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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
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
The search was limited to studies with human subjects and to the English language. Shriners Hospitals for Children Galveston. the modiﬁed Sackett scale (table 1) as developed by Teasell et al15 was used to determine the strength of evidence. This is expressed as levels from 1. *Adapted from Teasell et al. 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. posttest. the methodological quality was assessed by applying the PEDro assessment scale. which were used to compare physical ﬁtness in burned and nonburned people. Data Extraction Information was collected on characteristics of each study. muscular endurance. of which 7 had PEDro scores of 6 points or more (see table 2). Single case reports and studies limited to hand function were excluded from this review. September 2011 . NA. and functioning were used. to 5. the terms burn injury. so were classiﬁed as level 1 evidence according to the modiﬁed Sackett scale. Six studies provided data for the ﬁrst aim of this review. references from reviews and studies were checked. strength. The PEDro assessment scale scores range from 1 to 10 points. Nine studies were included for the second aim of this review. the evaluation of the effects of an exercise program on the physical ﬁtness of people with burns. the study design was determined. and experts in the ﬁeld associated with the Dutch burn centers were consulted. RCT. For the evaluation of effectiveness. *Levels of evidence are determined using a modiﬁed Sackett scale. 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. Further. the comparison of the physical ﬁtness in burned and nonburned subjects. body composition. Methodological Quality of the Included Studies Eight studies were randomized controlled trials. Second. and case series Observational studies. with a PEDro score of 5 points. SHCG. rehabilitation. body composition. outcome. and single case reports study provides sufﬁcient statistical information to make results interpretable. such as study design and intervention. and ﬂexibility.15 One randomized controlled trial. MU. RESULTS Eleven relevant studies could be included (table 2). randomized controlled trial. Third. and 1 nonrandomized controlled trial provided level 2 evidence. Data Synthesis The methodological quality of the included studies was assessed in 3 steps. the 5 health-related components of physical ﬁtness as originally described by Caspersen10 were used as a framework in this review. in addition. not applicable. endurance. Results were reported for each component separately. physical ﬁtness. Two static group comparison studies.1502 PHYSICAL FITNESS IN PEOPLE AFTER BURN INJURY. and 4 of these were used in both parts of this review. For the comparison of the physical ﬁtness in burn patients and healthy subjects. One of these studies16 reports on 2 different study groups. The framework comprises muscular strength. To provide a structured overview. Arch Phys Med Rehabil Vol 92. which are discussed separately throughout this review. mean ages and burn sizes). 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. 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. the weakest level of evidence. where 10 indicates excellent methodological quality and 1 indicates very poor methodological quality. yielding a total of 7 study groups for this comparison. First. and exercise. 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. were considered as level 3 evidence (see table 2). Johns Hopkins University School of Medicine Baltimore. McGill University Quebec. cardiorespiratory endurance. only studies with a description of the applied exercise training program were included. clinical consensus. Whether the data search was complete was checked by 2 independent researchers.15 ence were searched with the key words burns. for all randomized controlled trials. as well as on characteristics of the subjects (eg. cohort and non-RCTs Case-control trials Pre-post studies. randomized controlled trials. the strongest level of evidence.
20 showed great differences in VO2peak between the groups. number of participants. Six study groups provided information about muscular strength. expressed as peak torque.21 the differences in TLBM were nonsigniﬁcant. the physical ﬁtness of burn patients with that of healthy control subjects.4 46. sex. Suman and Herndon21 and Alloju17 reported signiﬁcant differences (P . 22.20 did not apply statistical analyses. with a minimum of 40%. time postburn of assessment.8 12. Texas.7%. In 1 study.5–6* 0.16. Body composition was evaluated in 4 study groups (table 5). month. P . September 2011 .5 to 12 months postburn (table 3). at velocities of 1.20. 10. The subjects in the study by De Lateur et al22 were adults with burns involving a mean TBSA of 19. The mean TBSA involved in the burns of these children was greater than 50%. Muscular strength. in the upper and lower extremities bilaterally.93) between burned and nonburned children. and patients with burns involving greater than 30% TBSA. and in one of them. but without statistical analyses. showed lower values than controls on all measures of muscular endurance.3% 15. LLM. SHCG. and/or lean trunk mass were measured by dual-energy X-ray absorptiometry (DEXA) in kilograms. The group with greater than 30% TBSA burned scored lower than controls on every measure. Controls for both study groups were matched for age. Alloju17 also reported signiﬁcantly lower values (64. Disseldorp Table 3: Characteristics of Included Study Groups and Corresponding Subjects. Less obvious. Five of the 7 included study groups originated from Shriners Hospitals for Children in Galveston.5–3 and 3. The other 2 studies18.6 10. respectively).21 included only subjects whose burns involved more than 40% TBSA. Obviously.14rad/s. scored higher than the control group on both work and power in knee as well as elbow ﬂexion and extension. 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. is measured by treadmill testing in 3 study groups (see table 5). and the time of assessment varied from 0. no signiﬁcant differences in the strength of knee ﬂexors and extensors were found between the burned group and the healthy control group. All 4 study groups17.PHYSICAL FITNESS IN PEOPLE AFTER BURN INJURY.0 39. In one of the studies. *Range. were compared (see table 4). In elbow ﬂexion and extension. The results did not show signiﬁcant differences (P . The study group of St-Pierre. Body composition. 20. matched also for sex. and 12 6 14† 16† 24 16 Unknown 26 46 86† 75† 58 56 65† 94 52 40. 15–92 days postburn. Arch Phys Med Rehabil Vol 92. Time PB. 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). but this betweengroup difference was signiﬁcant only for knee extension at 3. Flexibility. In 3 of these 5 study groups the controls were matched for age. with the higher values on the side of nonburned subjects. and combined and averaged the results of both for every limb.14rad/s (16%. Total lean body mass (TLBM). All but 1 trial were from Shriners Hospitals for Children (Galveston. Only 1 study17 measured ﬂexibility (see table 5).3 12.5 11. expressed in terms of work and power.7 11 11.17 the differences were signiﬁcant (TLBM. and the other 2 studies18. The same methods were used as for muscular strength. The group of burned subjects was split into 2 study groups: patients with burns involving 30% TBSA or less. Of these. In 3 study groups.05) in cardiorespiratory endurance. † Matched with burned subjects.17 the muscular endurance of patients with burns and healthy controls.18. For the group with burns involving 30% TBSA or less.5 58.2%).0 53. the participants of these 5 study groups were children (mean ages. Muscular endurance. n. while in the other 2 studies18.1 58. 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 40.0 0.5y).05). however.5–3 and 3. St-Pierre16 measured peak torque.6† 39.0† 12. Shriners Hospitals for Children Galveston.011 and 68.5–6* 6 and 9 6 and 9 6 and 9 6. MU.7–12. One study19 reported a signiﬁcant between-group difference (P . expressed as peak oxygen consumption (VO2peak).1% without a P value.8 23. Texas) and clearly involved just children. and all found less strength in burned subjects than in controls. which is exceptionally large. and all found lower values in children with burns than in nonburned controls.5† 12. lean arm mass.2† 13.1† Abbreviations: mo. The study group with burns involving greater than 30% TBSA. St-Pierre16 included adults aged 24 to 69 years with upper extremity burns involving at least 15% TBSA. but hereby provided results of burned and nonburned subjects before the start of the program. measured with an isokinetic dynamometer.16 consisting of subjects with burns involving 30% TBSA or less.8 10.8 56. Overall. though not all between-group differences were signiﬁcant (see table 4). McGill University Quebec.20 statistical analyses were not applied (table 4). The 4 Shriners’ studies measured peak torque in the dominant leg extensors. and physical activity level.2% without a P value) of total work in burned subjects than in the control group. Functional dynamic range of motion (ROM) was assessed during the performance of leg extension. The cardiorespiratory endurance. most subjects were male. No signiﬁcant between-group differences were found. Cardiorespiratory endurance. The other 4 studies18-21 aimed to evaluate the effect of a physical training program in burn patients.6 57.3%. both groups did not show signiﬁcant between-group differences. lean leg mass (LLM).05 and 3. however. 9.
14rad/s NB (15.2%) B NB Knee extensor power* .Sign (16%) NB -Sign at 3. † Measured at 150°/s.14rad/s. NT. nonsigniﬁcant between-group differences.14rad/s B NB Elbow ﬂexor Other measures NB (20.2%) PHYSICAL FITNESS IN PEOPLE AFTER BURN INJURY. NB.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 92.5%) B NB Elbow extensor .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 . signiﬁcant between-group differences.05rad/s -Sign at 3.05 and 3. nonburned subjects.011) NT Isokinetic total work† Knee extensor (dominant side) Knee extensor total work: B NB Sign (64. . September 2011 B B B B B B B B B B B B NB Sign (68. NS.14rad/s (17. Sign. *Measured at 1.05rad/s B NB Knee ﬂexor and average 3. not tested. burned subjects.NS Knee extensor power: -NS at 1.1%) 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. 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.
quadriceps. LTM. tailored burn rehabilitation protocol of the John Hopkins Burn Center. not tested. Sign. burned subjects. Subjects in the study by De Lateur22 started at a mean of 37. The intervention group received. Two studies of Shriners Hospitals investigated the effect of additional drugs (oxandralone18 and growth hormone20). of which 20 to 40 minutes was aerobic exercise (for exceptions see table 6). this was supplemented with 30 minutes of aerobic treadmill exercise 3 times a week. 1505 All studies comprised an intervention with a duration of 12 weeks. September 2011 Statistics Results Table 5: Results for the Comparison of Body Composition.21. NT. in addition to 5h/wk of rehabilitation therapy. measured by DEXA and expressed as lean mass in kilograms.20. One of the studies21 applied a follow-up measure after another 12 weeks with home-based exercise prescriptions. Muscular endurance. In the Shriners’ studies. 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. Body composition. LAM. NS.24 subjects who received growth hormone were included in both the intervention and control groups. Cardiorespiratory Endurance. note that SDs were very large in the studies by Przkora18 and Al-Mousawi25 and colleagues (see table 7).5 days postburn. but this did not cause signiﬁcant changes in both groups.22 all participants received the standardized. Subjects in the study by Neugebauer23 joined the exercise and music groups as soon as they were medically ready. For the intervention groups. all signiﬁcantly greater than increases of the control group. Body composition. LAM. individualized and supervised exercise training programs consisting of aerobic as well as resistance training. was mentioned in 5 effect studies18. Disseldorp Abbreviations: B. 3 sessions of an exercise and music program per week. All studies reported averaged increases in strength of more than 40% in the intervention group. The study by Neugebauer et al23 is an exception in the Shriners’ studies. signiﬁcant between-group differences. lean arm mass. 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 exercise program started at 6 months postburn (see table 6). Most of these interventions involved 3 training sessions per week. nonburned subjects. triceps.24.20. Signiﬁcant differences persisted when increases in strength were normalized to individual changes in TLBM. For the “work-to-quota” group. All studies reported signiﬁcantly greater increases in the intervention group than in the control group over 12 weeks. the control group participated in a home-based rehabilitation program without exercise prescriptions. A dynamometer was used to measure isokinetic peak torque in the knee extensors of the dominant leg. Suman et al24 measured total work and average power in the leg extensors. Information about the changes in muscular strength as a result of the exercise training program of 12 weeks was given in 5 studies18. In the study of De Lateur.25 (see table 7). nonsigniﬁcant between-group differences. lean trunk mass. as participants were trained and given a home-based rehabilitation program or received outpatient therapy at the hospital. while Cucuzzo et al8 used the calculated total volume of work produced by the biceps. but only results of the relevant (nondrugged) groups were used in this review. Two studies reported data on muscular endurance (see table 7). LLM. In all but 2 studies.25 However. this rehabilitation program was supplemented with hospital-based.24.25 (table 7). in 2 other studies of Shiners Hospitals used here.3%) LLM: Sign (22. NB.21. forearms. For the intervention groups. which is not further speciﬁed. The “work-to-tolerance” group was instructed to tolerate the exercise at the individual target heart rate for as long as possible. The control group was heterogeneous in the number of sessions and the location of therapy.24. each lasting 60 minutes. The time postburn at the start of the intervention varied between studies. Signiﬁcant between-group differences in the improvement of muscular endurance over 12 weeks were found on all 3 variables. and hamstrings. It was unclear on which criteria this was based.2%) Statistics NT Functional dynamic ROM in leg extension Parameter B NB NS . this exercise was intensiﬁed throughout the 12 weeks by increasing the target exercise heart rate and time according to preset quotas.PHYSICAL FITNESS IN PEOPLE AFTER BURN INJURY. and Flexibility in Burned and Nonburned Subjects Flexibility NT NT Sign (no values) No statistical analyses Cardiorespiratory Endurance B NB. However.19. Al-Mousawi25 normalized the Arch Phys Med Rehabil Vol 92. Muscular strength. this intervention for young children was not individualized but comprised group sessions.
despite signiﬁcant increases in active ROM over the intervention. 9 to 122 days postburn. Disseldorp Table 6: Characteristics of Included Studies and Corresponding Subjects. Five studies included children with burns involving greater than 40% TBSA. time postburn of assessment. mean. 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. On the contrary. on average. burn size.0 19. for the right elbow and left knee.3 59. the included population in this review is a remarkable one—that is. endurance.5 61.0† 6 and 9 58. and time postburn. 2.1506 PHYSICAL FITNESS IN PEOPLE AFTER BURN INJURY. Shriners Hospitals for Children Galveston.6 58. the included studies show great similarity in subjects on the domains of age. between-group differences appeared nonsigniﬁcant.24 used treadmill tests and found increases greater than 20% in VO2peak in the intervention group.7 58. month. Five studies used treadmill exercise testing following the modiﬁed Bruce protocol. The ﬁfth study8 used the 6-minute walk test and reported that the performance of both the intervention and control group increased. Time PB.5 days.6 10. In 1 study. A follow-up measure in one of the studies21 did not show signiﬁcant changes from another 12 weeks of homebased exercise prescriptions. Active ROM increased signiﬁcantly more in the intervention group than in Arch Phys Med Rehabil Vol 92. Moreover. 60min Aerobic exercise 30min resistance training Abbreviations: JHU. The 1 study including adults22 (mean TBSA.6 6 and 9 6 and 9 6 and 9 3 3 3 3 5 3 3 56.7 10. DISCUSSION This review included 11 high-quality studies. which differed signiﬁcantly from increases in the control group.2* 6 and 9 54.3% of burn patients younger than 18 years have burns involving more than 40% TBSA. † This is a selection of the participants. and 4.5 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. and these outcomes were expressed in VO2peak for chil˙ dren and maximum oxygen consumption (VO2max) for adults. In 6 studies (table 8). Therefore. 19.8 6. In the Netherlands. which reported on 12 study groups. measurements to height and found that this signiﬁcant difference persisted. 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 10.26 Recent American data show that patients with a total burn size of more .7 10.3%) re˙ ported signiﬁcant increases in VO2max for both the work-toquota and work-to-tolerance intervention groups. but with a signiﬁcantly larger increase for the intervention group. The rest of the participants received growth hormone.2‡ Neugebauer et al23 SHCG 15 9 3. SHCG. which was measured in the elbow and knee joints by goniometry and expressed as passive and active ROM.6 11. and 12 1. number of participants. and are excluded in this review. *This is a selection of the participants.8 58. the other 5 involve only children. these children have exceptionally extensive burns. It showed that (1) children and adults with extensive burns score worse than nonburned controls on measures of all 5 components of physical ﬁtness. n. Flexibility. The control group did not improve signiﬁcantly. a selection of the patients generally admitted to burn centers. 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. only 1. Four of these18-20. and functional movement. Only 2 of the 7 included study groups concern adults. The rest of the participants received oxandrolone. intensiﬁed throughout 12wk by work-to-quota or work-totolerance protocol Exercise-based music activities to promote ROM.0 Al-Mousawi et al25 SHCG 11 10 12. 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.8 functional cardiorespiratory endurance was assessed with the 6-minute walk test. and (2) the effectiveness of exercise training programs in improving physical ﬁtness in people after burn injury. to provide an overview of (1) the physical ﬁtness of people after burn injury. Johns Hopkins University School of Medicine Baltimore. and both between-group differences were signiﬁcant. However. September 2011 controls for the left elbow and the right knee.5 38. 37. Only 1 study23 (see table 8) included ﬂexibility. and are excluded in this review. cardiorespiratory endurance was measured.3 12. ‡ Range. Cardiorespiratory endurance. mo.
7% 4.7% 1 TW: I: 78. sex. Concerning the methods of measurement. Hypermetabolism might play a role. and Body Composition in People With Burn Injury TLBM. This ﬁnding lies within expectations. Sign. especially since the precise location of the burns and their possible inﬂuence on leg or arm function are not taken into account.3% 2 6 –9mo PB: I: 6.7% 1 C: 2. lean arm mass. did not return to baseline levels at 6 months after discharge from the hospital. lean trunk mass. was somewhat decreased in children with extensive burns compared with controls. I. They assessed 86 adult burn patients (mean age. but whether they catch up later is yet unknown. and activity level. it is remarkable that in all reviewed studies. Because scars subsequent to burn injury can cause contractures in the affected joint. TW.3% 1 C: 12. mean TBSA.31-33 The pediatric burn patients might miss a part of this rapid gain because of metabolic responses and the sedentary period postburn.6% 1 C: 3. A much longer lasting deﬁcit in strength was reported in another study related to the Shriners Hospital. LLM.3% 16. Abbreviations: AP. Baker12 found that 35% of 83 young adult survivors of burns sustained in childhood (mean time postburn.9% 1 C: 1. 1 indicates improvement on this parameter.9% 2. intervention group.5%1 C: 2.5% 1 9 –12mo PB: I: 17. average power. 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. in this age span.13 This follow-up study by Jarrett et al13 did not measure a control group and was therefore not included in the review. 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. Cardiorespiratory endurance is affected in severely burned children compared with controls.3 whereas 71% had a TBSA of less than 10%.6% 1 9 –12mo PB: I: 10. the question arises whether ROM in the leg is a sufﬁcient parameter for the overall ﬂexibility. LLM.3% 40. mo. It is interesting that a similar conclusion was drawn for adults with smaller burn sizes at a relatively longer period postburn. considering the relatively short period postburn and the inactivity in this period. this ﬁnding also does not seem very surprising.2% 2.6% of all cases.4% 1.0% 2 LLM.3% 1 C: 8.13 Flexibility. healthy children are in the period of the most rapid gain in lean body mass. It can be questioned whether measuring only knee extension is a good indication of the overall muscular capacity. Moreover. For both muscular strength and endurance. LTM. Schneider et al34 reported that 38.5% 1 C: 6.2%) and reported that functional exercise capacity. LTM.5% 1 I: 42.8% 1 I: 8. in terms of the functional dynamic ROM in leg extension.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. 38y.28 Therefore. PB.1% 3. NT. for other joints the differences were nonsigniﬁcant.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. postburn. *By cumulative 3-repetition maximum tests in biceps. and LAM by DEXA TLBM. signiﬁcant between-group difference (1I 1C).7% of adult burn patients (n 985) have developed at least 1 contracture at discharge.1% 1 C: 37. 30%–99%) had deﬁcits in strength in any part of the body. TBSA range. but these differences were not signiﬁcant. control group.2% 13. and hamstrings. LAM.8% 6. Disseldorp NOTE. the children with extensive burns had lower mean values of lean body mass than their controls. 14 5y. total work. Values are mean SD or as otherwise indicated. compared with normative values.7% 4. the included populations are not truly representative of the general burn population. triceps.4% 1 I: 54. measured by a shuttle walk test.5% 1. and LTM: I: 1 and C: 1 I: 1 C: – 0. LAM. but this study by Baker et al12 was excluded from the review because a control group was lacking. forearm.4% 1 C: 5. 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. 11.0% 1 C: 6.1% 1 C: 7.PHYSICAL FITNESS IN PEOPLE AFTER BURN INJURY. with an average of 3 contractures Arch Phys Med Rehabil Vol 92. C. After extensive burns. muscular strength and muscular endurance were measured in the knee extensor of the dominant side.6% 1 C: –1. 1507 than 40% TBSA accounted for only 4.29.12 In all studies that measured body composition.6% 10.2% 1 Body Composition Results 6 –9mo PB: Signiﬁcance not reported 9 –12mo PB: Signiﬁcance not reported Sign Statistics .8% 5.4% 1 Results I: 44. the metabolic and catabolic disturbances are signiﬁcant relative to burns involving less than 40% TBSA and can persist up to 12 months postburn.8% 1 C: 3.7% 8.6% 15% 1 6 –9mo PB: I: 40. who were matched for age. Muscular Endurance.3% 44.4% 1.9% 10. adults with burns involving less than 30% TBSA scored higher than their controls.10% 1 AP: I: 72.27. month. Only in the adult groups were the knee ﬂexors and elbow extensors and ﬂexors also assessed. not tested. For the knee extensor the differences were signiﬁcant. On the other hand. children and adults with extensive burns scored lower than their controls on all parameters.3 Not only the low prevalence but also the physiologic consequences of such extensive burns make this group exceptional.4% 4. quadriceps. the subjects with a higher percentage of TBSA involved had lower mean strength. with the skeleton showing the highest responsiveness to physical activity.30 Overall. LTM.
5% 1 I: 23. Exercise can signiﬁcantly reduce the number of surgical scar releases39 and has been proven effective in improving pulmonary function in children with severe burns. 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. Their outcomes varied from no measurable physical impairment to more than 90% impairment. This review shows that because of a 12-week exercise training program.35 In the study by Moore et al. Only Suman and Herndon21 made a comparison and reported that after completion of the exercise program.3% 1 C:14. the critical remarks on the included study population and assessments as discussed above should be kept in mind. ROM of both upper and lower extremities was measured to calculate physical impairment in older children with extremely extensive burns ( 80% TBSA). speciﬁc to this review question. the possible recent surgical interventions should also be taken into account. 27mo.1% 1 I: 22. ﬂexibility around multiple joints (ie. with an average of 52%.12% 3. hand.35% 16. it is remarkable that only 1 study could be included that measured ﬂexibility. signiﬁcant between-group difference (1I 1C). . and 7 of these tested similar interventions. body composition. the question is whether the physical ﬁtness of burn patients returns to ﬁtness levels from before the injury (normal values). and lean body mass strongly increased. and 12 months postburn.35 not included in the review because of lack of a control group.35% 1 I: 24. 4. I-WTQ. 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. Values are mean SD or as otherwise indicated. 1 indicates improvement on this parameter. cardiorespiratory endurance. Likewise. but for none of these is there indisputable evidence yet.3% 4. In a study by Gorga et al. Whereas apparently signiﬁcant improvements in physical ﬁtness can be made with exercise training programs. muscular endurance. intervention group exercising by target heart rate and time intensiﬁed according to preset quotas. upper extremity. muscular endurance. Since measurements are done at a certain time point postburn. 6. Arch Phys Med Rehabil Vol 92. the mentioned similarity in studies caused a lack of variation in applied protocols and exercise interventions. intervention group exercising as long as possible at individual target heart rate. I. Given this. it proves difﬁcult to interpret.6% 1 C: 9. between-groups difference not signiﬁcant.1508 PHYSICAL FITNESS IN PEOPLE AFTER BURN INJURY.1% 1 C: ca. They concluded that at 1. according to normative values. 6%). Abbreviations: C. the comparison of burn patients in exercise groups with groups of matched healthy controls is lacking. not tested. Eight of the 9 included studies in this part of the review originated from Shriners Hospitals for Children. head/neck. the location of the burn is essential for ﬂexibility and should be reported with the results. and motor imagery. the values of patients with burns remained below those of nonburned subjects for lean mass and muscular strength. more beneﬁcial effects of exercise on physical outcomes are known.19 according to randomized controlled trials from the Shriners Hospitals. Furthermore. control group. Additional literature36-38 suggests that ROM in people with burns could also be increased by massages. mean TBSA.2% 16. 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. per person. and lower extremity) was tested in very young children with relatively small burns (mean age. Besides effects on the components muscular strength. starting 6 months postburn. I-WTT. In addition. however. Sign. September 2011 fewer different training protocols are evaluated in this review than one would like. virtual reality treatment. most of the children had ROMs within normal limits.14 which was also not included because of lack of a control group.7% 1 C: 1. children’s muscular strength.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. NT. exercise has also been proven effective in improving the cardiorespiratory endurance in adults as well as children.14 So whereas ROM seemed an easy and appropriate parameter for ﬂexibility in people after burn injury. and ﬂexibility.5% 1 I: 23. intervention group. NS.7% 1 C: 3. As all studies compared people with burns in exercise groups and nonexercise groups. Therefore.
94:2273-81. applied exercise programs. are necessary to ﬁll the hiatus in the current knowledge. References 1. Blakeney P.119:e109-16. Suman OE. Bloemsma GC. Physical and psychologic rehabilitation outcomes for young adults burned as children.88:S18-23. Herndon DN. to enable optimization of the effectiveness of exercise training protocols for individual patients. Herndon DN. 15. intensity. Caspersen CJ. 19. Oen IMMH.88:S57-64. 2. 12. Suman OE. Goodwin CW. 5. Mlcak RP. Herndon DN. quality. and none of the 8 randomized controlled trials received the maximum PEDro score. Thomas SJ. The effects of exercise programming vs traditional outpatient therapy in the rehabilitation of severely burned children. to maintain and further improve the ﬁtness levels achieved by exercise in the rehabilitation phase. However. Practical Implications We feel that physical ﬁtness and exercise deﬁnitely deserve a lot more attention in burn care. Patient perception of quality of life after burn injury. Boxma H. J Burn Care Rehabil 1995. 2010. Muscle strength in individuals with healed burns. 24. J Burn Care Rehabil 2002. Boxma H. Neugebauer CT. 10. Pruitt BAJ. the number of appropriate studies on physical ﬁtness is limited. and frequency of exercise. 3. the independent functioning and self-care in burn patients could get better.85:383-413.34:452-9.22:214-20. Herndon DN. Spies RJ. Public Health Rep 1985. Effect of exercise training on pulmonary function in children with thermal injury. 16. Because improved physical ﬁtness might have a positive impact on several areas of life. Magyar-Russell G. Bresnick MG. Epidemiology of burn injury and demography of burn care facilities. Magyar-Russell G. Preferably. Burn rehabilitation: state of the science. Essink-Bot ML. muscular endurance. exercise. 14. Effect of exogenous growth hormone and exercise on lean mass and muscle function in children with burns. et al. Choiniere M. 4. September 2011 .23:288-93. in a highly structured way. Murphy L. aimed at both shortterm and long-term physical ﬁtness outcomes. Mehta S. Report of data from 2000-2009. et al. Am J Phys Med Rehabil 2006. Herndon DN. 21. 7.7:235-51. 17. Brusselaers N. Physical ﬁtness is essential in the performance of activities of daily living.11:330-3. Burns 2008. 13. Moore P. Serghiou M. Only 11 studies could be included. Thombs BD. Dokter J. Outcome and changes over time in survival following severe burns from 1985 to 2004. Safﬂe JR. American Burn Association. J Burn Care Rehabil 2001. Arch Phys Med Rehabil 2007. Physical outcomes of patients with burn injuries—a 12 month follow-up. and healthy aging. Moore M.0. Mortality and causes of death in a burn centre. Since 9 studies were from the same institute and showed great similarities in study populations. Maxwell G. Silverstein P. Stiller K. Burns 2008. 22.91:816-31. Jarrett M. Probl Gen Surg 2010. National Burn Repository 2010. and similarity of the available studies. intervention studies should investigate varying duration. J Burn Care Res 2008. Fiatarone Singh MA. Proctor DN. St-Pierre DM. exercise. Herndon D. Arch Phys Med Rehabil 2007. A systematic review of pharmacologic treatments of pain after spinal cord injury. Christenson GM. Herndon DN. and research protocols. future studies would include assessment of all 5 components of physical ﬁtness. Intensive Care Med 2005. Effects of a 12-week rehabilitation program with music & exercise groups on range of motion in young children with severe burns. et al. J Appl Physiol 2003. McEntire SJ. McMahon M. using the 5 health-related components of physical ﬁtness: muscular strength. The effects of oxandrolone and exercise on muscle mass and function in children with severe burns. Competence and physical impairment of pediatric survivors of burns of more than 80% total body surface area. In this decade of increasing attention to physical ﬁtness. J Burn Care Rehabil 1996. et al.29:939-48. Pediatrics 2007. Fauerbach JA. Esselman PC. cardiorespiratory endurance. 18. Furthermore. and physical ﬁtness: deﬁnitions and distinctions for health-related research. Aubut JA. it can hasten reintegration into occupational and social activities and increase participation after burn injury. Meyer W. Ferrando A. Because of the great similarities of the subjects and protocols used in the included studies. Furthermore. Dokter J. Chodzko-Zajko WJ. many questions remain unanswered. Burns 2006. Thereby. Exercise and physical activity for older adults. Suman OE. Baker CP. J Burn Care Res 2008. Oen IM. Blakeney P. and ﬂexibility. Mason ADJ. the burn (research) community should take advantage of this trend. Controlled studies including both children and adults with minor and moderate burns. Functional outcome after burns: a review.32:1-9. Przkora R. Russell WJ. 23. Herndon DN.16:219-32. which brings new opportunities and growing knowledge. Arch Phys Med Rehabil 2010. the generalizability of the results is not optimal. Arch Phys Med Rehabil 2007.100:126-31.88:S24-9. Powell KE. Monstrey S. 6. American College of Sports Medicine position stand. Forget R.41: 1510-30. Suman OE. Three of those were not randomized controlled trials. Suman OE. Augmented exercise in the treatment of deconditioning from major burn injury. van Beeck EF. Mlcak RP. Effects of cessation of a structured and supervised exercise conditioning program on lean mass and muscle strength in severely burned children. Cobb N. 8. J Burn Care Rehabil 1990. Effects of a 12-wk resistance exercise program on skeletal muscle Arch Phys Med Rehabil Vol 92. Alloju SM. Van Baar ME. 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. Recent outcomes in the treatment of burn injury in the United States: a report from the American Burn Association Patient Registry.17:547-51. Cucuzzo NA. Physical activity. 20.PHYSICAL FITNESS IN PEOPLE AFTER BURN INJURY. Suman OE.31:1648-53. and the number of burn centers publishing on this topic is even smaller. CONCLUSIONS This review of 11 high-quality studies showed that physical ﬁtness is affected in people after extensive burn injury. Version 6. Suman OE. Teasell RW.24 By improving ﬁtness. body composition. Mlcak RP. it is assumed to improve the perceived quality of life. Herndon DN. Results of an eleven-year survey. Arch Phys Med Rehabil 1998. Meyer W III. 79:155-61. Wilkins JP. Hoste EA. Garrel DR. Assessment of muscle function in severely burned children. Furthermore. they should intensify and increase its efforts to limit the physical burden of burn injury as much as possible. 11. De Lateur BJ.34:1103-7. promotion of an active lifestyle is very important.29:975-84. Celis MM. 9. Med Sci Sports Exerc 2009. Disseldorp 1509 Study Limitations The present review is the ﬁrst to emphasize the hiatus in knowledge about physical ﬁtness in patients after burn injury. This review is mainly limited by the quantity. and that exercise training programs can bring on meaningful improvements in all components of physical ﬁtness.
J Burn Care Res 2006. J Burn Care Rehabil 2003. Krenning EP. Mlcak RP. Garrison D. Lebon F. Dutch Burn Repository 2010. Available at: http://www. 2011.363:1895-902. Kowalske K. J Bodyw Mov Ther 2008. Association of Dutch Burn Centers. Stegink Jansen CW. Bone densitometry in Canadian children 8-17 years of age. Arch Phys Med Rehabil 1985. Schneider JC. The physical. World J Surg 2000.30:785-91. strength in children with burn injuries. 30. Carrougher GJ. Herndon DN. 27. 31. Alwis G. J Burn Care Res 2010. Collet CP. Sernbo I. Holavanahalli R. Calcif Tissue Int 1996.24:57-61. Yen P. van der Sluis IM. Celis MM. Duppe H. Metabolic management of patients with severe burns. Mathiowetz V. Normative dual energy x-ray absorptiometry data in Swedish children and adolescents.12:67-71. Support of the metabolic response to burn injury. Demling RH.99: 1091-9. 37. Herndon DN. Seigne P. Accessed July 5. Faulkner RA. et al. 35. Arch Phys Med Rehabil Vol 92. Doyon JP. Contractures in burn injury: deﬁning the problem. Karlsson MK. 28. Gorga D. Volland G. Lancet 2004. Kashman N. September 2011 . Bentley A.30:686-93. 29.1510 PHYSICAL FITNESS IN PEOPLE AFTER BURN INJURY. Williams FN. Range of motion improves after massage in children with burns: a pilot study. Hoffman HG. Effect of motor imagery in the rehabilitation of burn patients. Effect of a supervised exercise and physiotherapy program on surgical interventions in children with thermal injury. Johnson J.59:344-51. Helm P. J Burn Care Rehabil 1999. Guillot AP. de Ridder MAJ. 39. Rosengren B. J Appl Physiol 2001.91:1168-75. J Burn Care Res 2009. et al.16:326-36.27.66:69-74. Goldstein R. Reference data for bone density and body composition measured with dual energy x ray absorptiometry in white children and young adults. 26. Grip and pinch strength: normative data for adults. Tompkins RG.nl. and developmental outcome of pediatric burn survivors from 1 to 12 months postinjury. Acta Paediatr 2010. Girbon JPM. Huang TT. Jeschke MG. Suman OE. Boot AM. 36. Smith NK. Herndon DN. 32. The effect of virtual reality on pain and range of motion in adults with burn injuries. functional. J Burn Care Res 2009.24:673-80.adbc.31:400-8. Morien A. J Hand Ther 2003. Arch Dis Child 2002. Suman OE.87:341-7. Stenevi-Lundgren S. 38. de Muinck Keizer-Schrama SMPF. Disseldorp 25. Vernay MM. Measurement of maximum voluntary pinch strength: effects of forearm position and outcome score. Al-Mousawi AM. Nakamura D.20:171-8. 34. Effects of exercise training on resting energy expenditure and lean mass during pediatric burn rehabilitation.508-14. 33.
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