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REVIEW ARTICLE (META-ANALYSIS)

Physical Fitness in People After Burn Injury: A Systematic Review
Laurien M. Disseldorp, BSc, Marianne K. Nieuwenhuis, PhD, Margriet E. Van Baar, PhD, Leonora J. Mouton, PhD
ABSTRACT. Disseldorp LM, Nieuwenhuis MK, Van Baar ME, Mouton LJ. Physical fitness in people after burn injury: a systematic review. Arch Phys Med Rehabil 2011;92:1501-10.
Objective: To gain insight into the physical fitness of people

have burnW ORLDWIDE,asMILLIONS OF PEOPLE earlierhigh. related disabilities and disfigurements. In days, the mortality rate a result of burn injuries was

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after burn injury compared with healthy subjects, and to present an overview of the effectiveness of exercise training programs in improving physical fitness in people after burn injury. Data Sources: Electronic databases EMBASE, PubMed, and Web of Science were searched for relevant publications. Additionally, references from retrieved publications were checked. Study Selection: The review includes studies that provide quantitative data from objective measures of physical fitness of both the intervention group and the control group. Data Extraction: Characteristics of each study such as study design, institution, and intervention are reported, as well as mean ages and burn sizes of the subjects. Results are divided into 5 components of physical fitness—muscular strength, muscular endurance, body composition, cardiorespiratory endurance, and flexibility—and reported for each component separately. Data Synthesis: Eleven studies met the inclusion criteria, and their methodological quality was assessed using the PEDro score and a modified Sackett scale. Six studies were used for the comparison of physical fitness in burned and nonburned subjects, and 9 studies for evaluating the effectiveness of exercise training programs. Conclusions: Physical fitness is affected in people with extensive burns, and exercise training programs can bring on relevant improvements in all components. However, because of the great similarities in the subjects and protocols used in the included studies, the current knowledge is incomplete. Future research should include people of all ages with a broad range of burn sizes, for both short-term and long-term outcomes. Key Words: Burns; Exercise; Outcomes assessment; Physical fitness; Rehabilitation; Review. © 2011 by the American Congress of Rehabilitation Medicine

Because of major improvements in burn treatment and care during the last decades, the survival rate of burn patients has increased enormously,1,3-6 and nowadays even extensive burns involving a very large percentage of the total body surface area (% TBSA) can be survived.4 As more people survive burn injury, the long-term outcomes and quality of life of burn patients become increasingly important.7-9 An essential aspect of this is the patient’s physical fitness, defined as a state of well-being, with a low risk for health problems and the ability to perform physical activity (ie, body movement carried out by the skeletal muscles and requiring energy).10,11 Caspersen et al10 distinguished 5 health-related components that are required to perform activities of daily living and are therefore relevant outcome parameters to assess physical fitness: muscular strength, muscular endurance, body composition, cardiorespiratory endurance, and flexibility. Although there is no unambiguous conclusion yet on the state of physical fitness of patients after burns, there are indications that burn patients show a decline in physical functioning.12-14 There can be several reasons for deconditioning in burn patients, such as the consequences of open wounds, hypermetabolism, grafts or other surgeries, medication, the long duration of bed rest, inhalation injury, positioning, pain, and psychological issues. It is important to obtain knowledge regarding physical fitness in order to further adapt and improve rehabilitation protocols to facilitate a faster functional recovery. Therefore, the first aim of this review is to gain insight into the physical fitness of patients after burn injury as compared with nonburned subjects. Because it is well known that exercise improves physical fitness in healthy people as well as in many patient groups, the second aim of this review is to provide an overview of the effectiveness of exercise training programs in improving the physical fitness of patients after burn injury. METHODS Data Sources To identify relevant studies the electronic databases EMBASE (including Medline search), PubMed and Web of Sci-

From the Center for Human Movement Sciences, University Medical Center Groningen, University of Groningen, Groningen (Disseldorp, Mouton); Association of Dutch Burn Centers, Martini Hospital, Groningen (Nieuwenhuis); and Association of Dutch Burn Centers, Maasstad Hospital, Rotterdam (Van Baar), The Netherlands. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated. Correspondence to Leonora J. Mouton, PhD, Center for Human Movement Sciences, University Medical Center Groningen, University of Groningen, Ant. Deusinglaan 1, Bldg 3215, Room 329, 9713 AV Groningen, The Netherlands, e-mail: L.J.Mouton@med.umcg.nl. Reprints are not available from authors. 0003-9993/11/9209-01104$36.00/0 doi:10.1016/j.apmr.2011.03.025

List of Abbreviations DEXA LLM ROM TBSA TLBM ˙ VO2max VO2peak dual-energy x-ray absorptiometry lean leg mass range of motion total body surface area total lean body mass maximum oxygen consumption peak oxygen consumption

Arch Phys Med Rehabil Vol 92, September 2011

rehabilitation. were considered as level 3 evidence (see table 2). To provide a structured overview. RESULTS Eleven relevant studies could be included (table 2). One of these studies16 reports on 2 different study groups. the 5 health-related components of physical fitness as originally described by Caspersen10 were used as a framework in this review. Shriners Hospitals for Children Galveston. the weakest level of evidence. body composition.15 One randomized controlled trial. yielding a total of 7 study groups for this comparison. endurance. for all randomized controlled trials. *Levels of evidence are determined using a modified Sackett scale. Whether the data search was complete was checked by 2 independent researchers. only those studies were included that provided results on both the burned subjects and healthy controls to ensure that the results of the measures were comparable. so were classified as level 1 evidence according to the modified Sackett scale. Physical Fitness of People After Burn Injury Compared With Nonburned Subjects The studies of Alloju17 and St-Pierre16 and colleagues aimed to assess the physical consequences of burn injury and compare Abbreviation: RCTs. the terms burn injury. physical fitness. Third. and single case reports study provides sufficient statistical information to make results interpretable. and experts in the field associated with the Dutch burn centers were consulted.15 ence were searched with the key words burns. Study Selection Studies were selected only if they (1) used objective measurements and (2) provided quantitative data about the physical fitness of both the study group and the control group. randomized controlled trials. which evaluates both the internal validity and whether a Table 2: Quality Assessment of Included Studies Reference Year Institution Design PEDro Score Level of Evidence* St-Pierre et al16 Cucuzzo et al8 Suman et al24 Suman et al19 Suman et al20 Przkora et al18 Suman and Herndon21 De Lateur et al22 Alloju et al17 Neugebauer et al23 Al-Mousawi et al25 1998 2001 2001 2002 2003 2007 2007 2007 2008 2008 2010 MU SHCG SHCG SHCG SHCG SHCG SHCG JHU SHCG SHCG SHCG Static-group comparison RCT RCT RCT RCT RCT RCT RCT Static-group comparison Nonrandomized controlled trial RCT NA 7 6 6 5 6 6 8 NA NA 6 3 1 1 1 2 1 1 1 3 2 1 Abbreviations: JHU. Arch Phys Med Rehabil Vol 92. Two static group comparison studies. body composition. SHCG. September 2011 . and 1 nonrandomized controlled trial provided level 2 evidence. which are discussed separately throughout this review.1502 PHYSICAL FITNESS IN PEOPLE AFTER BURN INJURY. For the comparison of the physical fitness in burn patients and healthy subjects. For the evaluation of effectiveness. RCT. NA. which were used to compare physical fitness in burned and nonburned people. First. the study design was determined. and 4 of these were used in both parts of this review. the comparison of the physical fitness in burned and nonburned subjects. to 5. as well as on characteristics of the subjects (eg. references from reviews and studies were checked. the methodological quality was assessed by applying the PEDro assessment scale. McGill University Quebec. posttest. the evaluation of the effects of an exercise program on the physical fitness of people with burns. and flexibility. Johns Hopkins University School of Medicine Baltimore. and exercise. with a PEDro score of 5 points. The framework comprises muscular strength. The PEDro assessment scale scores range from 1 to 10 points. This is expressed as levels from 1. Disseldorp Table 1: Classification of Levels of Evidence* Level of Evidence Study Design 1 2 3 4 5 RCTs with a PEDro score 6 RCTs with a PEDro score 6. mean ages and burn sizes). muscular endurance. Nine studies were included for the second aim of this review. Results were reported for each component separately. Data Extraction Information was collected on characteristics of each study. the modified Sackett scale (table 1) as developed by Teasell et al15 was used to determine the strength of evidence. clinical consensus. cohort and non-RCTs Case-control trials Pre-post studies. of which 7 had PEDro scores of 6 points or more (see table 2). Data Synthesis The methodological quality of the included studies was assessed in 3 steps. Further. MU. and functioning were used. such as study design and intervention. *Adapted from Teasell et al. Methodological Quality of the Included Studies Eight studies were randomized controlled trials. where 10 indicates excellent methodological quality and 1 indicates very poor methodological quality. Single case reports and studies limited to hand function were excluded from this review. in addition. Six studies provided data for the first aim of this review. outcome. randomized controlled trial. Second. the strongest level of evidence. not applicable. only studies with a description of the applied exercise training program were included. and case series Observational studies. strength. cardiorespiratory endurance. The search was limited to studies with human subjects and to the English language.

2% without a P value) of total work in burned subjects than in the control group. Cardiorespiratory endurance. The study group of St-Pierre.18. For the group with burns involving 30% TBSA or less. however. which is exceptionally large.0 39.6 57. expressed in terms of work and power.8 12. The 4 Shriners’ studies measured peak torque in the dominant leg extensors. were compared (see table 4).5† 12.20 did not apply statistical analyses. month. 10.05) in cardiorespiratory endurance.3% 15. number of participants.5 11. Only 1 study17 measured flexibility (see table 5). In 3 study groups. St-Pierre16 measured peak torque. at velocities of 1. time postburn of assessment. No significant between-group differences were found. and 12 6 14† 16† 24 16 Unknown 26 46 86† 75† 58 56 65† 94 52 40. and the time of assessment varied from 0.8 10.0 0. sex. lean leg mass (LLM).8 56. and patients with burns involving greater than 30% TBSA.7–12. LLM. but this betweengroup difference was significant only for knee extension at 3.05). Body composition.5–6* 0.17 the differences were significant (TLBM. † Matched with burned subjects. expressed as peak torque. The study group with burns involving greater than 30% TBSA. matched also for sex. and in one of them. The cardiorespiratory endurance. measured with an isokinetic dynamometer.14rad/s. Suman and Herndon21 and Alloju17 reported significant differences (P . while in the other 2 studies18.5 to 12 months postburn (table 3). and/or lean trunk mass were measured by dual-energy X-ray absorptiometry (DEXA) in kilograms. scored higher than the control group on both work and power in knee as well as elbow flexion and extension.1% without a P value. SHCG.5–3 and 3.93) between burned and nonburned children. 20. Texas. the participants of these 5 study groups were children (mean ages. with a minimum of 40%.6† 39. with the higher values on the side of nonburned subjects.20. and all found less strength in burned subjects than in controls. The results did not show significant differences (P . is measured by treadmill testing in 3 study groups (see table 5). Controls for both study groups were matched for age. The group of burned subjects was split into 2 study groups: patients with burns involving 30% TBSA or less. but hereby provided results of burned and nonburned subjects before the start of the program.3%. McGill University Quebec. Effect of an Exercise Program on the Physical Fitness of People After Burn Injury Nine controlled trials were included to evaluate the effectiveness of exercise training programs in improving physical fitness in people after burn injury (table 6).0† 12. The group with greater than 30% TBSA burned scored lower than controls on every measure. All but 1 trial were from Shriners Hospitals for Children (Galveston. but important for the results found in these studies was that all the studies were done with patients whose burns involved more than 40% TBSA. In elbow flexion and extension. most subjects were male. In 1 study.3 12. St-Pierre16 included adults aged 24 to 69 years with upper extremity burns involving at least 15% TBSA. n.7%. and the other 2 studies18. Body composition was evaluated in 4 study groups (table 5). Functional dynamic range of motion (ROM) was assessed during the performance of leg extension.17 the muscular endurance of patients with burns and healthy controls.5–3 and 3.2%). Muscular endurance. The subjects in the study by De Lateur et al22 were adults with burns involving a mean TBSA of 19.4 46. Disseldorp Table 3: Characteristics of Included Study Groups and Corresponding Subjects. Arch Phys Med Rehabil Vol 92.7 11 11. The same methods were used as for muscular strength.05 and 3.20 showed great differences in VO2peak between the groups. MU. and all found lower values in children with burns than in nonburned controls. however.5y).PHYSICAL FITNESS IN PEOPLE AFTER BURN INJURY.21 included only subjects whose burns involved more than 40% TBSA. The other 4 studies18-21 aimed to evaluate the effect of a physical training program in burn patients. *Range. Five of the 7 included study groups originated from Shriners Hospitals for Children in Galveston. Obviously.011 and 68. Less obvious. Texas) and clearly involved just children. One study19 reported a significant between-group difference (P . though not all between-group differences were significant (see table 4). 22. In one of the studies.0 53. but without statistical analyses. expressed as peak oxygen consumption (VO2peak).14rad/s (16%. All 4 study groups17. Flexibility. Time PB. in the upper and lower extremities bilaterally. P . Shriners Hospitals for Children Galveston. the physical fitness of burn patients with that of healthy control subjects. 15–92 days postburn.20 statistical analyses were not applied (table 4).5 58.2† 13.1† Abbreviations: mo.8 23.16 consisting of subjects with burns involving 30% TBSA or less. Overall. Total lean body mass (TLBM). The other 2 studies18. lean arm mass. 9. both groups did not show significant between-group differences. Six study groups provided information about muscular strength. no significant differences in the strength of knee flexors and extensors were found between the burned group and the healthy control group. showed lower values than controls on all measures of muscular endurance.1 58. September 2011 . respectively). Muscular strength.6 10.16. In 3 of these 5 study groups the controls were matched for age. and combined and averaged the results of both for every limb. Alloju17 also reported significantly lower values (64. and physical activity level. Regarding Physical Fitness in Burned and Nonburned Subjects Burned Subjects Mean Age (y) Study Group Institution n % Male 18 18 Mean TBSA (%) 30 30 Time PB (mo) n % Male Nonburned Subjects 1503 Mean Age (y) St-Pierre et al16 ( 30% TBSA) St-Pierre et al16 ( 30% TBSA) Suman et al19 Suman et al20 Przkora et al18 Suman and Herndon21 Alloju et al17 MU MU SHCG SHCG SHCG SHCG SHCG 14 16 31 44 51 20 33 86 75 77 56 80 85 76 40. The mean TBSA involved in the burns of these children was greater than 50%. Of these.21 the differences in TLBM were nonsignificant.5–6* 6 and 9 6 and 9 6 and 9 6.

significant between-group differences. NS. nonsignificant between-group differences.14rad/s B NB Elbow flexor Other measures NB (20. nonburned subjects.8%) Knee flexor work and power: -NS Elbow work and power: -NS NB No statistical NT analyses NB No statistical NT analyses NB Sign (P . NB.011) NT Isokinetic total work† Knee extensor (dominant side) Knee extensor total work: B NB Sign (64. burned subjects. Disseldorp St-Pierre et al ( 30% TBSA) 16 Isokinetic peak Knee flexor torque* Knee extensor Elbow flexor Elbow extensor St-Pierre et al16 Isokinetic peak Knee flexor torque* Knee extensor ( 30% Elbow flexor TBSA) Elbow extensor Suman et al20 Przkora et al18 Suman and Herndon21 Alloju et al17 Isokinetic peak torque Isokinetic peak torque Isokinetic peak torque Isokinetic peak torque† Knee extensor (dominant side) Knee extensor (dominant side) Knee extensor (dominant side) Knee extensor (dominant side) Abbreviations: B.05 and 3.05rad/s -Sign at 3.14rad/s NB (15.1504 Table 4: Results for the Comparison of Muscular Strength and Muscular Endurance in Burned and Nonburned Subjects Muscular Strength Joints Results Statistics Parameters Joints Results Muscular Endurance Statistics Study Group Parameters Arch Phys Med Rehabil Vol 92. not tested. † Measured at 150°/s. *Measured at 1.05rad/s B NB Knee flexor and average 3. Sign.2%) PHYSICAL FITNESS IN PEOPLE AFTER BURN INJURY.14rad/s.Sign (16%) NB -Sign at 3.1%) NS (All differences Isokinetic total work Work and power: For work and power: NS NB B NB Knee flexor 10%) and average NB and B NB B NB Knee extensor power* NB and B NB B NB Elbow flexor NB B NB Elbow extensor Isokinetic total work Work and power: For work and power: Knee extensor work: Knee extensor at NB -Sign at 1.5%) B NB Elbow extensor . .14rad/s (17. September 2011 B B B B B B B B B B B B NB Sign (68.2%) B NB Knee extensor power* .NS Knee extensor power: -NS at 1. NT.

All studies reported averaged increases in strength of more than 40% in the intervention group. lean arm mass. For the intervention groups. The intervention group received. quadriceps.3%) LLM: Sign (22. One of the studies21 applied a follow-up measure after another 12 weeks with home-based exercise prescriptions.25 However. of which 20 to 40 minutes was aerobic exercise (for exceptions see table 6).21. burned subjects. Al-Mousawi25 normalized the Arch Phys Med Rehabil Vol 92. All studies reported significantly greater increases in the intervention group than in the control group over 12 weeks. which is not further specified. tailored burn rehabilitation protocol of the John Hopkins Burn Center. in addition to 5h/wk of rehabilitation therapy. nonburned subjects. and hamstrings. Significant between-group differences in the improvement of muscular endurance over 12 weeks were found on all 3 variables. and LTM by DEXA TLBM by DEXA 19 Suman et al20 Study Group Suman et al Suman and Herndon21 Alloju et al17 TLBM and LLM by DEXA Parameters NT B NB B NB B NB TLBM: Sign (20. Cardiorespiratory Endurance. this was supplemented with 30 minutes of aerobic treadmill exercise 3 times a week. as participants were trained and given a home-based rehabilitation program or received outpatient therapy at the hospital. triceps. 3 sessions of an exercise and music program per week. LTM. lean trunk mass. individualized and supervised exercise training programs consisting of aerobic as well as resistance training. For the intervention groups. was mentioned in 5 effect studies18. nonsignificant between-group differences.21. Suman et al24 measured total work and average power in the leg extensors. Body composition.2%) Statistics NT Functional dynamic ROM in leg extension Parameter B NB NS .20. NT. Two studies reported data on muscular endurance (see table 7). The time postburn at the start of the intervention varied between studies. all significantly greater than increases of the control group. In all but 2 studies.5 days postburn.24. A dynamometer was used to measure isokinetic peak torque in the knee extensors of the dominant leg. It was unclear on which criteria this was based. For the “work-to-quota” group. not tested. Information about the changes in muscular strength as a result of the exercise training program of 12 weeks was given in 5 studies18. Subjects in the study by Neugebauer23 joined the exercise and music groups as soon as they were medically ready. measured by DEXA and expressed as lean mass in kilograms. LLM. LAM. NS. Significant differences persisted when increases in strength were normalized to individual changes in TLBM. The study by Neugebauer et al23 is an exception in the Shriners’ studies. in 2 other studies of Shiners Hospitals used here. However.24. 1505 All studies comprised an intervention with a duration of 12 weeks. LAM. significant between-group differences.22 all participants received the standardized.25 (table 7). this exercise was intensified throughout the 12 weeks by increasing the target exercise heart rate and time according to preset quotas. each lasting 60 minutes. and Flexibility in Burned and Nonburned Subjects Flexibility NT NT Sign (no values) No statistical analyses Cardiorespiratory Endurance B NB. Muscular strength. Two studies of Shriners Hospitals investigated the effect of additional drugs (oxandralone18 and growth hormone20). no data B NB Results VO2 peak by treadmill test VO2peak by treadmill test VO2peak by treadmill test NT No statistical analyses B NB B NB TLBM by DEXA NS Przkora et al18 Parameter B NB No statistical analyses Statistics NT NT No statistical analyses Body Composition Results Averaged values of TLBM. the control group participated in a home-based rehabilitation program without exercise prescriptions. the exercise program started at 6 months postburn (see table 6). forearms. In the study of De Lateur. Body composition. Sign. Muscular endurance. but only results of the relevant (nondrugged) groups were used in this review. Most of these interventions involved 3 training sessions per week. this rehabilitation program was supplemented with hospital-based. this intervention for young children was not individualized but comprised group sessions. Subjects in the study by De Lateur22 started at a mean of 37.24. Disseldorp Abbreviations: B. but this did not cause significant changes in both groups. while Cucuzzo et al8 used the calculated total volume of work produced by the biceps.25 (see table 7). note that SDs were very large in the studies by Przkora18 and Al-Mousawi25 and colleagues (see table 7). September 2011 Statistics Results Table 5: Results for the Comparison of Body Composition. The “work-to-tolerance” group was instructed to tolerate the exercise at the individual target heart rate for as long as possible.24 subjects who received growth hormone were included in both the intervention and control groups.19.PHYSICAL FITNESS IN PEOPLE AFTER BURN INJURY. The control group was heterogeneous in the number of sessions and the location of therapy. In the Shriners’ studies. NB.20.

† This is a selection of the participants.7 10. which reported on 12 study groups. and both between-group differences were significant. only 1.3 59. cardiorespiratory endurance was measured. Johns Hopkins University School of Medicine Baltimore. number of participants. burn size.5 days. Therefore. which differed significantly from increases in the control group.3 12. and 12 1.8 functional cardiorespiratory endurance was assessed with the 6-minute walk test. ‡ Range. Only 2 of the 7 included study groups concern adults.8 58.2* 6 and 9 54. *This is a selection of the participants. and functional movement. September 2011 controls for the left elbow and the right knee. However. The rest of the participants received oxandrolone.24 used treadmill tests and found increases greater than 20% in VO2peak in the intervention group.5 Recently discharged from intensive care unit and medically ready (not specified) 6 and 9 5 3 Resistance and aerobic exercise 60min several therapies Aerobic exercise 20–40min resistance training Aerobic exercise 20–40min resistance training Aerobic exercise 20–40min resistance training Aerobic exercise 20–40min resistance training Aerobic exercise 20–40min resistance training Aerobic exercise 30min. month. 19.5 61. 2.0† 6 and 9 58. time postburn of assessment.6 58. A follow-up measure in one of the studies21 did not show significant changes from another 12 weeks of homebased exercise prescriptions. Physical Fitness in People After Burn Injury This review brings to light important insights on the physical fitness of people after burn injury compared with that of nonburned controls. mo. On the contrary. endurance. Time PB. and (2) the effectiveness of exercise training programs in improving physical fitness in people after burn injury. The 1 study including adults22 (mean TBSA. for the right elbow and left knee.3%) re˙ ported significant increases in VO2max for both the work-toquota and work-to-tolerance intervention groups. on average.6 10. Five studies used treadmill exercise testing following the modified Bruce protocol. Flexibility. despite significant increases in active ROM over the intervention.2‡ Neugebauer et al23 SHCG 15 9 3. 60min Aerobic exercise 30min resistance training Abbreviations: JHU.7 58.1506 PHYSICAL FITNESS IN PEOPLE AFTER BURN INJURY. and 4. Only 1 study23 (see table 8) included flexibility. In the Netherlands. Five studies included children with burns involving greater than 40% TBSA. Shriners Hospitals for Children Galveston. but with a significantly larger increase for the intervention group.6 6 and 9 6 and 9 6 and 9 3 3 3 3 5 3 3 56. Active ROM increased significantly more in the intervention group than in Arch Phys Med Rehabil Vol 92. The rest of the participants received growth hormone. these children have exceptionally extensive burns.8 6. Moreover.7 10.0 19. It showed that (1) children and adults with extensive burns score worse than nonburned controls on measures of all 5 components of physical fitness.26 Recent American data show that patients with a total burn size of more . Cardiorespiratory endurance. to provide an overview of (1) the physical fitness of people after burn injury. measurements to height and found that this significant difference persisted. and are excluded in this review. which was measured in the elbow and knee joints by goniometry and expressed as passive and active ROM. the included studies show great similarity in subjects on the domains of age. 9. n. and are excluded in this review.6 11. Regarding Effectiveness of an Exercise Program on Physical Fitness n Mean Age (y) 18 18 Mean TBSA (%) 40 40 Time PB (mo) Sessions/wk 12-wk Intervention Content per Session Reference Institution Study Control Cucuzzo et al8 Suman et al24 Suman et al19 Suman et al20 Przkora et al18 Suman and Herndon21 De Lateur et al22 SHCG SHCG SHCG SHCG SHCG SHCG JHU 11 19 17 13* 17† 11 15 10 16 14 11* 11† 9 9 10. The change in passive ROM after 12 weeks of intervention in the intervention group was not significantly different from the change in passive ROM in the control group. the included population in this review is a remarkable one—that is. In 6 studies (table 8). and (2) burn patients participating in a 12-week exercise training program improve more on all parameters than burn patients without this specific training. 9 to 122 days postburn. and time postburn. SHCG. The control group did not improve significantly. The fifth study8 used the 6-minute walk test and reported that the performance of both the intervention and control group increased.5 38. between-group differences appeared nonsignificant. Disseldorp Table 6: Characteristics of Included Studies and Corresponding Subjects. DISCUSSION This review included 11 high-quality studies. In 1 study. a selection of the patients generally admitted to burn centers.0 Al-Mousawi et al25 SHCG 11 10 12. intensified throughout 12wk by work-to-quota or work-totolerance protocol Exercise-based music activities to promote ROM. mean. the other 5 involve only children. and these outcomes were expressed in VO2peak for chil˙ dren and maximum oxygen consumption (VO2max) for adults.3% of burn patients younger than 18 years have burns involving more than 40% TBSA. Four of these18-20. 37.

Cardiorespiratory endurance is affected in severely burned children compared with controls. Schneider et al34 reported that 38.2% 2. postburn.10% 1 AP: I: 72. and LAM by DEXA Parameters TLBM by DEXA TLBM by DEXA Statistics Sign Muscular Endurance Total work and average power in knee extensor (dominant side) NT Total volume of work* Parameters I: 80.28 Therefore. quadriceps. measured by a shuttle walk test.3 whereas 71% had a TBSA of less than 10%. and hamstrings. LLM.7% of adult burn patients (n 985) have developed at least 1 contracture at discharge. this finding also does not seem very surprising.3% 44.13 This follow-up study by Jarrett et al13 did not measure a control group and was therefore not included in the review. average power.1% 1 C: 37. and LAM by DEXA TLBM.6% 1 9 –12mo PB: I: 10. Because scars subsequent to burn injury can cause contractures in the affected joint. LTM. mean TBSA.0% 1 C: 6. but whether they catch up later is yet unknown. but these differences were not significant. lean arm mass. total work. Hypermetabolism might play a role. it is remarkable that in all reviewed studies. It can be questioned whether measuring only knee extension is a good indication of the overall muscular capacity. LTM.5% 1. Muscular Endurance. They assessed 86 adult burn patients (mean age. considering the relatively short period postburn and the inactivity in this period. children and adults with extensive burns scored lower than their controls on all parameters. the question arises whether ROM in the leg is a sufficient parameter for the overall flexibility.3 Not only the low prevalence but also the physiologic consequences of such extensive burns make this group exceptional.1% 3.4% 1 Results I: 44. LAM.2%) and reported that functional exercise capacity. with an average of 3 contractures Arch Phys Med Rehabil Vol 92.6% 1 C: –1.1% 1 C: 7. but taking into account that the severely burned children were only 6 months postburn and will just have had a long period of (bed) rest. in terms of the functional dynamic ROM in leg extension. I.31-33 The pediatric burn patients might miss a part of this rapid gain because of metabolic responses and the sedentary period postburn. Concerning the methods of measurement.2% 1 Body Composition Results 6 –9mo PB: Significance not reported 9 –12mo PB: Significance not reported Sign Statistics . who were matched for age. and activity level.27.4% 1. for other joints the differences were nonsignificant.5% 1 I: 42. triceps.9% 2.3% 40.7% 4. healthy children are in the period of the most rapid gain in lean body mass.4% 1 C: 5.7% 1 C: 2. *By cumulative 3-repetition maximum tests in biceps.6% of all cases. September 2011 TLBM and LTM: Sign LLM and LAM: NS TLBM: Sign LLM: Sign LAM and LTM: NS Table 7: Results for Effectiveness of an Exercise Program on Muscular Strength. forearm. Sign.7% 4. For the knee extensor the differences were significant. A much longer lasting deficit in strength was reported in another study related to the Shriners Hospital. month.12 In all studies that measured body composition. did not return to baseline levels at 6 months after discharge from the hospital. mo. Only in the adult groups were the knee flexors and elbow extensors and flexors also assessed. PB. Values are mean SD or as otherwise indicated. significant between-group difference (1I 1C). the metabolic and catabolic disturbances are significant relative to burns involving less than 40% TBSA and can persist up to 12 months postburn.2% 13. Abbreviations: AP.4% 1.8% 1 I: 8. On the other hand.5% 1 C: 6. After extensive burns. the included populations are not truly representative of the general burn population. C. LAM.0% 2 LLM. sex. and Body Composition in People With Burn Injury TLBM. but this study by Baker et al12 was excluded from the review because a control group was lacking.6% 10.30% 1 Results Sign NT NT Muscular Strength Peak torque at knee extensor (dominant side) Peak torque at knee extensor (dominant side) Peak torque at knee extensor (dominant side) Peak torque at knee extensor (dominant side) Przkora et al18 8 Suman et al24 Suman et al20 Suman and Herndon21 Cucuzzo et al Reference Al-Mousawi et al25 Peak torque at knee extensor (dominant side) Parameters I: 47. 11. control group.6% 1 6 –9mo PB: Significance not reported 9 –12mo PB: Significance not reported Sign Statistics Sign Sign Sign NT TLBM by DEXA TLBM and LTM: I: 1 and C: 2 LLM and LAM: I: 1 and C: 1 TLBM: I: 5. This finding lies within expectations.8% 5. It is interesting that a similar conclusion was drawn for adults with smaller burn sizes at a relatively longer period postburn.6% 15% 1 6 –9mo PB: I: 40. not tested. especially since the precise location of the burns and their possible influence on leg or arm function are not taken into account. 30%–99%) had deficits in strength in any part of the body.7% 8. muscular strength and muscular endurance were measured in the knee extensor of the dominant side. 1 indicates improvement on this parameter.9% 1 C: 1. intervention group.3% 1 C: 8. 14 5y. lean trunk mass. with the skeleton showing the highest responsiveness to physical activity. TW. compared with normative values. LTM.8% 1 C: 3. Baker12 found that 35% of 83 young adult survivors of burns sustained in childhood (mean time postburn. was somewhat decreased in children with extensive burns compared with controls.8% 6.13 Flexibility. TBSA range.9% 10. 38y.PHYSICAL FITNESS IN PEOPLE AFTER BURN INJURY. For both muscular strength and endurance.7% 1 TW: I: 78.4% 1 I: 54. in this age span. and LTM: I: 1 and C: 1 I: 1 C: – 0.6% 1 C: 3. adults with burns involving less than 30% TBSA scored higher than their controls. the subjects with a higher percentage of TBSA involved had lower mean strength.3% 2 6 –9mo PB: I: 6.4% 4.3% 16.29. 1507 than 40% TBSA accounted for only 4. Disseldorp NOTE.3% 1 C: 12. Moreover.5% 1 9 –12mo PB: I: 17. the children with extensive burns had lower mean values of lean body mass than their controls. LLM. NT.5%1 C: 2.30 Overall.

2% 16. Arch Phys Med Rehabil Vol 92. Disseldorp Table 8: Results for Effectiveness of an Exercise Program on Cardiorespiratory Endurance and Flexibility in People With Burn Injury Cardiorespiratory Endurance Reference Parameters Results Statistics Parameters Flexibility Results Statistics Cucuzzo et al8 Suman et al24 Suman et al19 Suman et al20 Przkora et al18 De Lateur et al22 Neugebauer et al23 Six-minute walk test VO2peak by treadmill test (modified Bruce Protocol) VO2peak by treadmill test (modified Bruce Protocol) VO2peak by treadmill test (modified Bruce Protocol) VO2peak by treadmill test (modified Bruce Protocol) VO2max by treadmill test (modified Bruce Protocol) I: 47. and motor imagery. upper extremity. and flexibility. Effectiveness of Exercise Training Programs in People After Burn Injury Exercise training programs have shown very positive effects on the physical fitness of patients after burn injury. They concluded that at 1. NS. and lean body mass strongly increased. and lower extremity) was tested in very young children with relatively small burns (mean age. exercise has also been proven effective in improving the cardiorespiratory endurance in adults as well as children. more beneficial effects of exercise on physical outcomes are known. the comparison of burn patients in exercise groups with groups of matched healthy controls is lacking. Sign. the possible recent surgical interventions should also be taken into account. Besides effects on the components muscular strength.35% 16. hand. per person. intervention group. 27mo. and 7 of these tested similar interventions. the critical remarks on the included study population and assessments as discussed above should be kept in mind.7% 1 C: 3. cardiorespiratory endurance.3% 4. specific to this review question.1% 1 C: ca.19 according to randomized controlled trials from the Shriners Hospitals. however. the question is whether the physical fitness of burn patients returns to fitness levels from before the injury (normal values).6% 1 C: 9. intervention group exercising as long as possible at individual target heart rate.35 not included in the review because of lack of a control group. Passive and active ROM increased in very young children with extensive burns due to participation in exercise and music groups as part of the rehabilitation. ROM of both upper and lower extremities was measured to calculate physical impairment in older children with extremely extensive burns ( 80% TBSA). the mentioned similarity in studies caused a lack of variation in applied protocols and exercise interventions. the values of patients with burns remained below those of nonburned subjects for lean mass and muscular strength. virtual reality treatment.14 So whereas ROM seemed an easy and appropriate parameter for flexibility in people after burn injury.35 In the study by Moore et al. NT. children’s muscular strength. . intervention group exercising by target heart rate and time intensified according to preset quotas. Furthermore. most of the children had ROMs within normal limits. In addition. In a study by Gorga et al. I-WTT. head/neck. Only Suman and Herndon21 made a comparison and reported that after completion of the exercise program. September 2011 fewer different training protocols are evaluated in this review than one would like. Exercise can significantly reduce the number of surgical scar releases39 and has been proven effective in improving pulmonary function in children with severe burns.8% 1 I-WTQ: 1 I-WTT: 1 C: 1 Sign Sign Sign Sign Sign I-WTQ: Sign I-WTT: Sign NT NT NT NT NT NT Passive ROM: -Elbow (left and right) -Knee (left and right) Active ROM: -Elbow left -Elbow right -Knee left -Knee right Passive ROM: -I 1 C 2 -I 1 C 1 Active ROM: -I 1 C 1 -I 1 C 1 -I 1 C 1 -I 1 C 1 Passive ROM: -NS -NS Active ROM: -Sign -NS -NS -Sign NOTE.5% 1 I: 23. with an average of 52%.12% 3. according to normative values. Eight of the 9 included studies in this part of the review originated from Shriners Hospitals for Children. 6%). Abbreviations: C. Likewise. but for none of these is there indisputable evidence yet. 6. Given this. I-WTQ. body composition.7% 1 C: 1. muscular endurance. Since measurements are done at a certain time point postburn. Additional literature36-38 suggests that ROM in people with burns could also be increased by massages. Therefore. and 12 months postburn.1508 PHYSICAL FITNESS IN PEOPLE AFTER BURN INJURY. mean TBSA.5% 1 I: 23. This review shows that because of a 12-week exercise training program.14 which was also not included because of lack of a control group.3% 1 C:14. Whereas apparently significant improvements in physical fitness can be made with exercise training programs. between-groups difference not significant. significant between-group difference (1I 1C). the location of the burn is essential for flexibility and should be reported with the results. Values are mean SD or as otherwise indicated. I. control group. As all studies compared people with burns in exercise groups and nonexercise groups. Their outcomes varied from no measurable physical impairment to more than 90% impairment. not tested.35% 1 I: 24. muscular endurance. 1 indicates improvement on this parameter. starting 6 months postburn. it proves difficult to interpret. it is remarkable that only 1 study could be included that measured flexibility. 4.1% 1 I: 22. flexibility around multiple joints (ie.

Forget R. St-Pierre DM.16:219-32. Boxma H. Cobb N. Preferably. J Appl Physiol 2003.119:e109-16. van Beeck EF. and flexibility. et al. applied exercise programs. Magyar-Russell G. Pediatrics 2007.7:235-51. Chodzko-Zajko WJ. and frequency of exercise. Ferrando A. A systematic review of pharmacologic treatments of pain after spinal cord injury. 14. Boxma H. Teasell RW. Arch Phys Med Rehabil 2010. Dokter J. Herndon DN. Powell KE. Oen IM. Furthermore. the burn (research) community should take advantage of this trend. Suman OE. 13. Meyer W. Mlcak RP. Serghiou M. 22. Results of an eleven-year survey. Mason ADJ. Disseldorp 1509 Study Limitations The present review is the first to emphasize the hiatus in knowledge about physical fitness in patients after burn injury.34:452-9. Meyer W III. American College of Sports Medicine position stand. et al. September 2011 . Burn rehabilitation: state of the science. McEntire SJ. Herndon DN. Herndon DN. Patient perception of quality of life after burn injury. Magyar-Russell G. Suman OE. 17. Goodwin CW. Only 11 studies could be included. Mlcak RP. 2. Brusselaers N. Silverstein P. Med Sci Sports Exerc 2009. McMahon M. Pruitt BAJ.0.31:1648-53. Jarrett M. intervention studies should investigate varying duration. to maintain and further improve the fitness levels achieved by exercise in the rehabilitation phase. Suman OE. muscular endurance. 5. 79:155-61. Effect of exercise training on pulmonary function in children with thermal injury. Van Baar ME. Suman OE. Fiatarone Singh MA. J Burn Care Res 2008. Suman OE. it is assumed to improve the perceived quality of life. Choiniere M. Assessment of muscle function in severely burned children. Blakeney P. Aubut JA. 24. Report of data from 2000-2009. J Burn Care Rehabil 2001. are necessary to fill the hiatus in the current knowledge. This review is mainly limited by the quantity. Oen IMMH. Furthermore. Dokter J. Herndon DN. J Burn Care Rehabil 1990. Physical outcomes of patients with burn injuries—a 12 month follow-up. 4. Thereby. and healthy aging. Competence and physical impairment of pediatric survivors of burns of more than 80% total body surface area. 12. 23. and the number of burn centers publishing on this topic is even smaller. Am J Phys Med Rehabil 2006. The effects of oxandrolone and exercise on muscle mass and function in children with severe burns.41: 1510-30. 18. References 1. Arch Phys Med Rehabil 2007. Russell WJ. 94:2273-81.88:S57-64. Physical and psychologic rehabilitation outcomes for young adults burned as children. J Burn Care Rehabil 1995.29:975-84. Arch Phys Med Rehabil 2007. 2010. Stiller K. Baker CP. Augmented exercise in the treatment of deconditioning from major burn injury. Suman OE. in a highly structured way.100:126-31. Burns 2008. 20. 7. promotion of an active lifestyle is very important. Three of those were not randomized controlled trials. 15. Suman OE.91:816-31. J Burn Care Res 2008. Since 9 studies were from the same institute and showed great similarities in study populations. 11. Esselman PC. Effects of cessation of a structured and supervised exercise conditioning program on lean mass and muscle strength in severely burned children. exercise. Thombs BD. Controlled studies including both children and adults with minor and moderate burns. Physical activity. CONCLUSIONS This review of 11 high-quality studies showed that physical fitness is affected in people after extensive burn injury.32:1-9. Burns 2008. Arch Phys Med Rehabil 2007. Bresnick MG. Exercise and physical activity for older adults. J Burn Care Rehabil 1996. The main strength of this review is that it reports on the level of physical fitness and improvements in the fitness level resulting from exercise programs. Outcome and changes over time in survival following severe burns from 1985 to 2004. Herndon DN. and physical fitness: definitions and distinctions for health-related research. Herndon DN. Probl Gen Surg 2010. The effects of exercise programming vs traditional outpatient therapy in the rehabilitation of severely burned children. intensity. Because improved physical fitness might have a positive impact on several areas of life. the independent functioning and self-care in burn patients could get better. Blakeney P. Essink-Bot ML. Hoste EA. Proctor DN. Mlcak RP. Functional outcome after burns: a review. 6.34:1103-7. Garrel DR.85:383-413. Intensive Care Med 2005. Celis MM.22:214-20. 9. Monstrey S. Wilkins JP. Physical fitness is essential in the performance of activities of daily living. 19.23:288-93. Neugebauer CT.11:330-3. the number of appropriate studies on physical fitness is limited. quality. 21. Epidemiology of burn injury and demography of burn care facilities. Because of the great similarities of the subjects and protocols used in the included studies. and research protocols. which brings new opportunities and growing knowledge.88:S18-23. Burns 2006. Practical Implications We feel that physical fitness and exercise definitely deserve a lot more attention in burn care.17:547-51. Version 6. Cucuzzo NA. De Lateur BJ. Christenson GM. Murphy L. many questions remain unanswered. Thomas SJ. Alloju SM. Arch Phys Med Rehabil 1998. they should intensify and increase its efforts to limit the physical burden of burn injury as much as possible. Saffle JR. Effect of exogenous growth hormone and exercise on lean mass and muscle function in children with burns.PHYSICAL FITNESS IN PEOPLE AFTER BURN INJURY. the generalizability of the results is not optimal. 8. to enable optimization of the effectiveness of exercise training protocols for individual patients. aimed at both shortterm and long-term physical fitness outcomes. Moore P. Effects of a 12-week rehabilitation program with music & exercise groups on range of motion in young children with severe burns. J Burn Care Rehabil 2002. In this decade of increasing attention to physical fitness. Maxwell G. Caspersen CJ. Recent outcomes in the treatment of burn injury in the United States: a report from the American Burn Association Patient Registry. 10. Public Health Rep 1985. Mortality and causes of death in a burn centre. Mehta S. Przkora R. 3. Spies RJ. exercise. and none of the 8 randomized controlled trials received the maximum PEDro score.24 By improving fitness. and that exercise training programs can bring on meaningful improvements in all components of physical fitness. Effects of a 12-wk resistance exercise program on skeletal muscle Arch Phys Med Rehabil Vol 92. Furthermore. 16. Herndon DN. Herndon D. Herndon DN. using the 5 health-related components of physical fitness: muscular strength. Bloemsma GC. National Burn Repository 2010. body composition. et al. However. cardiorespiratory endurance. Fauerbach JA. Moore M. it can hasten reintegration into occupational and social activities and increase participation after burn injury.29:939-48. American Burn Association. and similarity of the available studies. et al.88:S24-9. Muscle strength in individuals with healed burns. future studies would include assessment of all 5 components of physical fitness.

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