Review: Long-Term Outcomes in Burn Rehabilitation
Takeaways
- Burn survivors commonly experience multisystem long-term challenges during their recovery.
- Long-term impairments, particularly in skin functions, sensory functions, joint and muscle functions, and mental function, drive the increasing recognition of burn injury as a chronic condition.
- The International Classification of Functioning, Disability, and Health considers the effects of disease not only on body structure and function, but also on activities of daily living and participation in societal roles.
- Long-term regular follow-up to prevent late or cumulative impairments is critical for comprehensive burn recovery.
Burn injury severe enough to require rehabilitation is a chronic condition that produces long-term multisystem functional and participation limitations. The International Classification of Functioning, Disability, and Health (ICF), developed by the World Health Organization in 2001, is used increasingly to guide a comprehensive understanding of burn-related outcomes.
Using the ICF as a framework, physicians at Spaulding Rehabilitation recently published a narrative review of common impairments after burn injury. This summary focuses on the most recent evidence about the long-term effects of burns on anatomical structures, physiological functions, activities of daily living and social integration.
The reviewers are Huan Deng, PhD, research fellow in the Department of Physical Medicine and Rehabilitation, Timothy J. Genovese, MD, MPH, a resident in the Department, and Jeffrey C. Schneider, MD, associate professor in the Department and director of the Boston–Harvard Burn Injury Model System.
Movement-Related Structures
The hypermetabolic response to burn injury alters skeletal muscle metabolism, especially when the burn is severe. Muscle catabolism may persist after wound closure and cause muscle wasting and atrophy. A study published in the Journal of Burn Care & Research detected 20% to 30% loss of lower extremity muscle strength an average of 20 weeks after injury in patients with severe lower extremity burns compared with healthy controls. Problems related to muscle, tendon, and bone also affect survivors' balance, gait, and movement coordination.
Genitourinary and Reproductive Systems
Sexual dysfunction after burn injuries is attributable to more than hypoesthesia or erectile dysfunction. Alteration in body image, hormonal imbalance, and adverse reactions to medications can have long-term effects. For pregnant individuals, burn injury increases the risk of abortion and premature labor.
Thermoregulatory Functions
Because of changes in metabolic activities and damage to skin structures, burn survivors are prone to long-term temperature sensitivity, such as heat and cold intolerance. An analysis of the Burn Model System National Database, published in the Journal of Burn Care & Research, documented temperature sensitivity in 43% of participants at hospital discharge, 17% at one year after injury, and 9% at two years.
Survivors commonly cite temperature sensitivity as a reason for limited participation in outdoor activities and physical exercise.
Laryngeal Injury
Inhalation of hot or toxic gas, and endotracheal intubation during associated medical and surgical care often cause laryngeal injury. The most common symptoms are cough and dysphonia; others are dysphasia, dyspnea, wheezes/rales, and stridor. Intubation can have sequelae of posterior glottic scarring and arytenoid cartilage dislocation.
A report in The Journal of Burn Care & Rehabilitation showed that over 16 to 25 years of follow-up, more than half of burn survivors with a history of inhalation injury, smoke exposure, or intubation had dysphonia, and all demonstrated various degrees of laryngeal mucosa abnormity.
Nervous System and Mental Functions
Traumatic brain injury (TBI) is a common co-diagnosis with burn injury and appears to be associated with higher mortality than other co-diagnoses. Many burn survivors with TBI have persistent cognitive deficits, especially in the domains of memory and problem-solving, that affect their rehabilitation outcomes.
Sleep disturbances are also now well documented in burn survivors. 40% to 73% of burn outpatients report general sleep disturbances, 27% to 37% have difficulty falling asleep or staying asleep, and 35% to 46% have nightmares, according to Sleep Medicine Reviews.
The review also discusses other aspects of body functions and structures (pain; skin; the digestive, endocrine, immunological, cardiovascular, and respiratory systems; and the eye and ear) and activities and participation (self-care and domestic life, interpersonal interactions and relationships, education, employment, and community and social life).
The Need to Promote Long-Term Care
Older patient age, medical and psychosocial comorbidities, greater burn severity, and involvement of critical structures such as the face or genitalia are predictors of impairments across domains. Long-term regular follow-up to prevent late or cumulative impairments is critical for comprehensive burn recovery.
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