Status of adult inpatient burn rehabilitation in Europe: are we neglecting metabolic outcomes?

Abstract

Background: Hypermetabolism, muscle wasting and insulin resistance are challenging yet important rehabilitation targets in the management of burns. In the absence of concrete practice guidelines, however, it remains unclear how these metabolic targets are currently managed. This study aimed to describe the current practice of inpatient rehabilitation across Europe. Methods: An electronic survey was distributed by the European Burn Association to burn centres throughout Europe, comprising generic and profession-specific questions directed at therapists, medical doctors and dieticians. Questions concerned exercise prescription, metabolic management and treatment priorities, motivation and knowledge of burn-induced metabolic sequelae. Odds ratios were computed to analyse associations between data derived from the responses of treatment priorities and knowledge of burn-induced metabolic sequelae. Results: Fifty-nine clinicians with 12.3 ± 9 years of professional experience in burns, representing 18 out of 91 burn centres (response rate, 19.8%) across eight European countries responded. Resistance and aerobic exercises were only provided by 42% and 38% of therapists to intubated patients, 87% and 65% once out-of-bed mobility was possible and 97% and 83% once patients were able to leave their hospital room, respectively. The assessment of resting energy expenditure by indirect calorimetry, muscle wasting and insulin resistance was carried out by only 40.7%, 15.3% and 7.4% respondents, respectively, with large variability in employed frequency and methods. Not all clinicians changed their care in cases of hypermetabolism (59.3%), muscle wasting (70.4%) or insulin resistance (44.4%), and large variations in management strategies were reported. Significant interdisciplinary variation was present in treatment goal importance ratings, motivation and knowledge of burn-induced metabolic sequelae. The prevention of metabolic sequelae was regarded as the least important treatment goal, while the restoration of functional status was rated as the most important. Knowledge of burn-induced metabolic sequelae was linked to higher importance ratings of metabolic sequelae as a therapy goal (odds ratio, 4.63; 95% CI, 1.50–14.25; p < 0.01). Conclusion: This survey reveals considerable non-uniformity around multiple aspects of inpatient rehabilitation across European burn care, including, most notably, a potential neglect of metabolic outcomes. The results contribute to the necessary groundwork to formulate practice guidelines for inpatient burn rehabilitation.

Keywords

Burn care / Burn rehabilitation / Exercise / Early mobilization / Hypermetabolism / Adults

References

[1] Smolle C, Cambiaso-Daniel J, Forbes AA, Wurzer P, Hundeshagen G, Branski LK, et al. Recent trends in burn epidemiology worldwide: a systematic review. Burns. 2017; 43: 249-57.

[2] Porter C, Tompkins RG, Finnerty CC, Sidossis LS, Suman OE, Herndon DN. The metabolic stress response to burn trauma: current understanding and therapies. The Lancet. 2016; 388: 1417-26.

[3] Cuthbertson DP. Post-shock metabolic response. The Lancet. 1942; 239: 433-7.

[4] Jeschke MG, Gauglitz GG, Kulp GA, Finnerty CC, Williams FN, Kraft R, et al. Long-term persistance of the pathophysiologic response to severe burn injury. PLoS One. 2011. https://doi.org/10.1371/journal.pone.0021245.

[5] Hart DW, Wolf SE, Herndon DN, Chinkes DL, Lal SO, Obeng MK, et al. Energy expenditure and caloric balance after burn. Ann Surg. 2002; 235: 152-61.

[6] Cree MG, Fram RY, Barr D, Chinkes D, Wolfe RR, Herndon DN. Insulin resistance, secretion and breakdown are increased 9 months following severe burn injury. Burns. 2009; 35: 63-9.

[7] Gauglitz GG, Herndon DN, Kulp GA, Meyer WJ, Jeschke MG.Abnormal insulin sensitivity persists up to three years in pediatric patients post-burn. J Clin Endocrinol Metab. 2009; 94: 1656-64.

[8] Chung S-D, Chen C-S, Lin H-C, Kang J-H. Increased risk for stroke in burn patients: a population-based one-year follow-up study. Burns. 2014; 40: 54-60.

[9] Duke JM, Randall SM, Fear MW, Boyd JH, O’Halloran E, Rea S, et al. Increased admissions for diabetes mellitus after burn. Burns. 2016; 42: 1734-9.

[10] O’Halloran E, Shah A, Dembo L, Hool L, Viola H, Grey C, et al. The impact of non-severe burn injury on cardiac function and long-term cardiovascular pathology. Sci Rep. 2016. https://doi.org/10.1038/srep34650.

[11] Duke JM, Randall SM, Fear MW, Boyd JH, Rea S, Wood FM. Understanding the long-term impacts of burn on the cardiovascular system. Burns. 2016; 42: 366-74.

[12] Xie B, Xiao S, Zhu S, Xia Z. Evaluation of long term health-related quality of life in extensive burns: a 12-year experience in a burn center. Burns. 2012; 38: 348-55.

[13] Goei H, Hop MJ, van der Vlies CH, Nieuwenhuis MK, Polinder S, Middelkoop E, et al. Return to work after specialised burn care: a two-year prospective follow-up study of the prevalence, predictors and related costs. Injury. 2016; 47: 1975-82.

[14] Branski LK, Herndon DN, Barrow RE.1-A brief history of acute burn care management. In: Herndon DN (ed). Total Burn Care, 5th edn. London: Elsevier, 2018, 1-7.e2.

[15] Porter C, Hardee J, Herndon DN, Suman OE. The role of exercise in the rehabilitation of patients with severe burns. Exerc Sport Sci Rev. 2015; 43: 34-40.

[16] Rivas E, Herndon DN, Porter C, Meyer W, Suman OE. Short-term metformin and exercise training effects on strength, aerobic capacity, glycemic control, and mitochondrial function in children with burn injury. Am J Physiol Endocrinol Metab. 2018; 314: E232-40.

[17] Mowafy ZME, El-Sayed AF, El-Monaem MA, Osman MA. Effect of aerobic and resistive exercises on resting energy expenditure and lean body mass during paediatric burn rehabilitation. Int J Pharmtech Res. 2016; 9: 1-7.

[18] Suman OE, Spies RJ, Celis MM, Mlcak RP, Herndon DN. Effects of a 12-wk resistance exercise program on skeletal muscle strength in children with burn injuries. J Appl Physiol. 2001; 91: 1168-75.

[19] Rousseau A-F, Massion PB, Laungani A, Nizet J-L, Damas P, Ledoux D. Toward targeted early burn care: lessons from a European survey. J Burn Care Res. 2014; 35: e234-9.

[20] Nedelec B, Parry I, Acharya H, Benavides L, Bills S, Bucher JL, et al. Practice guidelines for cardiovascular fitness and strengthening exercise prescription after burn injury. J Burn Care Res. 2016; 37: e539-58.

[21] ISBI Practice Guidelines Committee.ISBI practice guidelines for burn care. Burns. 2016; 42: 953-1021.

[22] Palmieri T. ISBI practice guidelines committee. ISBI practice guidelines for burn care, part 2. Burns. 2018; 44: 1617-706.

[23] Gittings PM, Grisbrook TL, Edgar DW, Wood FM, Wand BM, O’Connell NE. Resistance training for rehabilitation after burn injury: a systematic literature review & meta-analysis. Burns. 2018; 44: 731-51.

[24] Flores O, Tyack Z, Stockton K, Ware R, Paratz JD. Exercise training for improving outcomes post-burns: a systematic review and meta-analysis. Clin Rehabil. 2018; 32: 734-46.

[25] European Burns Association.European Practice Guidelines for Burn Care: Minimum Level of Burn Care Provision in Europe (Version 4), 2017. https://www.euroburn.org/wp-content/uploads/EBA-Guidelines-Version-4-2017-1.pdf. (Accessed date 12 Dec 2017).

[26] Hickmann CE, Roeseler J, Castanares-Zapatero D, Herrera EI, Mongodin A, Laterre P-F. Energy expenditure in the critically ill performing early physical therapy. Intensive Care Med. 2014; 40: 548-55.

[27] Medrinal C, Combret Y, Prieur G, Robledo Quesada A, Bonnevie T, Gravier FE, et al. Comparison of exercise intensity during four early rehabilitation techniques in sedated and ventilated patients in ICU: a randomised cross-over trial. Crit Care. 2018. https://doi.org/10.1186/s13054-018-2030-0.

[28] Tipping CJ, Harrold M, Holland A, Romero L, Nisbet T, Hodgson CL. The effects of active mobilisation and rehabilitation in ICU on mortality and function: a systematic review. Intensive Care Med. 2017; 43: 171-83.

[29] Hermans G, De Jonghe B, Bruyninckx F, Van den Berghe G. Interventions for preventing critical illness polyneuropathy and critical illness myopathy. Cochrane Database Syst Rev. 2014; 1: CD006832.

[30] Pedersen BK, Saltin B. Exercise as medicine-evidence for prescribing exercise as therapy in 26 different chronic diseases. Scand J Med Sci Sports. 2015; 25: 1-72.

[31] Malin SK, Liu Z, Barrett EJ, Weltman A. Exercise resistance across the prediabetes phenotypes: impact on insulin sensitivity and substrate metabolism. Rev Endocr Metab Disord. 2016; 17: 81-90.

[32] Kouidi E, Albani M, Natsis K, Megalopoulos A, Gigis P, Guiba-Tziampiri O, et al. The effects of exercise training on muscle atrophy in haemodialysis patients. Nephrol Dial Transplant. 1998; 13: 685-99.

[33] Patel BK, Pohlman AS, Hall JB, Kress JP. Impact of early mobilization on glycemic control and ICU-acquired weakness in critically ill patients who are mechanically ventilated. Chest. 2014; 146: 583-9.

[34] Whitehead C, Serghiou M. A 12-year comparison of common therapeutic interventions in the burn unit. J Burn Care Res. 2009; 30: 281-7.

[35] Cambiaso-Daniel J, Parry I, Rivas E, Kemp-Offenberg J, Sen S, Rizzo JA, et al. Strength and cardiorespiratory exercise rehabilitation for severely burned patients during intensive care units: a survey of practice. J Burn Care Res. 2018; 39: 897-901.

[36] Flores O, Tyack Z, Stockton K, Paratz JD. The use of exercise in burns rehabilitation: a worldwide survey of practice. Burns. 2020; 46: 322-32.

[37] Wallner C, Wagner JM, Dittfeld S, Drysch M, Lehnhardt M, Behr B. Myostatin serum concentration as an indicator for deviated muscle metabolism in severe burn injuries. Scand J Surg. 2019; 108: 297-304.

[38] Rehou S, Mason S, Burnett M, Jeschke MG. Burned adults develop profound glucose intolerance. Crit Care Med. 2016; 44: 1059-66.

[39] Gore DC, Chinkes DL, Hart DW, Wolf SE, Herndon DN, Sanford AP. Hyperglycemia exacerbates muscle protein catabolism in burn-injured patients. Crit Care Med. 2002; 30: 2438-42.

[40] Stanojcic M, Abdullahi A, Rehou S, Parousis A, Jeschke MG. Pathophysiological response to burn injury in adults. Ann Surg. 2018; 267: 576-84.

[41] Diego AM, Serghiou M, Padmanabha A, Porro LJ, Herndon DN, Suman OE. Exercise training following burn injury: a survey of practice. J Burn Care Res. 2013; 34: e311-7.

[42] Hundeshagen G, Suman OE, Branski LK. Rehabilitation in the acute versus outpatient setting. Clin Plast Surg. 2017; 44: 729-35.

[43] Cromes GF, Helm PA. The status of burn rehabilitation services in the United States: results of a national survey. J Burn Care Rehabil. 1992; 13: 656-62.

[44] Holavanahalli RK, Helm PA, Parry IS, Dolezal CA, Greenhalgh DG. Select practices in management and rehabilitation of burns: a survey report. J Burn Care Res. 2011; 32: 210-23.

[45] Chen J, Li-Tsang CWP, Yan H, Liang G, Tan J, Yang S, et al. A survey on the current status of burn rehabilitation services in China. Burns. 2013; 39: 269-78.

[46] Parry I, Sen S, Palmieri T, Greenhalgh D. Current trends in practice for early mobility with the burn population. J Burn Care Res. 2019; 40: 29-33.

[47] Serghiou MA, Niszczak J, Parry I, Richard R. Clinical practice recommendations for positioning of the burn patient. Burns. 2016; 42: 267-75.

[48] Australian and New Zealand Burn Association.Burn Survivor Rehabilitation. In: Edgar DW (ed). Principles and Guidelines for the Allied Health Professional, 2007. https://anzba.org.au/care/allied-health-guidelines/. (Accessed 25 July 2018).

[49] Burn Therapy Standards Working Group, British Burn Association.Standards of Physiotherapy and Occupational Therapy Practice in the Management of Burn Injured Adults and Children, 2017. https://www.britishburnassociation.org/standards-of-physiotherapy-occupational-therapy-practice/ (Accessed 15 July 2019).

[50] Nedelec B, Serghiou MA, Niszczak J, McMahon M, Healey T. Practice guidelines for early ambulation of burn survivors after lower extremity grafts. J Burn Care Res. 2012; 33: 319-29.

[51] Sommers J, Engelbert RH, Dettling-Ihnenfeldt D, Gosselink R, Spronk PE, Nollet F, et al. Physiotherapy in the intensive care unit: an evidence-based, expert driven, practical statement and rehabilitation recommendations. Clin Rehabil. 2015; 29: 1051-63.

[52] Hodgson CL, Stiller K, Needham DM, Tipping CJ, Harrold M, Baldwin CE, et al. Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults. Crit Care. 2014. https://doi.org/10.1186/s13054-014-0658-y.

[53] Kayambu G, Boots R, Paratz J. Physical therapy for the critically ill in the ICU: a systematic review and meta-analysis. Crit Care Med. 2013; 41: 1543-54.

[54] Okhovatian F, Zoubine N. A comparison between two burn rehabilitation protocols. Burns. 2007; 33: 429-34.

[55] Deng H, Chen J, Li F, Li-Tsang CWP, Liu Q, Ma X, et al. Effects of mobility training on severe burn patients in the BICU: a retrospective cohort study. Burns 2016; 42: 1404-12.

[56] Clark DE, Lowman JD, Griffin RL, Matthews HM, Reiff DA. Effectiveness of an early mobilization protocol in a trauma and burns intensive care unit: a retrospective cohort study. Phys Ther. 2013; 93: 186-96.

[57] Hart DW, Wolf SE, Mlcak R, Chinkes DL, Ramzy PI, Obeng MK, et al. Persistence of muscle catabolism after severe burn. Surgery. 2000; 128: 312-9.

[58] Bird SR, Hawley JA. Update on the effects of physical activity on insulin sensitivity in humans. BMJ Open Sport Exerc Med. 2017. https://doi.org/10.1136/bmjsem-2016-000143.

[59] AbouAssi H, Slentz CA, Mikus CR, Tanner CJ, Bateman LA, Willis LH, et al. The effects of aerobic, resistance, and combination training on insulin sensitivity and secretion in overweight adults from STRRIDE AT/RT: a randomized trial. J Appl Physiol. 2015; 118: 1474-82.

[60] Liu Y, Ye W, Chen Q, Zhang Y, Kuo C-H, Korivi M. Resistance exercise intensity is correlated with attenuation of HbA1c and insulin in patients with type 2 diabetes: a systematic review and meta-analysis. Int J Environ Res Public Health. 2019. https://doi.org/10.3390/ijerph16010140.

[61] Al-Mousawi AM, Williams FN, Mlcak RP, Jeschke MG, Herndon DN, Suman OE. Effects of exercise training on resting energy expenditure and lean mass during pediatric burn rehabilitation. J Burn Care Res. 2010; 31: 400-8.

[62] Young AE, Davies A, Bland S, Brookes S, Blazeby JM. Systematic review of clinical outcome reporting in randomised controlled trials of burn care. BMJ Open. 2019. https://doi.org/10.1136/bmjopen-2018-025135.

[63] Rousseau A-F, Losser M-R, Ichai C, Berger MM. ESPEN endorsed recommendations: nutritional therapy in major burns. Clin Nutr. 2013; 32: 497-502.

[64] Gore DC, Chinkes DL, Wolf SE, Sanford AP, Herndon DN, Wolfe RR. Quantification of protein metabolism in vivo for skin, wound, and muscle in severe burn patients. JPEN J Parenter Enteral Nutr. 2006; 30: 331-8.

[65] Chao T, Herndon DN, Porter C, Chondronikola M, Chaidemenou A, Abdelrahman DR, et al. Skeletal muscle protein breakdown remains elevated in pediatric burn survivors up to one year post injury. Shock. 2015; 44: 397-401.

[66] Branski LK, Norbury WB, Herndon DN, Chinkes DL, Cochran A, Suman O, et al. Measurement of body composition in burned children: is there a gold standard? J Parenter Enteral Nutr. 2010; 34: 55-63.

[67] Puthucheary ZA, Rawal J, McPhail M, Connolly B, Ratnayake G, Chan P, et al. Acute skeletal muscle wasting in critical illness. JAMA. 2013; 310: 1591-600.

[68] Haines RW, Zolfaghari P, Wan Y, Pearse RM, Puthucheary Z, Prowle JR. Elevated urea-to-creatinine ratio provides a biochemical signature of muscle catabolism and persistent critical illness after major trauma. Intensive Care Med. 2019; 45: 1718-31.

[69] Kenworthy P, Phillips M, Grisbrook TL, Gibson W, Wood FM, Edgar DW. An objective measure for the assessment and management of fluid shifts in acute major burns. Burns Trauma. 2018. https://doi.org/10.1186/s41038-017-0105-9.

[70] Paris MT, Lafleur B, Dubin JA, Mourtzakis M. Development of a bedside viable ultrasound protocol to quantify appendicular lean tissue mass. J Cachexia Sarcopenia Muscle. 2017; 8: 713-26.

[71] Price KL, Earthman CP. Update on body composition tools in clinical settings: computed tomography, ultrasound, and bioimpedance applications for assessment and monitoring. Eur J Clin Nutr. 2019; 73: 187-93.

[72] Connolly B, MacBean V, Crowley C, Lunt A, Moxham J, Rafferty GF, et al. Ultrasound for the assessment of peripheral skeletal muscle architecture in critical illness: a systematic review. Crit Care Med. 2015; 43: 897-905.

[73] Witteveen E, Sommers J, Wieske L, Doorduin J, van Alfen N, Schultz MJ, et al. Diagnostic accuracy of quantitative neuromuscular ultrasound for the diagnosis of intensive care unit-acquired weakness: a cross-sectional observational study. Ann Intensive Care. 2017. https://doi.org/10.1186/s13613-017-0263-8.

[74] Looijaard WGPM, Stapel SN, Dekker IM, Rusticus H, Remmelzwaal S, Girbes ARJ, et al. Identifying critically ill patients with low muscle mass: agreement between bioelectrical impedance analysis and computed tomography. Clin Nutr. 2020; 39: 1809-17.

[75] Kuchnia A, Earthman C, Teigen L, Cole A, Mourtzakis M, Paris M, et al. Evaluation of bioelectrical impedance analysis in critically ill patients: results of a multicenter prospective study. J Parenter Enteral Nutr. 2017; 41: 1131-8.

[76] Kim D, Sun JS, Lee YH, Lee JH, Hong J, Lee J-M. Comparative assessment of skeletal muscle mass using computerized tomography and bioelectrical impedance analysis in critically ill patients. Clin Nutr. 2019; 38: 2747-55.

[77] Parry SM, El-Ansary D, Cartwright MS, Sarwal A, Berney S, Koopman R, et al. Ultrasonography in the intensive care setting can be used to detect changes in the quality and quantity of muscle and is related to muscle strength and function. J Crit Care. 2015. https://doi.org/10.1016/j.jcrc.2015.05.024.

[78] Hadda V, Kumar R, Khilnani GC, Kalaivani M, Madan K, Tiwari P, et al. Trends of loss of peripheral muscle thickness on ultrasonography and its relationship with outcomes among patients with sepsis. J Intensive Care. 2018. https://doi.org/10.1186/s40560-018-0350-4.

[79] Thibault R, Makhlouf A-M, Mulliez A, Cristina Gonzalez M, Kekstas G, Kozjek NR, et al. Fat-free mass at admission predicts 28-day mortality in intensive care unit patients: the international prospective observational study phase angle project. Intensive Care Med. 2016; 42: 1445-53.

[80] Stapel SN, Looijaard WGPM, Dekker IM, Girbes ARJ, Weijs PJM, Oudemans-van Straaten HM. Bioelectrical impedance analysis-derived phase angle at admission as a predictor of 90-day mortality in intensive care patients. Eur J Clin Nutr. 2018; 72: 1019-25.

[81] Duke JM, Randall SM, Fear MW, Boyd JH, Rea S, Wood FM. Diabetes mellitus after injury in burn and non-burned patients: a population based retrospective cohort study. Burns. 2018; 44: 566-72.

[82] Bonora E, Targher G, Alberiche M, Bonadonna RC, Saggiani F, Zenere MB, et al. Homeostasis model assessment closely mirrors the glucose clamp technique in the assessment of insulin sensitivity: studies in subjects with various degrees of glucose tolerance and insulin sensitivity. Diabetes Care. 2000; 23: 57-63.

[83] Parry I, Forbes L, Lorello D, Benavides L, Calvert C, Hsu SC, et al. Burn rehabilitation therapists competency tool-version 2: an expansion to include long-term rehabilitation and outpatient care. J Burn Care Res. 2017; 38: e261-8.

[84] Parry SM, Remedios L, Denehy L, Knight LD, Beach L, Rollinson TC, et al. What factors affect implementation of early rehabilitation into intensive care unit practice? A qualitative study with clinicians. J Crit Care. 2017; 38: 137-43.

[85] Taylor S, Manning S, Quarles J. A multidisciplinary approach to early mobilization of patients with burns. Crit Care Nurs Q. 2013; 36: 56-62.