, and psychological
outcomes. J Trauma Acute Care Surg 2012;73(1):186 94.
[47] Sacks DB. Hemoglobin A1c in diabetes: panacea or pointless?
Diabetes 2013;62(1):41 3.
[48] Kim MS, Jo DS, Lee DY. Comparison of HbA1c and OGTT for the
diagnosis of type 2 diabetes in children at risk of diabetes. Pediatr Neonatol
2019;60(4):428 34.
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