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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 tness in people after burn injury: a systematic review. Arch Phys Med Rehabil 2011;92:1501-10.
Objective: To gain insight into the physical tness of people

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

1,2

after burn injury compared with healthy subjects, and to present an overview of the effectiveness of exercise training programs in improving physical tness 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 tness 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 tnessmuscular strength, muscular endurance, body composition, cardiorespiratory endurance, and exibilityand 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 modied Sackett scale. Six studies were used for the comparison of physical tness in burned and nonburned subjects, and 9 studies for evaluating the effectiveness of exercise training programs. Conclusions: Physical tness 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 tness; 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 patients physical tness, dened 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 tness: muscular strength, muscular endurance, body composition, cardiorespiratory endurance, and exibility. Although there is no unambiguous conclusion yet on the state of physical tness 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 tness in order to further adapt and improve rehabilitation protocols to facilitate a faster functional recovery. Therefore, the rst aim of this review is to gain insight into the physical tness of patients after burn injury as compared with nonburned subjects. Because it is well known that exercise improves physical tness 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 tness 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 nancial interest in the results of the research supporting this article has or will confer a benet 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

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PHYSICAL FITNESS IN PEOPLE AFTER BURN INJURY, Disseldorp Table 1: Classication 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, cohort and non-RCTs Case-control trials Pre-post studies, posttest, and case series Observational studies, clinical consensus, and single case reports

study provides sufcient statistical information to make results interpretable. The PEDro assessment scale scores range from 1 to 10 points, where 10 indicates excellent methodological quality and 1 indicates very poor methodological quality. Third, the modied 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, the strongest level of evidence, to 5, the weakest level of evidence. Data Extraction Information was collected on characteristics of each study, such as study design and intervention, as well as on characteristics of the subjects (eg, mean ages and burn sizes). To provide a structured overview, the 5 health-related components of physical tness as originally described by Caspersen10 were used as a framework in this review. The framework comprises muscular strength, muscular endurance, body composition, cardiorespiratory endurance, and exibility. Results were reported for each component separately. RESULTS Eleven relevant studies could be included (table 2), and 4 of these were used in both parts of this review. Six studies provided data for the rst aim of this review, the comparison of the physical tness in burned and nonburned subjects. One of these studies16 reports on 2 different study groups, which are discussed separately throughout this review, yielding a total of 7 study groups for this comparison. Nine studies were included for the second aim of this review, the evaluation of the effects of an exercise program on the physical tness of people with burns. Methodological Quality of the Included Studies Eight studies were randomized controlled trials, of which 7 had PEDro scores of 6 points or more (see table 2), so were classied as level 1 evidence according to the modied Sackett scale.15 One randomized controlled trial, with a PEDro score of 5 points, and 1 nonrandomized controlled trial provided level 2 evidence. Two static group comparison studies, which were used to compare physical tness in burned and nonburned people, were considered as level 3 evidence (see table 2). 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, randomized controlled trials. *Adapted from Teasell et al.15

ence were searched with the key words burns, physical tness, and exercise; in addition, the terms burn injury, strength, endurance, body composition, rehabilitation, outcome, and functioning were used. The search was limited to studies with human subjects and to the English language. Further, references from reviews and studies were checked, and experts in the eld associated with the Dutch burn centers were consulted. Whether the data search was complete was checked by 2 independent researchers. Study Selection Studies were selected only if they (1) used objective measurements and (2) provided quantitative data about the physical tness of both the study group and the control group. Single case reports and studies limited to hand function were excluded from this review. For the comparison of the physical tness in burn patients and healthy subjects, 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. For the evaluation of effectiveness, only studies with a description of the applied exercise training program were included. Data Synthesis The methodological quality of the included studies was assessed in 3 steps. First, the study design was determined. Second, for all randomized controlled trials, the methodological quality was assessed by applying the PEDro assessment scale, 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, Johns Hopkins University School of Medicine Baltimore; MU, McGill University Quebec; NA, not applicable; RCT, randomized controlled trial; SHCG, Shriners Hospitals for Children Galveston. *Levels of evidence are determined using a modied Sackett scale.

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PHYSICAL FITNESS IN PEOPLE AFTER BURN INJURY, Disseldorp Table 3: Characteristics of Included Study Groups and Corresponding Subjects, 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

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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 39.8 10.7 11 11.3 12.5 11.8

23.4 46.1 58.6 57.0 53.5 58.8 56.0

0.53 and 3.56* 0.53 and 3.56* 6 and 9 6 and 9 6 and 9 6, 9, and 12 6

14 16 24 16 Unknown 26 46

86 75 58 56 65 94 52

40.6 39.0 12.6 10.8 12.2 13.5 12.1

Abbreviations: mo, month; MU, McGill University Quebec; n, number of participants; SHCG, Shriners Hospitals for Children Galveston; Time PB, time postburn of assessment. *Range, 1592 days postburn. Matched with burned subjects.

the physical tness of burn patients with that of healthy control subjects. The other 4 studies18-21 aimed to evaluate the effect of a physical training program in burn patients, but hereby provided results of burned and nonburned subjects before the start of the program. Overall, most subjects were male, and the time of assessment varied from 0.5 to 12 months postburn (table 3). Five of the 7 included study groups originated from Shriners Hospitals for Children in Galveston, Texas. Obviously, the participants of these 5 study groups were children (mean ages, 10.712.5y). Less obvious, 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, which is exceptionally large. In 3 of these 5 study groups the controls were matched for age, and in one of them, matched also for sex. St-Pierre16 included adults aged 24 to 69 years with upper extremity burns involving at least 15% TBSA. The group of burned subjects was split into 2 study groups: patients with burns involving 30% TBSA or less, and patients with burns involving greater than 30% TBSA. Controls for both study groups were matched for age, sex, and physical activity level. Muscular strength. Six study groups provided information about muscular strength, expressed as peak torque, measured with an isokinetic dynamometer. The 4 Shriners studies measured peak torque in the dominant leg extensors, and all found less strength in burned subjects than in controls. Of these, Suman and Herndon21 and Alloju17 reported signicant differences (P .011 and 68.1% without a P value, respectively), while in the other 2 studies18,20 statistical analyses were not applied (table 4). St-Pierre16 measured peak torque, at velocities of 1.05 and 3.14rad/s, in the upper and lower extremities bilaterally, and combined and averaged the results of both for every limb. The group with greater than 30% TBSA burned scored lower than controls on every measure, but this betweengroup difference was signicant only for knee extension at 3.14rad/s (16%, P .05). In elbow exion and extension, both groups did not show signicant between-group differences. For the group with burns involving 30% TBSA or less, however, no signicant differences in the strength of knee exors and extensors were found between the burned group and the healthy control group. Muscular endurance. In 3 study groups,16,17 the muscular endurance of patients with burns and healthy controls, expressed in terms of work and power, were compared (see table 4). The same methods were used as for muscular strength. The study group of St-Pierre,16 consisting of subjects with burns

involving 30% TBSA or less, scored higher than the control group on both work and power in knee as well as elbow exion and extension. No signicant between-group differences were found. The study group with burns involving greater than 30% TBSA, however, showed lower values than controls on all measures of muscular endurance, though not all between-group differences were signicant (see table 4). Alloju17 also reported signicantly lower values (64.2% without a P value) of total work in burned subjects than in the control group. Body composition. Body composition was evaluated in 4 study groups (table 5). Total lean body mass (TLBM), lean leg mass (LLM), lean arm mass, and/or lean trunk mass were measured by dual-energy X-ray absorptiometry (DEXA) in kilograms. All 4 study groups17,18,20,21 included only subjects whose burns involved more than 40% TBSA, and all found lower values in children with burns than in nonburned controls. In one of the studies,17 the differences were signicant (TLBM, 20.3%; LLM, 22.2%). In 1 study,21 the differences in TLBM were nonsignicant, and the other 2 studies18,20 did not apply statistical analyses. Cardiorespiratory endurance. The cardiorespiratory endurance, expressed as peak oxygen consumption (VO2peak), is measured by treadmill testing in 3 study groups (see table 5). One study19 reported a signicant between-group difference (P .05) in cardiorespiratory endurance, with the higher values on the side of nonburned subjects. The other 2 studies18,20 showed great differences in VO2peak between the groups, but without statistical analyses. Flexibility. Only 1 study17 measured exibility (see table 5). Functional dynamic range of motion (ROM) was assessed during the performance of leg extension. The results did not show signicant differences (P .93) between burned and nonburned children. 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 tness in people after burn injury (table 6). All but 1 trial were from Shriners Hospitals for Children (Galveston, Texas) and clearly involved just children. The mean TBSA involved in the burns of these children was greater than 50%, with a minimum of 40%. The subjects in the study by De Lateur et al22 were adults with burns involving a mean TBSA of 19.3% 15.7%.
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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, September 2011 B B B B B B B B B B B B NB Sign (68.1%) NS (All differences Isokinetic total work Work and power: For work and power: NS NB B NB Knee exor 10%) and average NB and B NB B NB Knee extensor power* NB and B NB B NB Elbow exor NB B NB Elbow extensor Isokinetic total work Work and power: For work and power: Knee extensor work: Knee extensor at NB -Sign at 1.05rad/s B NB Knee exor and average 3.14rad/s NB (15.2%) B NB Knee extensor power* - Sign (16%) NB -Sign at 3.14rad/s B NB Elbow exor Other measures NB (20.5%) B NB Elbow extensor - NS Knee extensor power: -NS at 1.05rad/s -Sign at 3.14rad/s (17.8%) Knee exor work and power: -NS Elbow work and power: -NS NB No statistical NT analyses NB No statistical NT analyses NB Sign (P .011) NT Isokinetic total work Knee extensor (dominant side) Knee extensor total work: B NB Sign (64.2%) PHYSICAL FITNESS IN PEOPLE AFTER BURN INJURY, Disseldorp

St-Pierre et al ( 30% TBSA)

16

Isokinetic peak Knee exor torque* Knee extensor Elbow exor Elbow extensor

St-Pierre et al16 Isokinetic peak Knee exor torque* Knee extensor ( 30% Elbow exor 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, burned subjects; NB, nonburned subjects; NS, nonsignicant between-group differences; NT, not tested; Sign, signicant between-group differences. *Measured at 1.05 and 3.14rad/s. Measured at 150/s.

PHYSICAL FITNESS IN PEOPLE AFTER BURN INJURY, Disseldorp Abbreviations: B, burned subjects; LAM, lean arm mass; LTM, lean trunk mass; NB, nonburned subjects; NS, nonsignicant between-group differences; NT, not tested; Sign, signicant between-group differences.

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All studies comprised an intervention with a duration of 12 weeks. In the Shriners studies, the control group participated in a home-based rehabilitation program without exercise prescriptions. For the intervention groups, this rehabilitation program was supplemented with hospital-based, individualized and supervised exercise training programs consisting of aerobic as well as resistance training. Most of these interventions involved 3 training sessions per week, of which 20 to 40 minutes was aerobic exercise (for exceptions see table 6). The study by Neugebauer et al23 is an exception in the Shriners studies; this intervention for young children was not individualized but comprised group sessions. The intervention group received, in addition to 5h/wk of rehabilitation therapy, 3 sessions of an exercise and music program per week, each lasting 60 minutes. The control group was heterogeneous in the number of sessions and the location of therapy, as participants were trained and given a home-based rehabilitation program or received outpatient therapy at the hospital. In the study of De Lateur,22 all participants received the standardized, tailored burn rehabilitation protocol of the John Hopkins Burn Center. For the intervention groups, this was supplemented with 30 minutes of aerobic treadmill exercise 3 times a week. For the work-to-quota group, this exercise was intensied throughout the 12 weeks by increasing the target exercise heart rate and time according to preset quotas. The work-to-tolerance group was instructed to tolerate the exercise at the individual target heart rate for as long as possible. The time postburn at the start of the intervention varied between studies. In all but 2 studies, the exercise program started at 6 months postburn (see table 6). Subjects in the study by Neugebauer23 joined the exercise and music groups as soon as they were medically ready, which is not further specied. Subjects in the study by De Lateur22 started at a mean of 37.5 days postburn. It was unclear on which criteria this was based. Two studies of Shriners Hospitals investigated the effect of additional drugs (oxandralone18 and growth hormone20), but only results of the relevant (nondrugged) groups were used in this review. However, in 2 other studies of Shiners Hospitals used here,19,24 subjects who received growth hormone were included in both the intervention and control groups. Muscular strength. Information about the changes in muscular strength as a result of the exercise training program of 12 weeks was given in 5 studies18,20,21,24,25 (table 7). A dynamometer was used to measure isokinetic peak torque in the knee extensors of the dominant leg. All studies reported averaged increases in strength of more than 40% in the intervention group, all signicantly greater than increases of the control group. Signicant differences persisted when increases in strength were normalized to individual changes in TLBM.24,25 However, note that SDs were very large in the studies by Przkora18 and Al-Mousawi25 and colleagues (see table 7). One of the studies21 applied a follow-up measure after another 12 weeks with home-based exercise prescriptions, but this did not cause signicant changes in both groups. Muscular endurance. Two studies reported data on muscular endurance (see table 7). Suman et al24 measured total work and average power in the leg extensors, while Cucuzzo et al8 used the calculated total volume of work produced by the biceps, triceps, forearms, quadriceps, and hamstrings. Signicant between-group differences in the improvement of muscular endurance over 12 weeks were found on all 3 variables. Body composition. Body composition, measured by DEXA and expressed as lean mass in kilograms, was mentioned in 5 effect studies18,20,21,24,25 (see table 7). All studies reported signicantly greater increases in the intervention group than in the control group over 12 weeks. Al-Mousawi25 normalized the
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Statistics

Results

Table 5: Results for the Comparison of Body Composition, Cardiorespiratory Endurance, and Flexibility in Burned and Nonburned Subjects

Flexibility

NT

NT

Sign (no values) No statistical analyses

Cardiorespiratory Endurance

B NB, 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, LLM, LAM, 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 (20,3%) LLM: Sign (22,2%)

Statistics

NT

Functional dynamic ROM in leg extension

Parameter

B NB

NS

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PHYSICAL FITNESS IN PEOPLE AFTER BURN INJURY, Disseldorp Table 6: Characteristics of Included Studies and Corresponding Subjects, 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

10.6 10.7 10.7 10.6 11.3 12.5 38.0 19.3

59.7 58.8 58.6

6 and 9 6 and 9 6 and 9

3 3 3 3 5 3 3

56.2* 6 and 9 54.0 6 and 9 58.8 6, 9, and 12 1, 2, and 4.2

Neugebauer et al23

SHCG

15

3.5

61.0

Al-Mousawi et al25

SHCG

11

10

12.6

58.5

Recently discharged from intensive care unit and medically ready (not specied) 6 and 9

Resistance and aerobic exercise 60min several therapies Aerobic exercise 2040min resistance training Aerobic exercise 2040min resistance training Aerobic exercise 2040min resistance training Aerobic exercise 2040min resistance training Aerobic exercise 2040min resistance training Aerobic exercise 30min; intensied throughout 12wk by work-to-quota or work-totolerance protocol Exercise-based music activities to promote ROM, endurance, and functional movement; 60min Aerobic exercise 30min resistance training

Abbreviations: JHU, Johns Hopkins University School of Medicine Baltimore; mo, month; n, number of participants; SHCG, Shriners Hospitals for Children Galveston; Time PB, time postburn of assessment. *This is a selection of the participants. The rest of the participants received growth hormone, and are excluded in this review. This is a selection of the participants. The rest of the participants received oxandrolone, and are excluded in this review. Range, 9 to 122 days postburn; mean, 37.5 days.

measurements to height and found that this signicant difference persisted. A follow-up measure in one of the studies21 did not show signicant changes from another 12 weeks of homebased exercise prescriptions. Cardiorespiratory endurance. In 6 studies (table 8), cardiorespiratory endurance was measured. Five studies used treadmill exercise testing following the modied Bruce protocol, and these outcomes were expressed in VO2peak for chil dren and maximum oxygen consumption (VO2max) for adults. In 1 study,8 functional cardiorespiratory endurance was assessed with the 6-minute walk test. Five studies included children with burns involving greater than 40% TBSA. Four of these18-20,24 used treadmill tests and found increases greater than 20% in VO2peak in the intervention group, which differed signicantly from increases in the control group. The fth study8 used the 6-minute walk test and reported that the performance of both the intervention and control group increased, but with a signicantly larger increase for the intervention group. The 1 study including adults22 (mean TBSA, 19.3%) re ported signicant increases in VO2max for both the work-toquota and work-to-tolerance intervention groups. The control group did not improve signicantly, and both between-group differences were signicant. Flexibility. Only 1 study23 (see table 8) included exibility, which was measured in the elbow and knee joints by goniometry and expressed as passive and active ROM. The change in passive ROM after 12 weeks of intervention in the intervention group was not signicantly different from the change in passive ROM in the control group. Active ROM increased signicantly more in the intervention group than in
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controls for the left elbow and the right knee. On the contrary, for the right elbow and left knee, between-group differences appeared nonsignicant, despite signicant increases in active ROM over the intervention. DISCUSSION This review included 11 high-quality studies, which reported on 12 study groups, to provide an overview of (1) the physical tness of people after burn injury, and (2) the effectiveness of exercise training programs in improving physical tness in people after burn injury. It showed that (1) children and adults with extensive burns score worse than nonburned controls on measures of all 5 components of physical tness, and (2) burn patients participating in a 12-week exercise training program improve more on all parameters than burn patients without this specic training. Physical Fitness in People After Burn Injury This review brings to light important insights on the physical tness of people after burn injury compared with that of nonburned controls. However, the included studies show great similarity in subjects on the domains of age, burn size, and time postburn. Therefore, the included population in this review is a remarkable onethat is, a selection of the patients generally admitted to burn centers. Only 2 of the 7 included study groups concern adults; the other 5 involve only children. Moreover, these children have exceptionally extensive burns. In the Netherlands, on average, only 1.3% of burn patients younger than 18 years have burns involving more than 40% TBSA.26 Recent American data show that patients with a total burn size of more

PHYSICAL FITNESS IN PEOPLE AFTER BURN INJURY, Disseldorp


NOTE. Values are mean SD or as otherwise indicated. 1 indicates improvement on this parameter. Abbreviations: AP, average power; C, control group; I, intervention group; LAM, lean arm mass; LTM, lean trunk mass; mo, month; NT, not tested; PB, postburn; Sign, signicant between-group difference (1I 1C); TW, total work. *By cumulative 3-repetition maximum tests in biceps, triceps, forearm, quadriceps, and hamstrings.

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than 40% TBSA accounted for only 4.6% of all cases,3 whereas 71% had a TBSA of less than 10%.3 Not only the low prevalence but also the physiologic consequences of such extensive burns make this group exceptional. After extensive burns, the metabolic and catabolic disturbances are signicant relative to burns involving less than 40% TBSA and can persist up to 12 months postburn.27,28 Therefore, the included populations are not truly representative of the general burn population. For both muscular strength and endurance, children and adults with extensive burns scored lower than their controls on all parameters. For the knee extensor the differences were signicant; for other joints the differences were nonsignicant. On the other hand, adults with burns involving less than 30% TBSA scored higher than their controls, who were matched for age, sex, and activity level, but these differences were not signicant. Concerning the methods of measurement, it is remarkable that in all reviewed studies, muscular strength and muscular endurance were measured in the knee extensor of the dominant side. Only in the adult groups were the knee exors and elbow extensors and exors also assessed. It can be questioned whether measuring only knee extension is a good indication of the overall muscular capacity, especially since the precise location of the burns and their possible inuence on leg or arm function are not taken into account. A much longer lasting decit in strength was reported in another study related to the Shriners Hospital, but this study by Baker et al12 was excluded from the review because a control group was lacking. Baker12 found that 35% of 83 young adult survivors of burns sustained in childhood (mean time postburn, 14 5y; TBSA range, 30%99%) had decits in strength in any part of the body, compared with normative values.29,30 Overall, the subjects with a higher percentage of TBSA involved had lower mean strength.12 In all studies that measured body composition, the children with extensive burns had lower mean values of lean body mass than their controls. Hypermetabolism might play a role, 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, this nding also does not seem very surprising. Moreover, in this age span, healthy children are in the period of the most rapid gain in lean body mass, with the skeleton showing the highest responsiveness to physical activity.31-33 The pediatric burn patients might miss a part of this rapid gain because of metabolic responses and the sedentary period postburn, but whether they catch up later is yet unknown. Cardiorespiratory endurance is affected in severely burned children compared with controls. This nding lies within expectations, considering the relatively short period postburn and the inactivity in this period. It is interesting that a similar conclusion was drawn for adults with smaller burn sizes at a relatively longer period postburn.13 This follow-up study by Jarrett et al13 did not measure a control group and was therefore not included in the review. They assessed 86 adult burn patients (mean age, 38y; mean TBSA, 11.2%) and reported that functional exercise capacity, measured by a shuttle walk test, did not return to baseline levels at 6 months after discharge from the hospital.13 Flexibility, in terms of the functional dynamic ROM in leg extension, was somewhat decreased in children with extensive burns compared with controls. Because scars subsequent to burn injury can cause contractures in the affected joint, the question arises whether ROM in the leg is a sufcient parameter for the overall exibility. Schneider et al34 reported that 38.7% of adult burn patients (n 985) have developed at least 1 contracture at discharge, with an average of 3 contractures
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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, Muscular Endurance, and Body Composition in People With Burn Injury

TLBM, LTM, LLM, and LAM by DEXA

TLBM, LTM, LLM, 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: 80.1% 1 C: 37.7% 1 TW: I: 78.5%1 C: 2.10% 1 AP: I: 72.3% 1 C: 8.30% 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

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: 47.3% 40.5% 1 C: 6.6% 15% 1 6 9mo PB: I: 40.7% 8.6% 1 C: 3.4% 4.5% 1 9 12mo PB: I: 17.9% 10.1% 1 C: 7.2% 13.4% 1 I: 54.3% 44.3% 1 C: 12.3% 16.5% 1

I: 42.6% 10.0% 1 C: 6.7% 4.4% 1

Results

I: 44.4% 1 C: 5.6% 1

6 9mo PB: Signicance not reported 9 12mo PB: Signicance 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: 5.4% 1.6% 1 C: 1.2% 2.0% 2 LLM, LAM, and LTM: I: 1 and C: 1 I: 1 C: 0.8% 6.3% 2 6 9mo PB: I: 6.4% 1.9% 1 C: 1.9% 2.6% 1 9 12mo PB: I: 10.7% 4.8% 1 C: 3.5% 1.8% 1 I: 8.8% 5.7% 1 C: 2.1% 3.2% 1

Body Composition

Results

6 9mo PB: Signicance not reported 9 12mo PB: Signicance not reported Sign

Statistics

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PHYSICAL FITNESS IN PEOPLE AFTER BURN INJURY, 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 (modied Bruce Protocol) VO2peak by treadmill test (modied Bruce Protocol) VO2peak by treadmill test (modied Bruce Protocol) VO2peak by treadmill test (modied Bruce Protocol) VO2max by treadmill test (modied Bruce Protocol)

I: 47.3% 1 C:14.1% 1 I: 22.7% 1 C: 1,35% 1 I: 24.3% 4.7% 1 C: 3.12% 3.5% 1 I: 23.1% 1 C: ca. 4.5% 1 I: 23.2% 16.6% 1 C: 9.35% 16.8% 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. Values are mean SD or as otherwise indicated. 1 indicates improvement on this parameter. Abbreviations: C, control group; I, intervention group; I-WTQ, intervention group exercising by target heart rate and time intensied according to preset quotas; I-WTT, intervention group exercising as long as possible at individual target heart rate; NS, between-groups difference not signicant; NT, not tested; Sign, signicant between-group difference (1I 1C).

per person. Given this, it is remarkable that only 1 study could be included that measured exibility. In a study by Gorga et al,35 not included in the review because of lack of a control group, exibility around multiple joints (ie, head/neck, upper extremity, hand, and lower extremity) was tested in very young children with relatively small burns (mean age, 27mo; mean TBSA, 6%). They concluded that at 1, 6, and 12 months postburn, most of the children had ROMs within normal limits, according to normative values.35 In the study by Moore et al,14 which was also not included because of lack of a control group, ROM of both upper and lower extremities was measured to calculate physical impairment in older children with extremely extensive burns ( 80% TBSA). Their outcomes varied from no measurable physical impairment to more than 90% impairment, with an average of 52%.14 So whereas ROM seemed an easy and appropriate parameter for exibility in people after burn injury, it proves difcult to interpret. Furthermore, the location of the burn is essential for exibility and should be reported with the results. Since measurements are done at a certain time point postburn, the possible recent surgical interventions should also be taken into account. Effectiveness of Exercise Training Programs in People After Burn Injury Exercise training programs have shown very positive effects on the physical tness of patients after burn injury; however, the critical remarks on the included study population and assessments as discussed above should be kept in mind. In addition, specic to this review question, the mentioned similarity in studies caused a lack of variation in applied protocols and exercise interventions. Eight of the 9 included studies in this part of the review originated from Shriners Hospitals for Children, and 7 of these tested similar interventions. Therefore,
Arch Phys Med Rehabil Vol 92, September 2011

fewer different training protocols are evaluated in this review than one would like. This review shows that because of a 12-week exercise training program, starting 6 months postburn, childrens muscular strength, muscular endurance, and lean body mass strongly increased. Likewise, exercise has also been proven effective in improving the cardiorespiratory endurance in adults as well as children. 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. Additional literature36-38 suggests that ROM in people with burns could also be increased by massages, virtual reality treatment, and motor imagery, but for none of these is there indisputable evidence yet. Besides effects on the components muscular strength, muscular endurance, body composition, cardiorespiratory endurance, and exibility, more benecial effects of exercise on physical outcomes are known. Exercise can signicantly reduce the number of surgical scar releases39 and has been proven effective in improving pulmonary function in children with severe burns,19 according to randomized controlled trials from the Shriners Hospitals. Whereas apparently signicant improvements in physical tness can be made with exercise training programs, the question is whether the physical tness of burn patients returns to tness levels from before the injury (normal values). Only Suman and Herndon21 made a comparison and reported that after completion of the exercise program, the values of patients with burns remained below those of nonburned subjects for lean mass and muscular strength. As all studies compared people with burns in exercise groups and nonexercise groups, the comparison of burn patients in exercise groups with groups of matched healthy controls is lacking.

PHYSICAL FITNESS IN PEOPLE AFTER BURN INJURY, Disseldorp

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Study Limitations The present review is the rst to emphasize the hiatus in knowledge about physical tness in patients after burn injury. The main strength of this review is that it reports on the level of physical tness and improvements in the tness level resulting from exercise programs, in a highly structured way, using the 5 health-related components of physical tness: muscular strength, muscular endurance, body composition, cardiorespiratory endurance, and exibility. This review is mainly limited by the quantity, quality, and similarity of the available studies. Only 11 studies could be included. Three of those were not randomized controlled trials, and none of the 8 randomized controlled trials received the maximum PEDro score. Since 9 studies were from the same institute and showed great similarities in study populations, applied exercise programs, and research protocols, the generalizability of the results is not optimal. Practical Implications We feel that physical tness and exercise denitely deserve a lot more attention in burn care. Furthermore, to maintain and further improve the tness levels achieved by exercise in the rehabilitation phase, promotion of an active lifestyle is very important. Physical tness is essential in the performance of activities of daily living.24 By improving tness, the independent functioning and self-care in burn patients could get better. Furthermore, it can hasten reintegration into occupational and social activities and increase participation after burn injury. Because improved physical tness might have a positive impact on several areas of life, it is assumed to improve the perceived quality of life. CONCLUSIONS This review of 11 high-quality studies showed that physical tness is affected in people after extensive burn injury, and that exercise training programs can bring on meaningful improvements in all components of physical tness. However, the number of appropriate studies on physical tness is limited, and the number of burn centers publishing on this topic is even smaller. Because of the great similarities of the subjects and protocols used in the included studies, many questions remain unanswered. Controlled studies including both children and adults with minor and moderate burns, aimed at both shortterm and long-term physical tness outcomes, are necessary to ll the hiatus in the current knowledge. Preferably, future studies would include assessment of all 5 components of physical tness. Furthermore, intervention studies should investigate varying duration, intensity, and frequency of exercise, to enable optimization of the effectiveness of exercise training protocols for individual patients. In this decade of increasing attention to physical tness, exercise, and healthy aging, the burn (research) community should take advantage of this trend, which brings new opportunities and growing knowledge. Thereby, they should intensify and increase its efforts to limit the physical burden of burn injury as much as possible.
References 1. Pruitt BAJ, Mason ADJ, Goodwin CW. Epidemiology of burn injury and demography of burn care facilities. Probl Gen Surg 2010;7:235-51. 2. Esselman PC, Thombs BD, Magyar-Russell G, Fauerbach JA. Burn rehabilitation: state of the science. Am J Phys Med Rehabil 2006;85:383-413. 3. National Burn Repository 2010. Version 6.0. Report of data from 2000-2009. American Burn Association; 2010.

4. Bloemsma GC, Dokter J, Boxma H, Oen IM. Mortality and causes of death in a burn centre. Burns 2008;34:1103-7. 5. Safe JR. Recent outcomes in the treatment of burn injury in the United States: a report from the American Burn Association Patient Registry. J Burn Care Rehabil 1995;16:219-32. 6. Brusselaers N, Hoste EA, Monstrey S, et al. Outcome and changes over time in survival following severe burns from 1985 to 2004. Intensive Care Med 2005;31:1648-53. 7. Cobb N, Maxwell G, Silverstein P. Patient perception of quality of life after burn injury. Results of an eleven-year survey. J Burn Care Rehabil 1990;11:330-3. 8. Cucuzzo NA, Ferrando A, Herndon DN. The effects of exercise programming vs traditional outpatient therapy in the rehabilitation of severely burned children. J Burn Care Rehabil 2001;22:214-20. 9. Van Baar ME, Essink-Bot ML, Oen IMMH, Dokter J, Boxma H, van Beeck EF. Functional outcome after burns: a review. Burns 2006;32:1-9. 10. Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical tness: denitions and distinctions for health-related research. Public Health Rep 1985;100:126-31. 11. Chodzko-Zajko WJ, Proctor DN, Fiatarone Singh MA, et al. American College of Sports Medicine position stand. Exercise and physical activity for older adults. Med Sci Sports Exerc 2009;41: 1510-30. 12. Baker CP, Russell WJ, Meyer W III, Blakeney P. Physical and psychologic rehabilitation outcomes for young adults burned as children. Arch Phys Med Rehabil 2007;88:S57-64. 13. Jarrett M, McMahon M, Stiller K. Physical outcomes of patients with burn injuriesa 12 month follow-up. J Burn Care Res 2008;29:975-84. 14. Moore P, Moore M, Blakeney P, Meyer W, Murphy L, Herndon D. Competence and physical impairment of pediatric survivors of burns of more than 80% total body surface area. J Burn Care Rehabil 1996;17:547-51. 15. Teasell RW, Mehta S, Aubut JA, et al. A systematic review of pharmacologic treatments of pain after spinal cord injury. Arch Phys Med Rehabil 2010;91:816-31. 16. St-Pierre DM, Choiniere M, Forget R, Garrel DR. Muscle strength in individuals with healed burns. Arch Phys Med Rehabil 1998; 79:155-61. 17. Alloju SM, Herndon DN, McEntire SJ, Suman OE. Assessment of muscle function in severely burned children. Burns 2008;34:452-9. 18. Przkora R, Herndon DN, Suman OE. The effects of oxandrolone and exercise on muscle mass and function in children with severe burns. Pediatrics 2007;119:e109-16. 19. Suman OE, Mlcak RP, Herndon DN. Effect of exercise training on pulmonary function in children with thermal injury. J Burn Care Rehabil 2002;23:288-93. 20. Suman OE, Thomas SJ, Wilkins JP, Mlcak RP, Herndon DN. Effect of exogenous growth hormone and exercise on lean mass and muscle function in children with burns. J Appl Physiol 2003; 94:2273-81. 21. Suman OE, Herndon DN. Effects of cessation of a structured and supervised exercise conditioning program on lean mass and muscle strength in severely burned children. Arch Phys Med Rehabil 2007;88:S24-9. 22. De Lateur BJ, Magyar-Russell G, Bresnick MG, et al. Augmented exercise in the treatment of deconditioning from major burn injury. Arch Phys Med Rehabil 2007;88:S18-23. 23. Neugebauer CT, Serghiou M, Herndon DN, Suman OE. Effects of a 12-week rehabilitation program with music & exercise groups on range of motion in young children with severe burns. J Burn Care Res 2008;29:939-48. 24. Suman OE, Spies RJ, Celis MM, Mlcak RP, Herndon DN. Effects of a 12-wk resistance exercise program on skeletal muscle
Arch Phys Med Rehabil Vol 92, September 2011

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PHYSICAL FITNESS IN PEOPLE AFTER BURN INJURY, Disseldorp

25.

26. 27. 28. 29.

30.

31.

32.

strength in children with burn injuries. J Appl Physiol 2001;91:1168-75. 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. Dutch Burn Repository 2010. Association of Dutch Burn Centers. Available at: http://www.adbc.nl. Accessed July 5, 2011. Herndon DN, Tompkins RG. Support of the metabolic response to burn injury. Lancet 2004;363:1895-902. Demling RH, Seigne P. Metabolic management of patients with severe burns. World J Surg 2000;24:673-80. Mathiowetz V, Kashman N, Volland G. Grip and pinch strength: normative data for adults. Arch Phys Med Rehabil 1985;66:69-74. Stegink Jansen CW. Measurement of maximum voluntary pinch strength: effects of forearm position and outcome score. J Hand Ther 2003;16:326-36. Alwis G, Rosengren B, Stenevi-Lundgren S, Duppe H, Sernbo I, Karlsson MK. Normative dual energy x-ray absorptiometry data in Swedish children and adolescents. Acta Paediatr 2010;99: 1091-9. Faulkner RA. Bone densitometry in Canadian children 8-17 years of age. Calcif Tissue Int 1996;59:344-51.

33. van der Sluis IM, de Ridder MAJ, Boot AM, Krenning EP, de Muinck Keizer-Schrama SMPF. Reference data for bone density and body composition measured with dual energy x ray absorptiometry in white children and young adults. Arch Dis Child 2002;87:341-7. 34. Schneider JC, Holavanahalli R, Helm P, Goldstein R, Kowalske K. Contractures in burn injury: dening the problem. J Burn Care Res 2006;27.508-14. 35. Gorga D, Johnson J, Bentley A, et al. The physical, functional, and developmental outcome of pediatric burn survivors from 1 to 12 months postinjury. J Burn Care Rehabil 1999;20:171-8. 36. Morien A, Garrison D, Smith NK. Range of motion improves after massage in children with burns: a pilot study. J Bodyw Mov Ther 2008;12:67-71. 37. Carrougher GJ, Hoffman HG, Nakamura D, et al. The effect of virtual reality on pain and range of motion in adults with burn injuries. J Burn Care Res 2009;30:785-91. 38. Guillot AP, Lebon F, Vernay MM, Girbon JPM, Doyon JP, Collet CP. Effect of motor imagery in the rehabilitation of burn patients. J Burn Care Res 2009;30:686-93. 39. Celis MM, Suman OE, Huang TT, Yen P, Herndon DN. Effect of a supervised exercise and physiotherapy program on surgical interventions in children with thermal injury. J Burn Care Rehabil 2003;24:57-61.

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