The use of exercise in burns rehabilitation: A worldwide survey of practice

JBUR 5772 No. of Pages 11

burns xxx (2019) xxx

xxx

ScienceDirect journal homepage: www.elsevier.com/locate/burns

The use of exercise in burns rehabilitation: A worldwide survey of practice Orlando Flores a, * , Zephanie Tyack b, Kellie Stockton c , Jennifer D. Paratz a,d a

Burns, Trauma & Critical Care Research Centre, Level 7, UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia b Centre for Children’s Burns and Trauma Research, Level 7, Centre for Children’s Health Research, 62 Graham St, South Brisbane 4101, QLD, The University of Queensland, Brisbane, Australia c Physiotherapy Department, Children’s Health QLD, Level 6, Queensland’s Children Hospital, 501 Stanley Street, South Brisbane 4101, QLD. Brisbane, Australia d Rehabilitation Science, Griffith University. Southport 4215, Australia

article info

abstract

Article history:

Introduction: Exercise-based interventions have been used to enhance the recovery of burn

Accepted 15 February 2019

patients affected by hypermetabolism, muscle wasting and contractures. Although the

Available online xxx

benefits of exercise in burn population have been previously reported, the extent of exercise prescription in burn patients worldwide remains unknown. Therefore, the purpose of this

Keywords: Burns Rehabilitation Exercise Survey World

study is to identify the extent and characteristics of exercise use in specialised and nonspecialised burn centres worldwide. Methods: A web-based survey was developed in English and translated into Spanish and Chinese languages. Distribution of the surveys was made via email using personal contacts of the authors and through six scientific societies related to burn care in 2018. Data were analysed using descriptive statistics and comparisons between frequency distribution on variables of interest using the Chi-Square test and contingency tables. Results: One hundred and fifty-six surveys were completed (103 from the English version, 20 from the Chinese version, and 33 from the Spanish version). The response rate varied from 36.2% (English version) to 9.3% (Chinese version). Fifty eight percent of the surveyed clinicians worked in cities of 1 million inhabitants or more, and 92.3% worked in hospitalbased burn centres. Exercise was used by 64.1% of the participants at the intensive care unit level, 75% in burn wards prior to complete wound healing, and 80.1% in rehabilitation units after wound healing. The type of exercise offered, parameters assessed, and characteristics of exercise programs varied notably among burn centres and clinicians consulted. Conclusion: The majority of the surveyed clinicians used exercise for rehabilitation of patients following burn injuries. Further investigation is required to elucidate the access to exercise interventions prescribed by health professionals in remote areas, in less developed countries, and the extent of home-based exercise performed by patients. © 2019 Elsevier Ltd and ISBI. All rights reserved.

* Corresponding author at: Burns, Trauma & Critical Care Research Centre, Level 7, UQ Centre for Clinical Research, Royal Brisbane and Women’s Hospital, Herston, 4029 QLD, Brisbane, Australia. E-mail addresses: [email protected] (O. Flores), [email protected] (Z. Tyack), [email protected] (K. Stockton), [email protected] (J.D. Paratz). https://doi.org/10.1016/j.burns.2019.02.016 0305-4179/© 2019 Elsevier Ltd and ISBI. All rights reserved.

Please cite this article in press as: O. Flores, et al., The use of exercise in burns rehabilitation: A worldwide survey of practice, Burns (2019), https://doi.org/10.1016/j.burns.2019.02.016

JBUR 5772 No. of Pages 11

2

1.

burns xxx (2019) xxx

Background

Severe burn injuries are a complex kind of trauma characterized by a hypermetabolic response that continues for at least three years after injury [1], and leads to chronic sequelae characterized by loss of lean body mass and bone density, muscle weakness and contractures [2 4]. Due to the large impact of severe burns on overall health and health related quality of life, interventions to improve outcomes in burn patients have been extensively studied. Exercise training is considered to be an intervention that positively impacts on outcomes in a number of chronic health conditions [5] including burn injuries [6 8]. The benefits of exercise in burn populations have been examined in a number of studies resulting in improved physical fitness and muscle strength [9 11]. A recent systematic review and meta-analysis summarised the effects of exercise in rehabilitation post-burns, showing that exercise (mainly aerobic plus resistance exercise) has a beneficial effect on body composition, need for surgical release of contractures and quality of life [12]. Although considered a safe and effective intervention in recovery of function post burns, exercise has received minor research attention in comparison to other interventions. The aforementioned systematic review evaluating the effectiveness of exercise interventions in burns showed that the studies included were conducted in a small number of countries (United States (USA) (14 studies), Australia (1 study), Egypt (4 studies)) [12] therefore, a paucity of information on the extent of use of exercise in other regions was noted. A recent literature review of burn rehabilitation practices for survivors in low and middle-income countries, reported that there is very limited research evaluating the effectiveness of burns treatment in these countries and that little is known about current practices [13]. Health care facilities and personnel involved in burn rehabilitation may differ according to the level of development of the country and investment in healthcare [14]. With regard to exercise practice, a report describing practices among burn care centres showed that the use of exercise in the USA was inconsistent [15]. A report on exercise rehabilitation in burn survivors in intensive care units further demonstrated the inconsistency of such interventions in the USA [16]. Additionally, the incorporation of new technologies into the rehabilitation process post burns such as telemedicine [17] or video game-based exercises [18] have not yet been assessed from a global perspective. To the best of our knowledge, there are no reports providing information regarding exercise prescription and practice in countries apart from the USA. Therefore, the extent, modalities, and characteristics of exercise use in burn rehabilitation worldwide remain unknown. The present study aims to investigate: a) the extent of the use of exercise in burn patients in specialized and nonspecialized centres worldwide; b) the modality, frequency, intensity and duration of exercise programs used in the treatment of burn injuries, and c) the criteria (baseline measurements used, intensity) used for prescription of exercise in the rehabilitation of burn injuries.

2.

xxx

Methods

This study was approved by the Human Research Ethics Sub-Committee, The University of Queensland, Australia (Approval number 2017001526, 24th October 2017).

2.1.

Survey development

A web-based survey was designed to gather information on the extent of use of exercise in burn rehabilitation and the characteristics of such exercise-based interventions. To facilitate the participation of as many burn professionals as possible, the survey was translated from its original language (English) to also be available in Spanish and Chinese language versions. Once developed, two burns professionals (one for the English language version and one for the Spanish language version) were invited to answer the questionnaire to provide content and face validity. The questionnaire was thereafter modified to incorporate the feedback provided and the final version was revised by the research team. A member of the research team who is fluent in both languages (OF) tested consistency between the English and Spanish versions of the survey. To assure consistency of the Chinese version of the survey, two professionals fluent in both English and Chinese translated the survey into Chinese and tested the consistency between the original (English) version and the Chinese version. The modifications suggested were incorporated into the final version of the survey. The survey used a “question routing” technique introducing logic jumps to customize questions to the answers previously selected. The questionnaire consisted of 47 questions, but it was estimated that each participant needed to answer 30 35 questions to complete the survey.

2.2.

Exercise definition

For standardization purposes, a definition of exercise was provided to all the participants prior to undertaking the survey. Exercise was defined as “a subcategory of physical activity that is planned, structured, repetitive, and purposeful in the sense that the improvement or maintenance of one or more components of physical fitness is the objective” based on the World Health Organization’s guideline on physical activity [19]. Participants were informed that exercise used for preventing contractures was considered to be included in the exercise definition offered.

2.3.

Outcomes

Outcomes of interests were divided into two main categories: outcomes related to the burn centre and burn professionals’ demographic characteristics, and outcomes related to the type of exercise offered by participants to the burn population. For the first category, questions were inclusive of but not restricted to: participants’ country of origin, profession, years of experience, and size of the centre. For the second category, questions included the type of exercise used throughout the

Please cite this article in press as: O. Flores, et al., The use of exercise in burns rehabilitation: A worldwide survey of practice, Burns (2019), https://doi.org/10.1016/j.burns.2019.02.016

JBUR 5772 No. of Pages 11

burns xxx (2019) xxx

continuum of care of burn recovery, barriers to the ability to offer exercise in their centres, and techniques used for exercise supervision from a distance (e.g. video calls, phone calls). Questions also included the criteria used for exercise prescription (i.e. intensity, baseline measure used), the criteria for excluding patients from exercise interventions, tests used for determining the baseline fitness of patients, and characteristics (length, frequency, time per session) of the programs offered.

2.4.

Survey distribution

Distribution of the survey was made via email, using two main methods. A purposeful sampling method using personal

3

xxx

contacts of the research team was used as a primary approach. Additionally, a gatekeeper letter was used to obtain consent to distribute the survey through scientific associations related to burn care (i.e. Australia New Zealand Burn Association (ANZBA), Federacion Latinoamericana de Quemaduras (FELAQ), European Burn Association (EBA), American Burn Association (ABA), South African Burn Society (SABS) and the Sociedad Chilena de Quemaduras (SOCHIQUEM)). In the Latin America region, the snowball technique (clinicians initially contacted sent the invitation to participate to their peers and colleagues) was also used to ensure optimal coverage. The web-based platform TypeformTM was used to generate a link to the survey and to collect the answers. The same software provided information on the number of surveys

Table 1 – Demographic characteristics of participants by country, region and development status. Country

America (n =70)

Canada

6

3.8

0.920

Very high

USA

32

20.5

0.920

Very high

Latin America and Caribbean (n =32) Argentina Brazil Chile Colombia Costa Rica Dominican Republic Ecuador Guatemala Peru

4 1 8 7 1 1 2 2 6

2.6 0.6 5.1 4.5 0.6 0.6 1.3 1.3 3.8

0.827 0.754 0.847 0.727 0.776 0.722 0.739 0.640 0.740

Very high High Very high High High High High High High

Europe and Central Asia (n = 31)

Belgium

4

2.6

0.896

Very high

Croatia Germany Greece Netherlands Norway Portugal Spain Sweden United Kingdom Uzbekistan

1 3 1 5 1 2 2 1 10 1

0.6 1.9 0.6 3.2 0.6 1.3 1.3 0.6 6.4 0.6

0.827 0.926 0.866 0.924 0.949 0.843 0.884 0.913 0.909 0.701

Very high Very high Very high Very high Very high Very high Very high Very high Very high High

India Pakistan

4 2

2.6 1.3

0.624 0.550

Medium Medium

China Singapore Thailand Australia

20 1 1 14

12.8 0.6 0.6 9.0

0.738 0.925 0.740 0.939

High Very high High Very high

New Zealand

1

0.6

0.915

Very high

Middle East and North Africa (n =2)

Kuwait Saudi Arabia

1 1

0.6 0.6

0.800 0.847

Very high Very high

Sub-Saharian Africa (n = 10)

Nigeria South Africa Zimbabwe

1 8 1

0.6 5.1 0.6

0.527 0.666 0.516

Low Medium Low

Europe (n =30)

North America (n =38)

Asia (n =31) South Asia (n =6)

East Asia and Pacific (n =37)

Oceania (n =15)

Frequency %

Human development index, 2016

Development status, UNDP

Continent World Bank region

Africa (n =10)

Abbreviations: UNDP =United Nations Human Development Program.

Please cite this article in press as: O. Flores, et al., The use of exercise in burns rehabilitation: A worldwide survey of practice, Burns (2019), https://doi.org/10.1016/j.burns.2019.02.016

JBUR 5772 No. of Pages 11

4

burns xxx (2019) xxx

completed, time used to complete each survey and devices used to complete it. Each answer registered in the system was also identified with an IP address code, which was also checked to avoid the risk of duplication of survey responses. Once the period for data collection was completed, the data was assigned a unique code and stored in a passwordprotected computer. It was then exported to an ExcelTM sheet to consolidate the information, create data sheets, summarise information and perform statistical analysis.

2.5.

Data analysis

Data was analysed using descriptive statistics and associations between the region and the proportion of participants delivering exercise at different stages was tested using Chi-Square test of independence. Post-hoc pairwise comparisons of proportions between regions were also tested, and adjusted using the Bonferroni method. Statistical analyses were performed using the IBM SPSS Statistics for Windows (Version 25.0. Armonk, NY: IBM Corp.).

3.

Results

The link to the English version of the survey was sent to 3805 contacts (3671 members of ANZBA, EBA, ABA and SABS and a further 34 personal contacts). Thirty-eight Spanish speaking clinicians (personal contacts) were invited to participate and

xxx

contacts from FELAQ and SOCHIQUEM used the snowball technique to further recruit participants. Finally, the Chinese version of the survey was sent to 288 personal contacts. A total number of 156 surveys were completed. From the 3805 invitations sent to complete the English version of the survey, 284 individual visits to the link provided were registered in the platform and 103 surveys were completed (36.2% response rate, based on access to the link provided). Given the use of the snowballing technique within the Latin American region, the number of invitations sent could not be determined. From 94 individual visits to the Spanish version of the questionnaire on the website, 33 surveys were completed (35.1% response rate). Finally, from the two hundred and sixteen individual visits to the Chinese version of the questionnaire, 20 completed surveys were obtained (9.3% response rate).

3.1.

Participating countries/regions

Detailed results on the geographic distribution of the sample, including distribution according to World Bank geographic area and the degree of development of participant countries according to United Nations Development Program (UNDP) report 2016 [20] are shown in Table 1 and Fig. 1. Clinicians working in large cities and metropolitan areas completed the majority of the surveys (58.3% worked in cities of one million inhabitants or more). Participants who completed the survey were most frequently from America (44.9%) followed by Asia (19.9%) and Europe (19.2%).

Fig. 1 – Records per country. Please cite this article in press as: O. Flores, et al., The use of exercise in burns rehabilitation: A worldwide survey of practice, Burns (2019), https://doi.org/10.1016/j.burns.2019.02.016

JBUR 5772 No. of Pages 11

burns xxx (2019) xxx

5

xxx

3.2. Burn centre and participating professional characteristics

exclusively. Finally, 12.8% of the participants worked treating only paediatric patients.

Of the 156 surveys received, 92.3% were completed by clinicians affiliated with a hospital based burn centre. Sixty clinicians (38.5%) worked in units having 10 beds or less and 32 (20.5%) worked in large units with more than 20 beds. The 156 participants worked in 146 different health centres, including general hospitals, specialized burns units or centres, and outpatient clinics. The participating clinicians were physiotherapists (41%), medical doctors (28.2%), occupational therapists (14.7%), nurses (9%), and other professionals (7.1%). Experience treating burn patients ranged from 0 to 2 years (10.9%) to more than 15 years (35.9%). Most of the clinicians (58.3%) treated both adult and paediatric patients, whilst 28.8% treated adult burn patients

3.3.

Exercise interventions

Exercise-based interventions in the intensive care unit (ICU) were offered by 64.1% of the participants, while 75% delivered exercise in the burn unit or ward prior to complete wound healing. The use of exercise to treat burn patients at burn ward or rehabilitation unit after wound healing was reported by 80.1% of the participants. Only 16% of clinicians offered exercise programs supervised from a distance (i.e. telehealth). Overall, 145 clinicians reported the use of exercise at any stage in the treatment of burn patients (92.9%). Eleven participants (7.1%) did not offer exercise at all. Results reported from this point and onwards that pertain to type, restrictions, prescription, characteristics, and

Table 2 – Type of exercise used in burns rehabilitation by treatment stage. Stage

Type of exercise

Intensive Care Unit (n = 145)

Passive movements Active/assisted exercises Tilt table Sitting out of bed Walking Othera Not applicable (centre does not have an ICU) Not applicable (centre does not offer exercise in ICU)

Burn ward/unit (prior to complete wound healing) (n =145)

Burn ward/unit or rehabilitation unit (after wound healing) (n = 145)

a b c

Frequency

%

116 122 62 111 96 33 12

80.0 84.1 42.8 76.6 66.2 22.8 8.3

7

4.8

Passive movements

126

86.9

Active/assisted exercises Resisted exercises Tilt Table Sitting out of bed Walking Play/functional activities Video game exercises Exercise in the burn bath Otherb Not applicable (centre does not have a burn/ward unit) Not applicable (centre does not offer exercise at burn ward/unit)

129 103 62 117 116 104 49 43 25 4

89.0 71.0 42.8 80.7 80.0 71.7 33.8 29.7 17.2 2.8

0

0.0

Aerobic exercise

103

71.0

Resisted exercises Stretching Play/functional exercises Video game exercises Otherc Not applicable (centre does not offer exercise after wound healing)

115 129 117 55 18 7

79.3 89.0 80.7 37.9 12.4 4.8

Abbreviation: ICU= intensive care unit. Other exercises at ICU included equipment-assisted movements, Tai-Chi and Yoga exercises. Other exercises at burn ward included yoga, treadmill exercise and resisted exercises using elastic bands. Other exercises at the rehabilitation unit included balance, proprioception, rowing and coordination exercises.

Please cite this article in press as: O. Flores, et al., The use of exercise in burns rehabilitation: A worldwide survey of practice, Burns (2019), https://doi.org/10.1016/j.burns.2019.02.016

JBUR 5772 No. of Pages 11

6

burns xxx (2019) xxx

outcomes of the exercise offered, are restricted to the 145 participants who reported the use of any kind of exercise in the treatment of burns survivors.

3.4.

Type of exercise used by treatment stage

Table 2 summarizes the type of exercise used by the surveyed clinicians according to the stage of treatment. Of the 145 participants using exercise, passive movements (n=116, 80%) and active/assisted exercises (n=122, 84.1%), were the most frequently used interventions in the ICU. Interventions in ICU listed as “other” included equipmentassisted movement, Tai Chi, Yoga exercises, arm ergometer, and a bed bicycle. Passive movements (n=126, 86.9%) and active/assisted exercises (n=129, 89%) were also the most frequent type of exercise used by clinicians at the burn ward/unit. Other exercise interventions such as endurance exercises (using arm and stationary bikes), yoga, treadmill exercise, aerobic exercise and resistive exercise using elastic bands were also reported. Finally, at the burn ward or rehabilitation unit after wound healing, stretching was the most frequently used modality (89.0%),with play and functional activities used by 80.7% of the clinicians. In addition, balance, proprioception, hydrotherapy, rowing, and coordination exercises were reported by participants.

3.5. burns

xxx

Barriers to the use of exercise-based interventions in

Of the 145 participants reporting the use of exercise, six (4.1%) stated that patient medical instability prevented the use of exercise in burn patients in the ICU. No other reason was reported as a barrier to exercise use in ICU. At burn ward/unit prior to complete wound healing, lack of facilities (6.9%), lack of staff (6.9%), unsupportive staff (0.7%) and medical instability of the patients (1.4%), prevented the use of exercise. Other reasons reported by 14.5% of participants included lack of skills, shortage of equipment, and the belief that the use of common spaces and equipment would increase the infection rates before wound healing. Post burn wound healing in the burns ward or the rehabilitation unit, barriers mentioned were lack of facilities (3.4%), lack of staff (6.9%), and unsupportive staff (0.7%). Other reasons reported by nine participants (6.2%) included distance from centre, concerns regarding time and cost of travel from home to the centre, and patient reluctance to attend exercise sessions once discharged from hospitalisation. Additionally, 116 out of 145 participants (80%) considered the use of the following criteria for excluding patients from an exercise intervention: co-morbidities (43.4%), behavioural problems (24.8%), low burn Total Body Surface Area (TBSA) (11%) and other reasons (27.6%). Other reasons for exclusion included patients under compassionate care, hemodynamic

Fig. 2 – Outcomes assessed before beginning exercise.

Please cite this article in press as: O. Flores, et al., The use of exercise in burns rehabilitation: A worldwide survey of practice, Burns (2019), https://doi.org/10.1016/j.burns.2019.02.016

JBUR 5772 No. of Pages 11

burns xxx (2019) xxx

instability, small burns not affecting joints, acute cardiac symptoms, chest pain, hypoglycaemia, signs of infection or sepsis, and signs of multiple organ failure.

3.6. Use of technologies for delivering exercise interventions from a distance All participants answered the question regarding support via technology. Of those who reported the use of exercise interventions supervised from a distance (35.2%), telephone-based support (27.6%) and video conferencebased supervision using video calls system as Skype (12.4%) were the most used methods. Applications on mobile devices (6.2%) and the use of exercise programs on digital video disc (DVD) (4.8%) were also reported. Other systems reported by (8.3%) of the clinicians surveyed, included written handouts, the use of logbooks with exercise prescription, and Quick Response (QR) code videos.

3.7.

Exercise prescription

Formal exercise tests before commencing exercise programs were conducted by 24.8% of the surveyed participants. Amongst them, the six-minute walking test (6MWT) was the most frequently used test (16.6%). Cardiopulmonary tests performed in an exercise laboratory (7.6%), the shuttlewalking test (3.4%) and other tests (9.7%) were used by a small proportion of the participants. Other tests used included single stage treadmill test, two minute walking test, and timed up and go test.

7

xxx

Outcomes assessed before commencing the exercise program were also investigated. Heart rate (75.2%) and blood pressure (71.7%) were the parameters most frequently assessed by clinicians (Fig. 2). Of the 135 participants answering the question regarding aerobic exercise prescription, 43.4% used an indicator to set the intensity of aerobic exercise. Heart rate was used by 29.7% and perceived exertion (Borg’s scale or similar) was used by 6.2% of the participants. Field test performance (e.g. 6MWT) (2.1%), peak oxygen uptake (VO2peak) (3.4%) and other tests (1.4%) were less frequently considered. The intensity usedfor prescribing aerobic exercise was also investigated. The majority of the participants (57.9%) stated that they did not aim for a specific intensity (considered as a percentage of the maximum baseline test). Of those that preferred to set the intensity for the aerobic training, the most frequently used intensities were 50 65% and 66 75% of the maximum baseline test (9.7% each). Intensities below 50% were used by 8.3% of the participants, while intensities over 75% were used by 2.8% of the participants. In regard to resisted exercise, 33.1% of the participants used an indicator to set the initial load, with manual muscle testing (23.4%), dynamometry (4.1%), maximal mechanical workload (2.8%) and other (1.4%) the reported methods. The isokinetic muscle test was not used as an indicator by any participant.

3.8.

Exercise program characteristics

The characteristics (length, frequency and duration of sessions) of exercise programs offered are summarised in Table 3.

Table 3 – Characteristics of exercise programs offered by burn professionals. Variable

Categories

Frequency

%

<3 weeks 3 5 weeks 6 11 weeks 12 18 weeks >18 weeks Othera N/A

14 15 10 4 14 76 12

9.7 10.3 6.9 2.8 9.7 52.4 8.3

Once/week Twice/week Three times/week Four or more times/week Otherb N/A

8 10 22 69 22 14

5.5 6.9 15.2 47.6 15.2 9.7

<30 min 30 45 min 46 60 min >60 min N/A

36 62 20 12 15

24.8 42.8 13.8 8.3 10.3

Average length (weeks) (n =145)

Average frequency (sessions per week) (n =145)

Average duration (minutes per session) (n = 145)

a b

Other lengths were used according to criteria such as length of hospitalisation, financial capacity and distance from the burn centre. Other frequencies were used such as daily exercise intervention or twice a day.

Please cite this article in press as: O. Flores, et al., The use of exercise in burns rehabilitation: A worldwide survey of practice, Burns (2019), https://doi.org/10.1016/j.burns.2019.02.016

JBUR 5772 No. of Pages 11

8

burns xxx (2019) xxx

The majority of the participants (52.4%) selected “other” lengths and described that the clinical progress of patients, financial reasons, duration of hospital stay, time needed to reach full return to school or work, and the time needed to become independent in daily life activities are considered to individually set the length of the exercise-based intervention. A frequency of four sessions per week (47.6%) and session duration ranging between 30 and 45min (42.8%) were the frequencies of exercise most commonly reported by the participants.

3.9.

xxx

The association between not offering exercise interventions and the region of origin of surveyed clinicians was significant (x2=12.09, df=3, n=138, p=0.018), but no significant differences between regions were found in the post-hoc pairwise comparison. Finally, the use of formal tests to prescribe exercise interventions was significantly associated with the region of origin of the clinicians surveyed (x2=8.67, df=3, n=124, p=0.03). The use of formal tests to prescribe exercise was significantly higher in the East Asia and Pacific region compared with the other regions (p=0.004).

Exercise intervention use among different regions

4. The proportion of participants using exercise-based interventions by stage of treatment, and according to their region of origin is summarised in Table 4. Data from four different World Bank regions (East Asia and Pacific, Europe and Central Asia, Latin America and Caribbean, and North America) was sufficient to allow comparisons between them. Using the Chi-square test of independence, a significant association was found between the World Bank region of origin and the delivery of exercise-based interventions at the ICU (x2 =19.98, df=3, n=138, p<0.001). The proportion of participants using exercise interventions at the ICU was significantly lower among clinicians from Latin America and the Caribbean compared with the other regions (p<0.001). The region of origin was also significantly associated with the delivery of exercise at burn ward or unit prior to complete wound healing (x2 =12.87, df=3, n=138, p=0.005). Post-hoc comparison showed that the proportion of clinicians delivering exercise in burn wards/units was significantly lower in Latin America and the Caribbean compared with the other regions (p=0.001). In rehabilitation units and after wound healing, the association between World Bank region and delivery of exercise interventions was significant (x2=9.40, df=3, n=138, p=0.02). However, no significant differences between regions were found in the post-hoc analysis. The use of exercise supervised from a distance was also significantly associated with the region of origin of the clinicians surveyed (x2=12.15, df=3, n=138, p=0.007). The use of exercise from a distance was significantly higher in East Asia and Pacific compared with the other regions (p=0.001).

Discussion

Exercise is regarded as one of the options used among burn professionals for improving outcomes post burns. The effectiveness of exercise and to a lesser degree, safety, have been ratified in two systematic reviews and one meta-analysis [6,12,21]. Despite this apparent agreement in the literature, there was a paucity of information regarding the extent and characteristics of the use of exercise beyond the USA. The present study fills this gap and ratifies that exercise is used as a part of the rehabilitation process in burn centres worldwide. Our study is the first in burns rehabilitation that aimed to determine how exercise is used in rehabilitation post burns by surveying clinicians in the three most widely used languages worldwide. Previous surveys conducted to explore the use of exercise in the treatment of burns were restricted to the English language and limited to a single country [15,16]. This, and the fact that our report covered all the continents and geographic regions set by the World Bank to characterize world economies, allowed a thorough analysis regarding differences that may be present in exercise prescription and use along the continuum of burn care. The modalities and characteristics of the exercise interventions used are difficult to standardize. Considerable variability was observed in terms of the interventions used in each recovery stage (intensive care unit, burn wards and rehabilitation units), the criteria used for exercise prescription and exclusion, the assessments performed and the characteristics of exercise programs delivered (length of programs, frequency, and duration of sessions). There were also differences in the extent of the use of exercise according to the region of origin of surveyed clinicians. Interestingly, while

Table 4 – Delivery of exercise intervention by stage of burn recovery according to World Bank region. Delivering Exercise/Region ICU Burn ward/unit Rehabilitation unit Exercise from a distance Exercise not offered

East Asia & Pacific (n=37)

Europe & Central Asia (n=31)

Latin America & Caribbean (n=32)

Middle East & North Africa (n=2)

North America (n=38)

South Asia (n=6)

Sub-Saharian Africa (n=10)

59.5% 73.0% 89.2% 35.1%

77.4% 90.3% 74.2% 16.1%

34.4% 53.1% 62.5% 6.3%

0% 50.0% 100% 0%

1.6% 81.6% 86.8% 10.5%

66.7% 83.3% 100% 16.7%

80.0% 80.0% 80.0% 0%

0%

0%

15.6%

0%

10.5%

0%

20%

Please cite this article in press as: O. Flores, et al., The use of exercise in burns rehabilitation: A worldwide survey of practice, Burns (2019), https://doi.org/10.1016/j.burns.2019.02.016

JBUR 5772 No. of Pages 11

burns xxx (2019) xxx

Europe and North America showed higher rates of exercise use in ICU and burn wards/units, in the East Asia and Pacific region the rate of exercise delivery in the rehabilitation units and the use of tele-supervised exercise appeared to be more frequent. Our study shows that the majority of the participants (58.3%) worked in burns centres situated in large cities of over 1 million inhabitants. As some of the participating countries (e.g. Australia, Argentina, Canada, Chile, China, USA) have vast territories, accessibility to supervised exercise post burns may be an issue for patients living in small towns distant from metropolitan regions. In a study published in 2012, Paratz et al. [22] highlighted that due to large distances in Australia and financial concerns, patients residing far away from the reference burn centre are, in some cases, unable to undertake tertiary rehabilitation care after burn injuries. Our study is the first one investigating the extent of the use of exercise supervised from a distance in burn patients and the different technologies used to facilitate supervision, with less than 20% of the participants using this modality. As previously discussed, accessibility to exercise in remote areas is an issue that needs to be considered. Both telehealth and community based exercises [23,24] are potential alternatives to overcome logistical challenges by providing exercise options to patients with burns living far from metropolitan areas. However, the safety of these interventions, which involves a less direct supervision, requires further investigation given the potential cardiovascular risk experienced by subjects post burns [25]. The majority of the participants of our study offered exercise at burn wards post wound healing and in rehabilitation units. Our data shows that passive movements and active/ assisted exercises were the most used exercise interventions at the intensive care units. A recently published study investigated the use of strengthening and cardiorespiratory exercises during intensive care unit stay in six burn centres of the USA (states of Texas and California) [16]. The reported data showed that all the centres surveyed used strengthening exercises while 83% used aerobic exercises. Other forms of exercise as general mobilization, ambulation, and standing on tilt table were also reported as highly used which is in agreement with the results of our study. At burns wards or units, exercise for inpatients is offered including active/assisted movements, walking activities, sitting out of bed and passive movements. Interestingly, resisted exercises (n=103, 71.0%) and play/functional activities (n=104, 71.7%) are among the most used interventions in this recovery stage. The use of new technologies such as videogame exercises was also reported by one third of the participants, paralleling research on the use of these interventions in recent years [18,26,27]. The vast majority of the participants in our study (80.1%) used exercise interventions either in the burn ward after completion of wound healing or in rehabilitation units after discharge. Stretching was the most widely reported exercise technique (by 89% of the participants). In addition, both aerobic and resistance exercise (with the goal of improving muscle strength) were highly used at this recovery stage. These two exercise interventions are, by far, the most studied in terms of effectiveness and have been demonstrated to improve body composition, physical fitness and function, as well as reduce the need for surgical release of contractures [12].

xxx

9

Clinicians excluded patients from exercise interventions due to comorbidities, medical instability (especially at the ICU stage), and lack of staff or facilities. Comorbidities were the most common reason to exclude patients from exercise programs. Specific co-morbidities were not stated but considering the increase in worldwide rates of obesity and diabetes, this area should be further investigated. Modifications for patients with co-morbidities should be investigated as it is not ideal that these patients are not receiving exercise post burns. It is noted that there was a lack of agreement among burn professionals on what constituted an exclusion criteria to include patients in an exercise program post burns. As described in the literature, exercise programs based on both strengthening and aerobic exercise are the most frequently used and the interventions that had been more extensively assessed [8,12,21,22,28,29]. Our results suggest, however, that formal tests to accurately prescribe exercise interventions are used by less than 30% of the surveyed professionals, with clinicians from the East Asia and Pacific region using formal tests significantly more than the other regions. Additionally, when a formal test is used there is a high variability regarding the test selected to set the intensity of the aerobic exercise, the optimal intensity and the indicator used to set the intensity. A similar variability is noticed in regards to strengthening exercises, making it difficult to establish standard outcomes and interventions. Similarly, the results of our survey question the assumption that the interventions and outcome measures commonly used in research are representative of practices in the burns wards and rehabilitation units worldwide. First, despite the relative homogeneity of the exercise interventions reported in clinical trials and a systematic review [9 12], the interventions being reported in the survey largely varied, and differences can be observed in the type and extent of exercise delivered according to the region of origin of the participants. Secondly, clinicians rarely reported the outcomes considered as relevant in most of the interventional studies [9 11]. Body composition (2.8%), metabolic rate (8.3%) or maximal oxygen uptake (4.8%) were all used by less than one out of ten participants of the survey, showing that integrating objective assessment tools into clinical practice is likely to be a challenge in most burn centres globally. The fact that assessments of these outcomes are relatively expensive and time-consuming for clinicians could explain infrequent use of these assessments in practice. Furthermore, it is not clear whether patients consider these outcomes as relevant to their rehabilitation post burns. Future consensus guidelines are needed to establish standard outcomes, interventions, and exclusion from exercise interventions in burn population, as well as helping to accurately target the most cost-effective interventions needed to specifically address the needs of particular groups of patients (e.g. children vs adults, large vs small burns). Finally, the characteristics of exercise delivery for patients with burn injuries were also examined showing different approaches in terms of the length of exercise programs, frequency (sessions per week) and the duration of each session. Most of the research examining the effectiveness of exercise post burns has used the same intensity and frequency of exercise (12 weeks of length, 3 sessions per week) to assess the effectiveness [6,7,12]. Thus, evidence of the effectiveness

Please cite this article in press as: O. Flores, et al., The use of exercise in burns rehabilitation: A worldwide survey of practice, Burns (2019), https://doi.org/10.1016/j.burns.2019.02.016

JBUR 5772 No. of Pages 11

10

burns xxx (2019) xxx

of other exercise delivery intensities and frequencies has not been established.

5.

Limitations

Our study has some limitations. The first one is related to the countries covered. Our study used two main ways to invite health professionals to participate in our study. Firstly, we sent invitations using personal contacts of the research team. Additionally, we distributed the surveys to burn professional societies worldwide. Both strategies may be biased in favour of those countries with a more advanced network of professionals and consequently, with better practices in burn rehabilitation. The fact that almost 90% of the participants lived in countries considered as “highly” or “very highly” developed, prevent us from generalising our findings to the entire world population. Limitations related to both language spoken and internet penetration are acknowledged and require further investigation regarding whether exercise is employed in low and middle income countries and in those countries where English, Spanish or Chinese languages are not spoken. The strategy used may be also be biased in favour of specialised burn centres rather than those clinicians that worked in varied caseloads and practice areas. The relatively low response rate obtained may introduce potential selection bias. The use of a web-based survey may have influenced the low response rate, but allowed the coverage of different countries without incurring in excessive costs. The fact that the survey was mainly distributed by professional/scientific societies allowed us to reach a potentially higher number of participants, but affected the ability to follow-up non-responses by participants and thus to achieve a higher response rate. Because the distribution made by the professional boards could not be controlled by our research team, the percentage of answers received from those clinicians that effectively accessed to the platform was provided, and this indicator better reflects the rate of responses compared with similar surveys of practice. If the last method is considered, the overall response rate of our survey is 26.2%, which is comparable with other web surveys reported in burn practice [30,31]. Furthermore, there is some evidence that few differences in outcomes are observed when comparing paper-based (high response rate) and web-based (lower response rate) surveys [32]. A further limitation is that our survey may have under surveyed the countries and regions with a higher incidence of severe burn injuries. The global burden of disease study [33] showed that in 2004, incidence of injuries due to fire was 5.9 million people in the South-East Asia region and 1.7 million in Africa, while the incidence in the same year was 0.3 million people in the Americas region and 0.8 in Europe. Consequently, most of the participants of the present study worked in regions with a relatively low incidence of burn injuries.

6.

Conclusion

The majority of clinicians use exercise for improving outcomes after burns. However, differences are noticed regarding the

xxx

extent of use by the stage of the treatment, region and intensity and frequency. The type of exercise interventions used in each recovery stage, the criteria used for exercise prescription, the outcomes assessed and the characteristics of the exercise programs varied notably. Further investigations are required to determine whether exercise is accessible for patients living in remote areas and specially, to understand the accessibility to exercise in low and middle developed countries.

Declaration of interests Mr. Orlando Flores is funded by a PhD scholarship provided by CONICYT, Chilean Government.

Acknowledgements The authors want to thank Professor Alice Jones (The University of Sydney) and Dr. Alan Liao (JORU Rehabilitation Hospital, China) for helping with the translation of the survey into Chinese and for checking its consistency with the original version. We also thank Ms. Solange Campana (Hospital Roberto del Rio, Santiago de Chile) and Dr. Peter Thomas (Royal Brisbane and Women’s Hospital, Brisbane, Australia) for providing content and face validity for the development of the survey. We acknowledge the help of the Australia and New Zealand Burn Association (ANZBA), American Burn Association (ABA), European Burn Association (EBA), Federacion Latinoamericana de Quemaduras (FELAQ), South African Burn Society (SABS), Sociedad Chilena de Quemaduras (SOCHIQUEM), and Ms. Maria Isabel Meneses (Hospital del Trabajador, Santiago de Chile) in the distribution of our survey. Finally, we would like to express our appreciation to all the colleagues who took the time to answer our questions.

REFERENCES

[1] 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;6(7):e21245. [2] Herndon DN, Tompkins RG. Support of the metabolic response to burn injury. Lancet 2004;363(9424):1895 902. [3] Hart DW, Wolf SE, Mlcak R, Chinkes DL, Ramzy PI, Obeng MK, et al. Persistence of muscle catabolism after severe burn. Surgery 2000;128(2):312 9. [4] Oosterwijk AM, Mouton LJ, Schouten H, Disseldorp LM, van der Schans CP, Nieuwenhuis MK. Prevalence of scar contractures after burn: a systematic review. Burns 2017;43(1):41 9. [5] 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(Suppl 3):1 72. [6] 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 2015;37(6):e539 58. [7] 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(9):1501 10.

Please cite this article in press as: O. Flores, et al., The use of exercise in burns rehabilitation: A worldwide survey of practice, Burns (2019), https://doi.org/10.1016/j.burns.2019.02.016

JBUR 5772 No. of Pages 11

burns xxx (2019) xxx

[8] Porter C, Hardee JP, Herndon DN, Suman OE. The role of exercise in the rehabilitation of patients with severe burns. Exerc Sport Sci Rev 2015;43(1):34 40. [9] 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(1):e109 16. [10] 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(6):2273 81. [11] 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(3):1168 75. [12] 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(6):734 46. [13] Jagnoor J, Lukaszyk C, Fraser S, Chamania S, Harvey LA, Potokar T, et al. Rehabilitation practices for burn survivors in low and middle income countries: a literature review. Burns 2018;44(5):1052 64. [14] Atiyeh B, Masellis A, Conte C. Optimizing burn treatment in developing low- and middle-income countries with limited health care resources (part 1). Ann Burns Fire Disasters 2009;22 (3):121 5. [15] Diego AM, Serghiou M, Padmanabha A, Porro LJ, Herndon DN, Suman OE. Exercise training after burn injury: a survey of practice. J Burn Care Res 2013;34(6):e311 7. [16] 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(6):897 901. [17] Wallace DL, Hussain A, Khan N, Wilson YT. A systematic review of the evidence for telemedicine in burn care: with a UK perspective. Burns 2012;38(4):465 80. [18] Parry I, Carbullido C, Kawada J, Bagley A, Sen S, Greenhalgh D, et al. Keeping up with video game technology: objective analysis of Xbox kinect [TM] and playstation 3 move [TM] for use in burn rehabilitation. Burns (03054179) 2014;40(5):852 98. [19] WHO Guidelines. Global recommendations on physical activity for health. global recommendations on physical activity for health. Geneva: World Health Organization; 2010 Copyright (c) World Health Organization. [20] United Nations Development Program. Human development report 2016: human development for everyone. New York: United Nations; 2016.

xxx

11

[21] 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(9)1501 10 10p. [22] Paratz JD, Stockton K, Plaza A, Muller M, Boots RJ. Intensive exercise after thermal injury improves physical, functional, and psychological outcomes. J Trauma Acute Care Surg 2012;73(1):186 94. [23] Voigt CD, Foncerrada G, Pena R, Guillory AN, Andersen CR, Crandall CG, et al. Effects of community-based exercise in adults with severe burns: a randomized controlled trial. Arch Phys Med Rehabil 2018 Epub ahead of print. [24] Pena R, Ramirez LL, Crandall CG, Wolf SE, Herndon DN, Suman OE. Effects of community-based exercise in children with severe burns: a randomized trial. Burns 2016;42(1):41 7. [25] Leung B, Younger JF, Stockton K, Muller M, Paratz J. Cardiovascular risk profile in burn survivors. Burns 2017;43 (7):1411 7. [26] Parry I, Painting L, Bagley A, Kawada J, Molitor F, Sen S, et al. A pilot prospective randomized control trial comparing exercises using videogame therapy to standard physical therapy: 6 months follow-up. J Burn Care Res 2015;36(5):534 44. [27] Voon K, Silberstein I, Eranki A, Phillips M, Wood FM, Edgar DW. Xbox Kinect based rehabilitation as a feasible adjunct for minor upper limb burns rehabilitation: a pilot RCT. Burns 2016;42(8):1797 804. [28] Hardee JP, Porter C, Sidossis LS, Borsheim E, Carson JA, Herndon DN, et al. Early rehabilitative exercise training in the recovery from pediatric burn. Med Sci Sports Exerc 2014;46 (9):1710 6. [29] de Lateur BJ, Shore WS. Exercise following burn injury. Phys Med Rehabil Clin N Am 2011;22(2)347 50 4p. [30] Klotz T, Kurmis R, Munn Z, Heath K, Greenwood J. Moisturisers in scar management following burn: a survey report. Burns 2017;43(5):965 72. [31] Selig HF, Lumenta DB, Giretzlehner M, Jeschke MG, Upton D, Kamolz LP. The properties of an ideal burn dressingwhat do we need in clinical practice? Results of a worldwide online survey among burn care specialist. Burns 2012;38(7):960 6. [32] Gerbase MW, Germond M, Cerutti B, Vu NV, Baroffio A. How many responses do we need? Using generalizability analysis to estimate minimum necessary response rates for online student evaluations. Teach Learn Med 2015;27(4):395 403. [33] The Global Burden of Disease. 2004 Update. Global Burden of Disease: 2004 Update. 2008.

Please cite this article in press as: O. Flores, et al., The use of exercise in burns rehabilitation: A worldwide survey of practice, Burns (2019), https://doi.org/10.1016/j.burns.2019.02.016