Predictors of itch and pain in the 12 months following burn injury: results from the Burns Registry of Australia and New Zealand (BRANZ) Long-Term Outcomes Project

Abstract

Background: Itch and pain are common complaints of patients with burn injuries. This study aimed to describe the prevalence and predictors of itch and moderate to severe pain in the first 12 months following a burn injury, and determine the association between itch, moderate to severe pain, work-related outcomes, and health-related quality of life following a burn injury. Methods: Burn patients aged 18 years and older were recruited from five Australian specialist burn units. Patients completed the 36-item Short Form Health Survey Version 2 (SF-36 V2), the Sickness Impact Profile (SIP) work scale, and a specially developed questionnaire relating to itch at 1, 6, and 12 months post-injury. Moderate to severe pain was defined as a score less than 40 on the bodily pain domain of the SF-36 V2. Multivariate mixed-effects regression models were used to identify patient and burn injury predictors of itch and moderate to severe pain. Results: Three hundred and twenty-eight patients were included. The prevalence of itch decreased from 50% at 1 month to 27% at 12 months. Similarly, the prevalence of moderate to severe pain decreased from 23% at 1 month to 13% at 12 months. Compared to patients aged 18-34, the adjusted odds of experiencing any itch were 59% (95% CI: 0.20, 0.82) and 55% (95% CI: 0.22, 0.91) lower for patients aged between 35 and 49 and ≥50 years, respectively. Compared to patients aged 18-34, the adjusted odds of experiencing moderate to severe pain were 3.12 (95% CI: 1.35, 7.20) and 3.42 (95% CI: 1.47, 7.93) times higher for patients aged 35-49 and ≥50 years, respectively. Conclusions: Less than 15% of patients reported moderate or severe pain at 12 months, while approximately one-quarter of the patients reported itch at the same period. The presence of moderate to severe pain was associated with a greater negative impact on health-related quality of life and work outcomes compared to itch. Further research is needed to improve our ability to identify patients at higher risk of persistent itch and pain who would benefit from targeted review and intervention studies.

Keywords

Burn registry / Outcomes / Cohort study / Pain / Itch / Australia / New Zealand / Predictor

References

[1] Dahl O, Wickman M, Wengstrom Y. Adapting to life after burn injury-reflections on care. J Burn Care Res. 2012; 33: 595-605.

[2] Johnson RA, Taggart SB, Gullick JG.Emerging from the trauma bubble: redefining “normal” after burn injury. Burns. 2016; 42: 1223-32.

[3] Wiechman SA.Psychosocial recovery, pain, and itch after burn injuries. Phys Med Rehabil Clin N Am. 2011; 22: 327-45, vii.

[4] Upton D, Richardson C, Andrews A, Rippon M. Wound pruritus: prevalence, aetiology and treatment. J Wound Care. 2013; 22: 501-8.

[5] Kuipers HC, Bremer M, Braem L, Goemanne AS, Middelkoop E, van Loey NE. Itch in burn areas after skin transplantation: patient characteristics, influencing factors and therapy. Acta Derm Venereol. 2015; 95: 451-6.

[6] Van Loey NE, Bremer M, Faber AW, Middelkoop E, Nieuwenhuis MK. Itching following burns: epidemiology and predictors. Br J Dermatol. 2008; 158: 95-100.

[7] Choinière M, Melzack R, Rondeau J, Girard N, Paquin MJ. The pain of burns: characteristics and correlates. J Trauma. 1989; 29: 1531-9.

[8] Choinière M, Melzack R, Papillon J. Pain and paresthesia in patients with healed burns: an exploratory study. J Pain Symptom Manage. 1991; 6: 437-44.

[9] Malenfant A, Forget R, Papillon J, Amsel R, Frigon JY, Choiniere M. Prevalence and characteristics of chronic sensory problems in burn patients. Pain. 1996; 67: 493-500.

[10] Dauber A, Osgood PF, Breslau AJ, Vernon HL, Carr DB. Chronic persistent pain after severe burns: a survey of 358 burn survivors. Pain Med. 2002; 3: 6-17.

[11] Browne AL, Andrews R, Schug SA, Wood F. Persistent pain outcomes and patient satisfaction with pain management after burn injury. Clin J Pain. 2011; 27: 136-45.

[12] Vitale M, Fields-Blache C, Luterman A. Severe itching in the patient with burns. J Burn Care Rehabil. 1991; 12: 330-3.

[13] Blalock SJ, Bunker BJ, Moore JD, Foreman N, Walsh JF. The impact of burn injury: a preliminary investigation. J Burn Care Rehabil. 1992; 13: 487-92.

[14] Casaer M, Kums V, Wouters PJ, Van den kerckhove E, Van den Berghe G. Pruritus in patients with small burn injuries. Burns. 2008; 34: 185-91.

[15] Gauffin E, Oster C, Gerdin B, Ekselius L. Prevalence and prediction of prolonged pruritus after severe burns. J Burn Care Res. 2015; 36: 405-13.

[16] Carrougher GJ, Martinez EM, McMullen KS, Fauerbach JA, Holavanahalli RK, Herndon DN, et al. Pruritus in adult burn survivors: postburn prevalence and risk factors associated with increased intensity. J Burn Care Res. 2013; 34: 94-101.

[17] Klein MB, Lezotte DL, Fauerbach JA, Herndon DN, Kowalske KJ, Carrougher GJ, et al. The National Institute on Disability and Rehabilitation Research burn model system database: a tool for the multicenter study of the outcome of burn injury. J Burn Care Res. 2007; 28: 84-96.

[18] Australian and New Zealand Burn Association.Burns Registry of Australia and New Zealand Annual Report. 2016.

[19] Gabbe BJ, Cleland H, Watterson D, Schrale R, McRae S, Taggart S, et al. Predictors of moderate to severe fatigue 12 months following admission to hospital for burn: results from the Burns Registry of Australia and New Zealand (BRANZ) Long Term Outcomes project. Burns. 2016; 42: 1652-61.

[20] Gabbe BJ, Cleland H, Watterson DM, Schrale R, McRae S, Parker C, et al. Long term outcomes data for the Burns Registry of Australia and New Zealand: is it feasible? Burns. 2015; 41: 1732-40.

[21] Bergner M, Bobbitt RA, Carter WB, Gilson BS. The Sickness Impact Profile: development and final revision of a health status measure. Med Care. 1981; 19: 787-805.

[22] Brazier JE, Harper R, Jones NM, O’Cathain A, Thomas KJ, Usherwood T, et al. Validating the SF-36 health survey questionnaire: new outcome measure for primary care. BMJ. 1992; 305: 160-4.

[23] de Bruin AF, de Witte LP, Stevens F, Diederiks JP. Sickness Impact Profile: the state of the art of a generic functional status measure. Soc Sci Med. 1992; 35: 1003-14.

[24] McHorney CA, Ware JE, Lu JF, Sherbourne CD. The MOS 36-item Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups. Med Care. 1994; 32: 40-66.

[25] McHorney CA, Ware JE, Raczek AE. The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Med Care. 1993; 31: 247-63.

[26] Ware J, Kosinski M, Bjorner J, Turner-Bowker D, Gandek B, Maruish M. User’s Manual for the SF-36v2^® Health Survey. Rhode Island: QualityMetric Incorporated; 2007.

[27] Ware JE, Jr., Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992; 30: 473-83.

[28] Edgar D, Dawson A, Hankey G, Phillips M, Wood F. Demonstration of the validity of the SF-36 for measurement of the temporal recovery of quality of life outcomes in burns survivors. Burns. 2010; 36: 1013-20.

[29] Australian Bureau of Statistics.Socio-Economic Indexes for Areas (SEIFA). Available at: http://www.abs.gov.au/ausstats//mf/2039.0/. 2013.

[30] Department of Health and Aged Care.Measuring remoteness: Accessibility/Remoteness Index of Australia (ARIA) Canberra, Australia, 2001. Available at: http://www.health.gov.au/internet/main/publishing.nsf/content.

[31] R Development Core Team. R: A Language and Environment for Statistical Computing. Vienna: R Foundation for Statistical Computing; 2019.

[32] Gerbershagen HJ, Rothaug J, Kalkman CJ, Meissner W. Determination of moderate-to-severe postoperative pain on the numeric rating scale: a cut-off point analysis applying four different methods. Br JAnaesth. 2011; 107: 619-26.

[33] Kapstad H, Hanestad BR, Langeland N, Rustoen T, Stavem K. Cutpoints for mild, moderate and severe pain in patients with osteoarthritis of the hip or knee ready for joint replacement surgery. BMC Musculoskel Disord. 2008; 9: 55.

[34] Sterne JA, White IR, Carlin JB, Spratt M, Royston P, Kenward MG, et al. Multiple imputation for missing data in epidemiological and clinical research: potential and pitfalls. BMJ. 2009; 338: b2393.

[35] van Buuren S. Multiple imputation of discrete and continuous data by fully conditional specification. Stat Methods Med Res. 2007; 16: 219-42.

[36] White IR, Royston P, Wood AM. Multiple imputation using chained equations: issues and guidance for practice. Stat Med. 2011; 30: 377-99.

[37] Rubin D. Multiple Imputation for Non-Response Surveys. New York, NY: John Wiley and Sons; 1987.

[38] Demling RH, DeSanti L. Scar management strategies in wound care. Rehab Manage. 2001; 14: 26-30.

[39] Burns Registry of Australia and New Zealand. About us 2017. Available at: https://www.monash.edu/medicine/sphpm/branz/about.

[40] Quinn T, Wasiak J, Cleland H. An examination of factors that affect return to work following burns: a systematic review of the literature. Burns. 2010; 36: 1021-6.

[41] Giummarra MJ, Cameron PA, Ponsford J, Ioannou L, Gibson SJ, Jennings PA, et al. Return to work after traumatic injury: increased work-related disability in injured persons receiving financial compensation is mediated by perceived injustice. J Occup Rehabil. 2017; 27: 173-85.

[42] Bevan S, Quadrello T, McGee R, Mahdon M, Vavrovsky A, Barham L. Fit for work? Musculoskeletal disorders in the European workforce. 2012.

[43] Cunningham C, Flynn T, Blake C. Low back pain and occupation among Irish health service workers. Occup Med. 2006; 56: 447-54.

[44] Widanarko B, Legg S, Stevenson M, Devereux J, Eng A, t Mannetje A, et al. Prevalence and work-related risk factors for reduced activities and absenteeism due to low back symptoms. Appl Ergon. 2012; 43: 727-37.

[45] Patel S, Greasley K, Watson PJ. Barriers to rehabilitation and return to work for unemployed chronic pain patients: a qualitative study. Eur J Pain. 2007; 11: 831-40.

[46] Wynne-Jones G, Cowen J, Jordan JL, Uthman O, Main CJ, Glozier N, et al. Absence from work and return to work in people with back pain: a systematic review and meta-analysis. Occup Environ Med. 2014; 71: 448-56.

[47] Becker N, Bondegaard Thomsen A, Olsen AK, Sjogren P, Bech P, Eriksen J. Pain epidemiology and health related quality of life in chronic non-malignant pain patients referred to a Danish multidisciplinary pain center. Pain. 1997; 73: 393-400.

[48] Elliott TE, Reiner CM, Anderson DK, Palcher JA. Major depressive disorder in chronic pain patients: correlation of the SF-36 with physician determined diagnosis using DSM-IV criteria. Quality of Life Research. 2001; 10: 219.

[49] Elliott TE, Renier CM, Palcher JA. Chronic pain, depression, and quality of life: correlations and predictive value of the SF-36. Pain Med. 2003; 4: 331-9.

[50] Wang SJ, Fuh JL, Lu SR, Juang KD. Quality of life differs among headache diagnoses: analysis of SF-36 survey in 901 headache patients. Pain. 2001; 89: 285-92.

[51] Cook JL, Dzubow LM. Aging of the skin: implications for cutaneous surgery. Arch Dermatol. 1997; 133: 1273-7.

[52] Demling RH, DeSanti L. Topical doxepin significantly decreases itching and erythema in the chronically pruritic burn scar. Wounds. 2003; 15: 195-200.

[53] Goutos I. Neuropathic mechanisms in the pathophysiology of burns pruritus: redefining directions for therapy and research. J Burn Care Res. 2013; 34: 82-93.

[54] Corry NH, Klick B, Fauerbach JA. Posttraumatic stress disorder and pain impact functioning and disability after major burn injury. J Burn Care Res. 2010; 31: 13-25.

[55] Edwards RR, Smith MT, Klick B, Magyar-Russell G, Haythornthwaite JA, Holavanahalli R, et al. Symptoms of depression and anxiety as unique predictors of pain-related outcomes following burn injury. Ann Behav Med. 2007; 34: 313-22.

[56] Ullrich PM, Askay SW, Patterson DR. Pain, depression, and physical functioning following burn injury. Rehabil Psychol. 2009; 54: 211-6.

[57] Giummarra MJ, Baker KS, Ioannou L, Gwini SM, Gibson SJ, Arnold CA, et al. Associations between compensable injury, perceived fault and pain and disability 1 year after injury: a registry-based Australian cohort study. BMJ Open. 2017; 7: e017350.

[58] Blyth FM, March LM, Brnabic AJ, Jorm LR, Williamson M, Cousins MJ. Chronic pain in Australia: a prevalence study. Pain. 2001; 89: 127-34.

[59] Chakour MC, Gibson SJ, Bradbeer M, Helme RD. The effect of age on A delta-and C-fibre thermal pain perception. Pain. 1996; 64: 143-52.

[60] Cole LJ, Farrell MJ, Gibson SJ, Egan GF. Age-related differences in pain sensitivity and regional brain activity evoked by noxious pressure. Neurobiol Aging. 2010; 31: 494-503.

[61] Gibson SJ, Farrell M. A review of age differences in the neurophysiology of nociception and the perceptual experience of pain. Clin J Pain. 2004; 20: 227-39.

[62] Kwa KAA, Pijpe A, Rashaan ZM, Tuinebreijer WE, Breederveld RS, van Loey NE. Course and predictors of pruritus following burns: a multilevel analysis. Acta Derm Venereol. 2018; 98: 636-40.

[63] Willebrand M, Low A, Dyster-Aas J, Kildal M, Andersson G, Ekselius L, et al. Pruritus, personality traits and coping in long-term follow-up of burn-injured patients. Acta Derm Venereol. 2004; 84: 375-80.

[64] Van Loey NE, Hofland HW, Hendrickx H, Van de Steenoven J, Boekelaar A, Nieuwenhuis MK.Validation of the burns itch questionnaire. Burns. 2016; 42: 526-34.

[65] Reich A, Bozek A, Janiszewska K, Szepietowski JC. 12-item pruritus severity scale: development and validation of new itch severity questionnaire. BioMed Res Int. 2017; 2017: 3896423.