# data[].attributes.body
Jeschke et al (2020) - Burn Injury.

BritishBurnAssociation - Standards of Physiotherapy and Occupational Therapy in the Management of Burn Injured Adults and Children 2022.

British Association of Plastic Reconstructive and Aesthetic Surgeons.

The Royal Children's Hospital Melbourne.

O'Reilly et al (2021) - Use of Tape for the Management of Hypertrophic Scar Development: A Comprehensive Review.

Smailes et al (2021) - The Predictive Validity of the Functional Assessment for Burns — Critical Care (FAB-CC) score for discharge outcomes in major Burns.

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Pergolotti et al (2015) - The prevalence of potentially modifiable functional deficits and the subsequent use of occupational and physical therapy by older adults with cancer.

Silver et al (2015) - Cancer rehabilitation and palliative care: critical components in the delivery of high-quality oncology services - Supportive Care in Cancer.

Jensen-Battaglia (2022) - Association of Oncologist-Patient Communication With Functional Status and Physical Performance.

Principles and guidance for prehabilitation within the management and support of people with cancer - Macmillan Cancer Support.

Campbell et al, 2019.

Schmittz et al (2010) - American College of Sports Medicine Roundtable on Exercise... Medicine & Science in Sports & Exercise.

Spence et al (2010) - Exercise and Cancer Rehabilitation: A Systematic Review.

Faithfull et al (2019) - Prehabilitation for adults diagnosed with cancer: A systematic review of long-term physical function, nutrition and patient-reported outcomes.

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Sensitivity and Specificity of the Stemmer Sign for Lymphedema: A Clinical Lymphoscintigraphic Study - Goss et al 2019.

The O'Reilly Centre - The Gold Standard Treatment for Lymphoedema.

The O'Reilly Centre - Lymphoedema Loves Acqutherapy.

Management of ulcers in lymphoedematous limbs - PubMed - Karnasula (2012).

2020 Consensus Document Treatment of Peripheral Lymphoedema - Lymphology.

New PT-Focused Lymphedema Guideline Follows ‘Care Trajectory’ - American Physical Therapy Association (APTA) Clinical Practice Guidelines.

Ridner et al (2012) - Self-Management of Lymphoedema - A Systematic Review of the Literature from 2004 to 2011.

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Professor Jennifer Stinson. Children’s Pain Management Masterclass, RCSI, October 2016.

Kendall.

Complex Pain on Children and Young People - Assessment. British Journal of Anaesthesia Education.

Best Practices in Pain Assessment and Management for Children.

The Royal College of Emergency Medicine Best Practice Guideline for the Management of Pain in Children (2017).

Guidelines on the Management of Chronic Pain in Children - WHO.

Liossi et al (2019), Effectiveness of interdisciplinary interventions in paediatric chronic pain management: a systematic review and subset meta-analysis.

Boulkedid et al (2017), The Research Gap in Chronic Paediatric Pain: A Systematic Review of Randomised Controlled Trials.

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Obesity (2005), Nishida et al (2003).

Department of Health and Children (2015), Evans et al (2011), Barron et al (2009), Abarca-Gomez et al (2017), Bel-Serrat et al (2017), Singh et al (2008), Whitaker et al (1997).

Manoff et al (2005), Bhatia et al (2006).

De Sa Pinto et al (2006).

Goulding et al (2000).

De Sa Pinto et al (2006), O'Malley et al (2012), Goulding et al (2003), Hue et al (2007), Thivel et al (2016).

Montgomery et al (2010).

OECD (2019).

WHO (2003), Martin et al (2001), Department of Health (2001).

Medibank (2007).

Arenz et al (2004), Armstrong et al (2002).

PA Guidelines for Children - HSE Guidelines (2024).

NICE Guidelines: Obesity: identification, assessment and management (2014).

Scottish Intercollegiate Guidelines Network (2010). Management of Obesity: a national clinical guideline.

Waters E, de Silva-Sanigorski A, Burford BJ, Brown T, Campbell KJ, Gao Y, Armstrong R, Prosser L, Summerbell CD. Interventions for preventing obesity in children. Cochrane Database of Systematic Reviews 2011, Issue 12.

Sacher et al (2010), Randomised Controlled Trial of the MEND Programme: a family-based community intervention for childhood obesity.

Brown et al (2019), Effectiveness of a Family-Based Childhood Obesity Intervention at the YMCA: A Randomised Controlled Trial.

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This Padlet Portfolio has allowed me to reflect on key learnings from this module, identifying gaps in my own knowledge and areas for future research and investigation. The six topics that stood out the most to me were pelvic girdle pain (PGP) in pregnancy, childhood obesity, complex paediatric pain, lymphoedema, exercise oncology, and burns, plastics and scars. Being a physiotherapy student, these topics have expanded my understanding of multiple clinical presentations and the importance of interdisciplinary management strategies. Below, I will reflect on insights I made and how they are implemented into practice.

Learning about PGP allowed me to understand its multifactorial aetiology, being hormonal, psychosocial and biomechanical in nature. Studying how it can be assessed through load transfer strategies and treated with tailored motor control exercises allowed me to understand the necessity of restoring function while addressing the individual’s needs. I will prioritise patient education to empower individuals, helping them understand their condition and the reasoning behind treatment plans in future practice.

While collating resources and information on childhood obesity, the nature of how it affects patients, both their physical and psychological health really stood out to me. Reflecting on the economic burden of childhood obesity, physiotherapists can play a major role in preventative care and early intervention, not only to improve individual health outcomes, but also to alleviate the financial strain obesity imposes. Family-based interventions, such as the MEND programme highlight the role of holistic care. As a future physiotherapist, I will aim to develop engaging, age-appropriate physical activity programmes and promote preventative initiatives within communities. The importance of building a rapport with young patients and their families left an impression on me, especially among complex paediatric pain patients. Putting it into practice, I will aim to provide patient-centred care, with clear communication and education being at the forefront to support children to regain their function and enhance their self-efficacy.

Studying lymphoedema and exercise in oncology stressed my role as a physiotherapist and how I can improve a patient’s quality of life. This can be done by reducing fatigue, enhancing mobility, and addressing chronic-related symptoms. Gaining knowledge regarding tailored exercise programs and manual lymphatic drainage has prepared me for my pivotal role in the future as I contribute to the MDT, helping patients reach their goals. Burns, plastics and scars really opened up my eyes to the importance of early physiotherapy interventions. Scar mobilisation and compression therapy highlight the need to address physical and psychological outcomes. As a future clinician, I will ensure that patients feel supported throughout their entire rehabilitation journey.

Reflecting on these topics has deepened my appreciation for how much we, as physiotherapists, can help improve patients’ lives. This Padlet Portfolio will be an invaluable resource in my professional career, enabling me to provide evidence-based, tailored and individualised care to meet patient’s needs.

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Prehabilitation for adults diagnosed with cancer: A systematic review of long-term physical function, nutrition and patient-reported outcomes

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Prehabilitation for adults diagnosed with cancer: A systematic review of long-term physical function, nutrition and patient-reported outcomes

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Summary

Examines the impact of prehab on long-term physical function, nutrition and patient-reported outcomes (SF-36, HADS) in oncology patients.

16 RCTs, total of 2,017 participants.

6 observational studies, 289 participants.

Key Findings

Improvements in gait, cardiopulmonary function, urinary continence, lung function with prehab.

Some studies reported enhancements in mood and reductions in anxiety and depression following prehab.

Prehab and rehab combined demonstrated better benefits than just prehab alone at 30 days post treatment.

Limitations

Heterogeneity of studies.

Short-term focus, limited data on long-term effects.

Implications for Practice

Implementing both prehab and rehab may offer synergistic effects, improving recovery and long-term health.

Faithfull et al, 2019

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Exercise and Cancer Rehabilitation: A Systematic Review

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Exercise and Cancer Rehabilitation: A Systematic Review

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Summary

Focus is on exercise interventions immediately after primary cancer treatment.

Emphasis on outcomes - physical function, QoL, fatigue, immune function, body composition.

10 studies.

Approximately 80-90% adherence.

Key Findings

Improved aerobic capacity, muscle strength and agility with exercise.

Significant reductions in fatigue.

Enhanced psychological well-being.

Decrease in fat mass.

Limitations

Only 4 of the 10 studies used randomisation.

Lack of blinding in data collection.

Heterogeneity when it came to timing of interventions and exercises used.

Gaps in reporting null findings.

Implications for Practice

Incorporate tailored aerobic and resistance exercise programmes in post-treatment care.

Encourage MDT collaboration.

Investigate long-term effects RE recurrence and survival rates.

Spence et al, 2010

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# data[].attributes.headline
Recommendations for PTs on the Treatment of Lumbopelvic pain during Pregnancy: a Systematic Review

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Recommendations for PTs on the Treatment of Lumbopelvic pain during Pregnancy: a Systematic Review

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Summary

Evaluation of the effectiveness of various interventions for managing LPP in pregnant women.

11 RCTs, 1,257 pregnant women who experience LPP.

Key Findings

There was moderate evidence suggesting that tailored exercise programmes reduce pain and improve functional outcomes.

Limited evidence to suggest manual therapy can provide short-term pain relief.

The combination of exercise and manual therapy yields the best outcomes.

Limitations

Lack of blinding, small sample sizes.

Heterogeneity of interventions

Implications for Practice

Necessity for individualised and tailored programmes.

Use of manual therapy as an adjunct to exercise.

Holistic nature of care is key.

Van Benten et al, 2014.

# data[].attributes.attachment_link.readable_text
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Abstract

Study design: Systematic review of the literature.

Objectives: To review and assess the peer-reviewed literature on the effectiveness of physical therapy interventions in treating lumbopelvic pain during pregnancy.

Background: Current guidelines on interventions for lumbopelvic pain during pregnancy differ in their recommendations for assessment and intervention. Recent publications may allow revising current recommendations for the treatment of this complex problem.

Methods: An electronic search strategy was conducted in PubMed, PEDro, Scopus, and CINAHL of literature published from January 1992 to November 2013. Two authors independently assessed all abstracts for eligibility. Articles were independently rated for quality by 2 authors, using the Cochrane Back Review Group criteria for methodological quality. Where possible, effect sizes were calculated for the different interventions.

Results: A total of 22 articles (all randomized controlled trials) reporting on 22 independent studies were included. Overall, the methodological quality of the studies was moderate. Data for 4 types of interventions were considered: a combination of interventions (7 studies, n = 1202), exercise therapy (9 studies, n = 2149), manual therapy (5 studies, n = 360), and material support (1 study, n = 115).

Conclusion: All included studies on exercise therapy, and most of the studies on interventions combined with patient education, reported a positive effect on pain, disability, and/or sick leave. Evidence-based recommendations can be made for the use of exercise therapy for the treatment of lumbopelvic pain during pregnancy.

Level of evidence: Therapy, level 1a-. J Orthop Sports Phys Ther 2014;44(7):464-473. Epub 10 May 2014. doi:10.2519/jospt.2014.5098.

Keywords: back pain; gravida; intervention; pelvis.

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national center for biotechnology information

# data[].attributes.attachment_link.title
Recommendations for physical therapists on the treatment of lumbopelvic pain during pregnancy: a systematic review - PubMed

# data[].attributes.headline
Interventions for Preventing and Treating Low-Back and Pelvic Pain During Pregnancy: Cochrane Review

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Interventions for Preventing and Treating Low-Back and Pelvic Pain During Pregnancy: Cochrane Review

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Summary

Evaluation of various treatments aimed at managing LBP and PGP.

34 RCTs, involving 5,121 pregnant women aged 16-45 y/o, between 12 to 38 weeks' gestation.

Key Findings

There was low quality evidence suggesting that land-based exercises significantly reduced LBP.

There was moderate quality evidence suggesting that 8 to 12 week exercise programme reduces the number of women reporting combined LBP and PGP.

Land-based exercises reduced pain-related sick leave.

Limitations

The quality of evidence is only low or moderate.

There was clinical and statistical heterogeneity noted.

Implications for Practice

Incorporate exercise - may reduce pregnancy-related LBP and PGP.

Combining manual therapy, exercise and education may offer additional relief.

Liddle et al, 2015

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Health-related quality of life with lymphoedema: a review of the literature

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Health-related quality of life with lymphoedema: a review of the literature

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Summary

Evaluation of qualitative and quantitative studies on health-related QoL in people with lymphoedema.

Key Findings

There is a lack of professional understanding in the topic -> which leads to patients receiving insufficient information.

There is a large psychological toll accompanied with lymphoedema - reports on feelings of embarrassment, social isolation etc.

It hinders overall QoL and ability to perform ADLs.

Limitations

Large amounts of heterogeneity.

Selection bias noted in some studies.

Implications for Practice

Need for CPD or enhanced education on the topic.

Integration of psychological and social supports into treatment is key.

Morgan et al, 2005

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Self-Management of Lymphoedema - A Systematic Review of the Literature from 2004 to 2011

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Self-Management of Lymphoedema - A Systematic Review of the Literature from 2004 to 2011

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Summary

Examines strategies for managing lymphoedema.

11 databases searched, with 16 articles reaching the inclusion criteria.

Key Findings

Various techniques - compression therapy, skin care, exercise, manual lymphatic drainage - can be performed independently.

Evidence suggests that these practices can help reduce lymphoedema symptoms and improve QoL.

Limitations

Some studies lacked rigorous design -> affects the reliability of the findings.

Small sample sizes in the studies makes it difficult to generalise the results to a broader lymphoedema patient population.

Implications for Practice

Education is key.

Self-management strategies must be tailored and personalised.

Ensure regular follow-up and support.

Ridner et al, 2012

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Self-Management of Lymphedema: A Systematic Review of the... : Nursing Research

# data[].attributes.attachment_link.description
ical databases were searched. Articles were selected for inclusion or exclusion into the category of self-management of lymphedema by topic experts. The definition of self-management included activities that individuals initiate and perform for themselves without the assistance of others. Articles were scored according to the Oncology Nursing Society’s Putting Evidence Into Practice levels of evidence. Results: Sixteen articles met criteria for inclusion in this review, with self-management as the independent variable. Ten categories of self-management were established subsequently and articles were classified by levels of evidence. In these categories, no self-management studies were rated as “recommended for practice,” 2 studies were rated “likely to be effective,” none was rated “benefits balanced with harms,” 7were rated “effectiveness not established,” and 1 was rated “effectiveness unlikely.” Discussion: Few studies included measures of outcomes associated with lymphedema, and there was a scarcity of randomized controlled trials in lymphedema self-management. A demonstrated need exists for the design and testing of self-management interventions that include appropriate outcome measures.…

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The Research Gap in Chronic Paediatric Pain: A Systematic Review of Randomised Controlled Trials

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The Research Gap in Chronic Paediatric Pain: A Systematic Review of Randomised Controlled Trials

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Summary

Systematic review examining RCTs assessing pain management interventions in children and adolescents with chronic pain.

58 RCTs.

Key Findings

More RCTs focusing on non-pharmacological treatments.

There was an underrepresentation of younger children and infants.

Limitations

Limited sample sizes.

High or unclear risk of bias.

Variations in interventions, populations and outcomes - heterogeneity.

Implications for Practice

? Focus on integrating pharmacological and non-pharmacological interventions to enhance pain management.

Future research to include the younger patient population.

Boulkedid et al, 2017

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Effectiveness of interdisciplinary interventions in paediatric chronic pain management: a systematic review and subset meta-analysis

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Effectiveness of interdisciplinary interventions in paediatric chronic pain management: a systematic review and subset meta-analysis

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Summary

SR and MA to evaluate the effectiveness of interdisciplinary interventions in managing chronic pain among children and adolescents.

28 studies.

Assessing outcomes such as functional disability, pain, and psychological health.

Key Findings

Significantly lower pain intensity scores were associated with people who received interdisciplinary interventions versus those who didn't. This was at one month, as well as 3 and 12 month follow ups.

Improvements in anxiety, depression, catastrophising were noted in the intervention group that received interdisciplinary care.

Limitations

There was heterogeneity noted across studies (outcome measures).

Some analyses had limited sample sizes.

Implications to Practice

Supports interdisciplinary approach.

Need for standardised protocols and outcome measures for this cohort.

Liossi et al, 2019

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Effectiveness of a Family-Based Childhood Obesity Intervention at the YMCA: A Randomised Controlled Trial

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Effectiveness of a Family-Based Childhood Obesity Intervention at the YMCA: A Randomised Controlled Trial

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Summary

Evaluation of the impact of a family-centred programme on reducing childhood obesity.

Sample size = 124 families to intervention group, 62 families to control group (no care -> remained on waitlist).

Key Findings

BMI reduction in the intervention group.

Improved health behaviours RE diet and PA.

Active engagement of parents was linked with improved outcomes in their child's weight management.

Limitations

Short term follow up.

Lack of participant diversity.

Implications to Practice

Encourage parental involvement.

Family-oriented interventions are useful in addressing childhood obesity.

Brown et al, 2019

# data[].attributes.attachment_link.readable_text
The .gov means it's official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure.
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Abstract

Background: Prevention of childhood obesity is an international public health priority given the significant impact of obesity on acute and chronic diseases, general health, development and well-being. The international evidence base for strategies to prevent obesity is very large and is accumulating rapidly. This is an update of a previous review.

Objectives: To determine the effectiveness of a range of interventions that include diet or physical activity components, or both, designed to prevent obesity in children.

Search methods: We searched CENTRAL, MEDLINE, Embase, PsychINFO and CINAHL in June 2015. We re-ran the search from June 2015 to January 2018 and included a search of trial registers.

Selection criteria: Randomised controlled trials (RCTs) of diet or physical activity interventions, or combined diet and physical activity interventions, for preventing overweight or obesity in children (0-17 years) that reported outcomes at a minimum of 12 weeks from baseline.

Data collection and analysis: Two authors independently extracted data, assessed risk-of-bias and evaluated overall certainty of the evidence using GRADE. We extracted data on adiposity outcomes, sociodemographic characteristics, adverse events, intervention process and costs. We meta-analysed data as guided by the Cochrane Handbook for Systematic Reviews of Interventions and presented separate meta-analyses by age group for child 0 to 5 years, 6 to 12 years, and 13 to 18 years for zBMI and BMI.

Main results: We included 153 RCTs, mostly from the USA or Europe. Thirteen studies were based in upper-middle-income countries (UMIC: Brazil, Ecuador, Lebanon, Mexico, Thailand, Turkey, US-Mexico border), and one was based in a lower middle-income country (LMIC: Egypt). The majority (85) targeted children aged 6 to 12 years.Children aged 0-5 years: There is moderate-certainty evidence from 16 RCTs (n = 6261) that diet combined with physical activity interventions, compared with control, reduced BMI (mean difference (MD) -0.07 kg/m ², 95% confidence interval (CI) -0.14 to -0.01), and had a similar effect (11 RCTs, n = 5536) on zBMI (MD -0.11, 95% CI -0.21 to 0.01). Neither diet (moderate-certainty evidence) nor physical activity interventions alone (high-certainty evidence) compared with control reduced BMI (physical activity alone: MD -0.22 kg/m ², 95% CI -0.44 to 0.01) or zBMI (diet alone: MD -0.14, 95% CI -0.32 to 0.04; physical activity alone: MD 0.01, 95% CI -0.10 to 0.13) in children aged 0-5 years.Children aged 6 to 12 years: There is moderate-certainty evidence from 14 RCTs (n = 16,410) that physical activity interventions, compared with control, reduced BMI (MD -0.10 kg/m ², 95% CI -0.14 to -0.05). However, there is moderate-certainty evidence that they had little or no effect on zBMI (MD -0.02, 95% CI -0.06 to 0.02). There is low-certainty evidence from 20 RCTs (n = 24,043) that diet combined with physical activity interventions, compared with control, reduced zBMI (MD -0.05 kg/m2, 95% CI -0.10 to -0.01). There is high-certainty evidence that diet interventions, compared with control, had little impact on zBMI (MD -0.03, 95% CI -0.06 to 0.01) or BMI (-0.02 kg/m2, 95% CI -0.11 to 0.06).Children aged 13 to 18 years: There is very low-certainty evidence that physical activity interventions, compared with control reduced BMI (MD -1.53 kg/m2, 95% CI -2.67 to -0.39; 4 RCTs; n = 720); and low-certainty evidence for a reduction in zBMI (MD -0.2, 95% CI -0.3 to -0.1; 1 RCT; n = 100). There is low-certainty evidence from eight RCTs (n = 16,583) that diet combined with physical activity interventions, compared with control, had no effect on BMI (MD -0.02 kg/m2, 95% CI -0.10 to 0.05); or zBMI (MD 0.01, 95% CI -0.05 to 0.07; 6 RCTs; n = 16,543). Evidence from two RCTs (low-certainty evidence; n = 294) found no effect of diet interventions on BMI.Direct comparisons of interventions: Two RCTs reported data directly comparing diet with either physical activity or diet combined with physical activity interventions for children aged 6 to 12 years and reported no differences.Heterogeneity was apparent in the results from all three age groups, which could not be entirely explained by setting or duration of the interventions. Where reported, interventions did not appear to result in adverse effects (16 RCTs) or increase health inequalities (gender: 30 RCTs; socioeconomic status: 18 RCTs), although relatively few studies examined these factors.Re-running the searches in January 2018 identified 315 records with potential relevance to this review, which will be synthesised in the next update.

Authors' conclusions: Interventions that include diet combined with physical activity interventions can reduce the risk of obesity (zBMI and BMI) in young children aged 0 to 5 years. There is weaker evidence from a single study that dietary interventions may be beneficial.However, interventions that focus only on physical activity do not appear to be effective in children of this age. In contrast, interventions that only focus on physical activity can reduce the risk of obesity (BMI) in children aged 6 to 12 years, and adolescents aged 13 to 18 years. In these age groups, there is no evidence that interventions that only focus on diet are effective, and some evidence that diet combined with physical activity interventions may be effective. Importantly, this updated review also suggests that interventions to prevent childhood obesity do not appear to result in adverse effects or health inequalities.The review will not be updated in its current form. To manage the growth in RCTs of child obesity prevention interventions, in future, this review will be split into three separate reviews based on child age.

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Conflict of interest statement

Tamara Brown: no conflicts of interest to report Theresa Moore: no conflicts of interest to report Lee Hooper: no conflicts of interest to report Yang Gao: no conflicts of interest to report Amir Zayegh: no conflicts of interest to report Sharea Ijaz: no conflicts of interest to report Sophie Foxen: no conflicts of interest to report Lucia Magee: no conflicts of interest to report Claire O'Malley: no conflicts of interest to report Carolyn Summerbell: no conflicts of interest to report Martha Elwenspoek: no conflicts of interest to report

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pediatric obesity / prevention & control*

# data[].attributes.attachment_link.keywords[]
national center for biotechnology information

# data[].attributes.attachment_link.title
Interventions for preventing obesity in children - PubMed

# data[].attributes.attachment_link.description
Interventions that include diet combined with physical activity interventions can reduce the risk of obesity (zBMI and BMI) in young children aged 0 to 5 years. There is weaker evidence from a single study that dietary interventions may be beneficial.However, interventions that focus only on physica ...

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Randomised Controlled Trial of the MEND Programme: a family-based community intervention for childhood obesity

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Randomised Controlled Trial of the MEND Programme: a family-based community intervention for childhood obesity

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Summary

A Randomised Controlled Trial of the MEND programme as an intervention for childhood obesity.

Sample size = 116, who were randomly assigned to an intervention group (MEND programme) and control group (typical care).

Follow up at 6 and 12 months.

Key Findings

Significant BMI reduction in the intervention group versus control group.

Enhanced CV fitness in the intervention group.

There were notable improvements in behaviour changes regarding diet and PA among those in the intervention group.

Limitations

Short-term follow up.

Generalisability concern that the findings may not be universally applicable.

Implications for Practice

Demonstrates potential for community-based interventions.

A holistic approach yields the best outcomes.

Sacher et al, 2010

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Randomized controlled trial of the MEND program: a family-based community intervention for childhood obesity - PubMed

# data[].attributes.attachment_link.description
The aim of this study was to evaluate the effectiveness of the Mind, Exercise, Nutrition, Do it (MEND) Program, a multicomponent community-based childhood obesity intervention (www.mendcentral.org). One hundred and sixteen obese children (BMI >or= 98 th percentile, UK 1990 reference data) were ra …

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Vleeming A., et al (2008) - European Guidelines for the Diagnosis and Treatment of Pelvic Girdle Pain.

American Physical Therapy Association Clinical Practice Guidelines - Pelvic girdle pain in the antepartum population.

National Clinical Guideline (2012) - Management of Pelvic Girdle Pain in Pregnancy and Post-Partum.

Liddle et al (2015) - Interventions for Preventing and Treating Low-Back and Pelvic Pain During Pregnancy: Cochrane Review.

Van Benten et al (2014) - Recommendations for PTs on the Treatment of Lumbopelvic pain during Pregnancy: a Systematic Review.

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Great resource.

5 ways to address childhood obesity

Promote healthy eating habits.

Increase PA.

Enhance health education.

Create supportive environments.

Implement community-based programmes.

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5 Ways To Solve The Childhood Obesity Problem by Institute of Public Health

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by Aoife Prendergast

Session 1 Talk 1

Presented on 08/10/2013 at Croke Park Conference Centre at the IPH Open Conference (Institute of Public Health in Ireland)

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https://www.youtube.com/watch?v=tiQevGDPgRY

Talk about why it's so hard for a person living with obesity to lose weight.

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SIGN - Management of Obesity - a National Clinical Guideline (2010) - Resource

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SIGN - Management of Obesity - a National Clinical Guideline (2010) - Resource

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This guideline emphasises early intervention and the importance of creating supportive environments to foster healthy behaviours in children and adolescents.

Detailed guidance on multidisciplinary treatment and practical management approaches.

More suited for clinicians directly managing childhood obesity.

Scottish Intercollegiate Guidelines Network (2010). Management of Obesity: a national clinical guideline.

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Comprehensive recommendations.

Prevention

Whole-system approach.

Lifestyle education.

Environment.

Assessment

BMI.

Holistic Ax.

Risk factors.

Management

MDT approach.

Family and behavioural support.

Treatment

Tier-based interventions.

Medical, surgical.

Long-term support and psychological health.

The Identification, Assessment and Management of Overweight and Obesity in Adults and Children (2014) - NICE

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This guideline covers identifying, assessing and managing obesity in children (aged 2 years and over), young people and adults.

In July 2023, we reviewed the evidence on bariatric surgery for people living with overweight and obesity and updated the recommendations on surgical interventions.

NICE has also produced guidelines on obesity prevention, maintaining a healthy weight, and managing overweight and obesity in adults and in children and young people.

Recommendations

This guideline includes recommendations on:

Who is it for?

Healthcare professionals

Commissioners and providers

People who are living with obesity and their families and carers

Is this guideline up to date?

We are updating our suite of guidelines on weight management. See the guideline in development page for progress on the update.

Guideline development process
How we develop NICE guidelines
This guideline replaces NICE guideline PH46 (July 2013) and updates and replaces section 1.2 of NICE guideline CG43 (December 2006).

This guideline was previously called obesity: identification, assessment and management of overweight and obesity in children, young people and adults.

Your responsibility

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.

All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme.

Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

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This guideline covers identifying, assessing and managing obesity in children (aged 2 years and over), young people and adults

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Eat Smart Move More: Healthy Ireland Guide, HSE - Resource

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Eat Smart Move More: Healthy Ireland Guide, HSE - Resource

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Includes food and activity pyramids and planners

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Guided classes for different patient populations -> how to join.

Great resource as it brings a social aspect to exercise for this cohort of patients.

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Cancer rehabilitation programme | www.exwell.ie

# data[].attributes.attachment_link.description
ExWell Medical are proud to announce the resumption of our cancer specific ‘MoveOn’ programme. We have over 10 years’ experience delivering exercise classes to those who need it most.

# data[].attributes.body
Outcome Measures used to

Find a baseline.

Assess throughout the programme.

As a means of measuring progression and therefore provide motivation.

Frailty - Clinical Frailty Scale.

Strength - 30 sec STS.

Fatigue - FACIT F.

Aerobic Capacity - 6MWT.

Important for patient goal setting.

# data[].attributes.body
Great resource with lots of detail RE prehabilitation in oncology.

# data[].attributes.body
PDF resource that aims to empower patients with knowledge and practical steps to enhance their recovery journey after breast surgery.

Has components such as - post-operative care, lymphoedema prevention, exercise programmes and general advice.

# data[].attributes.headline
Current Rehabilitation / Palliative Care Screening Tools 

# data[].attributes.subject
Current Rehabilitation / Palliative Care Screening Tools 

# data[].attributes.body
Tools to screen for

Frailty.

Functional status.

Gait/mobility.

Cognition.

Quality of Life.

Distress.

Longitudinal Research.

# data[].attributes.attachment_link.readable_text
Abstract

Palliative care and rehabilitation practitioners are important collaborative referral sources for each other who can work together to improve the lives of cancer patients, survivors, and caregivers by improving both quality of care and quality of life. Cancer rehabilitation and palliative care involve the delivery of important but underutilized medical services to oncology patients by interdisciplinary teams. These subspecialties are similar in many respects, including their focus on improving cancer-related symptoms or cancer treatment-related side effects, improving health-related quality of life, lessening caregiver burden, and valuing patient-centered care and shared decision-making. They also aim to improve healthcare efficiencies and minimize costs by means such as reducing hospital lengths of stay and unanticipated readmissions. Although their goals are often aligned, different specialized skills and approaches are used in the delivery of care. For example, while each specialty prioritizes goal-concordant care through identification of patient and family preferences and values, palliative care teams typically focus extensively on using patient and family communication to determine their goals of care, while also tending to comfort issues such as symptom management and spiritual concerns. Rehabilitation clinicians may tend to focus more specifically on functional issues such as identifying and treating deficits in physical, psychological, or cognitive impairments and any resulting disability and negative impact on quality of life. Additionally, although palliative care and rehabilitation practitioners are trained to diagnose and treat medically complex patients, rehabilitation clinicians also treat many patients with a single impairment and a low symptom burden. In these cases, the goal is often cure of the underlying neurologic or musculoskeletal condition. This report defines and describes cancer rehabilitation and palliative care, delineates their respective roles in comprehensive oncology care, and highlights how these services can contribute complementary components of essential quality care. An understanding of how cancer rehabilitation and palliative care are aligned in goal setting, but distinct in approach may help facilitate earlier integration of both into the oncology care continuum-supporting efforts to improve physical, psychological, cognitive, functional, and quality of life outcomes in patients and survivors.

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References

1. Santiago-Palma J, Payne R (2001) Palliative care and rehabilitation. Cancer 92(4 Suppl):1049-1052

2. Commission on Cancer (2012) Cancer program standards 2012: ensuring patient-centered care. American College of Surgeons. https://www.facs.org/∼/media/files/quality%20programs/cancer/coc/programstandards2012.ashx. Accessed 2 Mar 2015

3. Institute of Medicine (2001) Crossing the quality chasm: a new health system for the 21st century. National Academy Press. https://www.iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx. Accessed 3 Mar 2015

4. Sami MB, Faruqui R (2015) The effectiveness of dopamine agonists for treatment of neuropsychiatric symptoms post brain injury and stroke. Acta Neuropsychiatr 1-11. doi: 10.1017/neu.2015.17

5. Johansson B, Wentzel AP, Andrell P, Mannheimer C, Ronnback L (2015) Methylphenidate reduces mental fatigue and improves processing speed in persons suffered a traumatic brain injury. Brain Inj 1-8. doi: 10.3109/02699052.2015.1004747

6. Who definition of palliative care (2015) World Health Organization. http://www.who.int/cancer/palliative/definition/en/. Accessed 2 Mar 2015

7. Center to advance palliative care (2011) Public opinion research on palliative care. https://www.capc.org/media/filer_public/18/ab/18ab708c-f835-4380-921d-fbf729702e36/2011-public-opinion-research-on-palliative-care.pdf. Accessed 3 Mar 2015

8. American Cancer Society (2014) A guide to palliative or supportive care: what is palliative care? http://www.cancer.org/treatment/treatmentsandsideeffects/palliativecare/supportive-care. Accessed 2 Mar 2015

9. What is MASCC? (2015) Multinational association of supportive care in cancer. http://www.mascc.org/about-mascc. Accessed 2 Mar 2015

10. Dhah S, Fu J (2015) Musculoskeletal disease management at the end of life: an opportunity for physiatrists to provide expert consultation. Poster presented at the Association of Academic Physiatrists, San Antonio, TX, March 10-14

11. Jones L, Fitzgerald G, Leurent B, Round J, Eades J, Davis S, Gishen F, Holman A, Hopkins K, Tookman A (2013) Rehabilitation in advanced, progressive, recurrent cancer: a randomized controlled trial. J Pain Symp Manag 46(3):315-325. doi: 10.1016/j.jpainsymman.2012.08.017, e313

Article Google Scholar

12. Etkind SN, Daveson BA, Kwok W, Witt J, Bausewein C, Higginson IJ, Murtagh FE (2014) Capture, transfer, and feedback of patient-centered outcomes data in palliative care populations: does it make a difference? A systematic review. J Pain Symp Manag. doi: 10.1016/j.jpainsymman.2014.07.010

Google Scholar

13. Alfano CM, Smith T, de Moor JS, Glasgow RE, Khoury MJ, Hawkins NA, Stein KD, Rechis R, Parry C, Leach CR, Padgett L, Rowland JH (2014) An action plan for translating cancer survivorship research into care. J Natl Cancer Inst 106(11). doi: 10.1093/jnci/dju287

14. National Institutes of Health Clinical Center (2015) Save the date-cancer rehabilitation conference http://www.cc.nih.gov/rmd/crc/index.html. Accessed March 2 2015

15. Cancer rehabilitation networking group (2013) American congress of rehabilitation medicine. http://www.acrm.org/acrm-communities/cancer/. Accessed 2 Mar 2015

16. About PQLC (2015) Patient quality of life coalition. http://patientqualityoflife.org/about-pqlc/. Accessed 15 May 2015

17. Chiu N, Cheon P, Lutz S, Lao N, Pulenzas N, Chiu L, McDonald R, Rowbottom L, Chow E (2014) Inadequacy of palliative training in the medical school curriculum. J Cancer Educ. doi: 10.1007/s13187-014-0762-3

Google Scholar

18. Gladieux JE, Basile M (2014) Jimmo and the improvement standard: implementing medicare coverage through regulations, policy manuals and other guidance. Am J Law Med 40(1):7-25

PubMed Google Scholar

Download references

Acknowledgments

The authors would like to thank Julie A. Poorman, PhD, for assistance with manuscript preparation.

Conflict of interest

Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article. Dr. Silver discloses that she is the founder of Oncology Rehab Partners, LLC that developed the STAR Program® (Survivorship Training and Rehabilitation). None of the other authors have disclosures.

Author information

Authors and Affiliations

1. Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, 300 First Avenue, Charlestown, MA, 02129, USA

Julie K. Silver

2. Department of Physical Medicine and Rehabilitation, Carolinas Rehabilitation, 1100 Blythe Boulevard, Charlotte, NC, 28203, USA

Vishwa S. Raj

3. Department of Palliative, Rehabilitation, and Integrative Medicine, MD Anderson Cancer Center, University of Texas, 1515 Holcombe Blvd. Unit 1414, Houston, TX, 77030, USA

Jack B. Fu

4. MedStar National Rehabilitation Network, 102 Irving St, NW, Washington, DC, 20010, USA

Eric M. Wisotzky

5. Department of Physical Medicine and Rehabilitation, University of Michigan, 325 E Eisenhower Pkwy, Ste 100, Ann Arbor, MI, 48108, USA

Sean Robinson Smith

6. American Cancer Society, 555 11th Street NW, Suite 300, Washington, DC, 20004, USA

Rebecca A. Kirch

Corresponding author

Correspondence to Julie K. Silver.

About this article

Cite this article

Silver, J.K., Raj, V.S., Fu, J.B. et al. Cancer rehabilitation and palliative care: critical components in the delivery of high-quality oncology services. Support Care Cancer 23, 3633-3643 (2015). https://doi.org/10.1007/s00520-015-2916-1
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DOI: https://doi.org/10.1007/s00520-015-2916-1

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Keywords

# data[].attributes.attachment_link.title
Cancer rehabilitation and palliative care: critical components in the delivery of high-quality oncology services - Supportive Care in Cancer

# data[].attributes.attachment_link.description
Palliative care and rehabilitation practitioners are important collaborative referral sources for each other who can work together to improve the lives of cancer patients, survivors, and caregivers by improving both quality of care and quality of life.

# data[].attributes.headline
So, What Does High Quality Cancer Care Look Like?

# data[].attributes.subject
So, What Does High Quality Cancer Care Look Like?

# data[].attributes.body
Emphasis must be put on the integration of both rehabilitation and palliative services to address the comprehensive needs of patients throughout their cancer journey.

There should be a push for early incorporation of rehabilitation and palliative care to enhance patient outcomes, quality of life, and overall satisfaction with care.

# data[].attributes.attachment_link.readable_text
Abstract

Palliative care and rehabilitation practitioners are important collaborative referral sources for each other who can work together to improve the lives of cancer patients, survivors, and caregivers by improving both quality of care and quality of life. Cancer rehabilitation and palliative care involve the delivery of important but underutilized medical services to oncology patients by interdisciplinary teams. These subspecialties are similar in many respects, including their focus on improving cancer-related symptoms or cancer treatment-related side effects, improving health-related quality of life, lessening caregiver burden, and valuing patient-centered care and shared decision-making. They also aim to improve healthcare efficiencies and minimize costs by means such as reducing hospital lengths of stay and unanticipated readmissions. Although their goals are often aligned, different specialized skills and approaches are used in the delivery of care. For example, while each specialty prioritizes goal-concordant care through identification of patient and family preferences and values, palliative care teams typically focus extensively on using patient and family communication to determine their goals of care, while also tending to comfort issues such as symptom management and spiritual concerns. Rehabilitation clinicians may tend to focus more specifically on functional issues such as identifying and treating deficits in physical, psychological, or cognitive impairments and any resulting disability and negative impact on quality of life. Additionally, although palliative care and rehabilitation practitioners are trained to diagnose and treat medically complex patients, rehabilitation clinicians also treat many patients with a single impairment and a low symptom burden. In these cases, the goal is often cure of the underlying neurologic or musculoskeletal condition. This report defines and describes cancer rehabilitation and palliative care, delineates their respective roles in comprehensive oncology care, and highlights how these services can contribute complementary components of essential quality care. An understanding of how cancer rehabilitation and palliative care are aligned in goal setting, but distinct in approach may help facilitate earlier integration of both into the oncology care continuum-supporting efforts to improve physical, psychological, cognitive, functional, and quality of life outcomes in patients and survivors.

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Get 10 units per month

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1 Unit = 1 Article or 1 Chapter

Cancel anytime

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Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

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References

1. Santiago-Palma J, Payne R (2001) Palliative care and rehabilitation. Cancer 92(4 Suppl):1049-1052

2. Commission on Cancer (2012) Cancer program standards 2012: ensuring patient-centered care. American College of Surgeons. https://www.facs.org/∼/media/files/quality%20programs/cancer/coc/programstandards2012.ashx. Accessed 2 Mar 2015

3. Institute of Medicine (2001) Crossing the quality chasm: a new health system for the 21st century. National Academy Press. https://www.iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx. Accessed 3 Mar 2015

4. Sami MB, Faruqui R (2015) The effectiveness of dopamine agonists for treatment of neuropsychiatric symptoms post brain injury and stroke. Acta Neuropsychiatr 1-11. doi: 10.1017/neu.2015.17

5. Johansson B, Wentzel AP, Andrell P, Mannheimer C, Ronnback L (2015) Methylphenidate reduces mental fatigue and improves processing speed in persons suffered a traumatic brain injury. Brain Inj 1-8. doi: 10.3109/02699052.2015.1004747

6. Who definition of palliative care (2015) World Health Organization. http://www.who.int/cancer/palliative/definition/en/. Accessed 2 Mar 2015

7. Center to advance palliative care (2011) Public opinion research on palliative care. https://www.capc.org/media/filer_public/18/ab/18ab708c-f835-4380-921d-fbf729702e36/2011-public-opinion-research-on-palliative-care.pdf. Accessed 3 Mar 2015

8. American Cancer Society (2014) A guide to palliative or supportive care: what is palliative care? http://www.cancer.org/treatment/treatmentsandsideeffects/palliativecare/supportive-care. Accessed 2 Mar 2015

9. What is MASCC? (2015) Multinational association of supportive care in cancer. http://www.mascc.org/about-mascc. Accessed 2 Mar 2015

10. Dhah S, Fu J (2015) Musculoskeletal disease management at the end of life: an opportunity for physiatrists to provide expert consultation. Poster presented at the Association of Academic Physiatrists, San Antonio, TX, March 10-14

11. Jones L, Fitzgerald G, Leurent B, Round J, Eades J, Davis S, Gishen F, Holman A, Hopkins K, Tookman A (2013) Rehabilitation in advanced, progressive, recurrent cancer: a randomized controlled trial. J Pain Symp Manag 46(3):315-325. doi: 10.1016/j.jpainsymman.2012.08.017, e313

Article Google Scholar

12. Etkind SN, Daveson BA, Kwok W, Witt J, Bausewein C, Higginson IJ, Murtagh FE (2014) Capture, transfer, and feedback of patient-centered outcomes data in palliative care populations: does it make a difference? A systematic review. J Pain Symp Manag. doi: 10.1016/j.jpainsymman.2014.07.010

Google Scholar

13. Alfano CM, Smith T, de Moor JS, Glasgow RE, Khoury MJ, Hawkins NA, Stein KD, Rechis R, Parry C, Leach CR, Padgett L, Rowland JH (2014) An action plan for translating cancer survivorship research into care. J Natl Cancer Inst 106(11). doi: 10.1093/jnci/dju287

14. National Institutes of Health Clinical Center (2015) Save the date-cancer rehabilitation conference http://www.cc.nih.gov/rmd/crc/index.html. Accessed March 2 2015

15. Cancer rehabilitation networking group (2013) American congress of rehabilitation medicine. http://www.acrm.org/acrm-communities/cancer/. Accessed 2 Mar 2015

16. About PQLC (2015) Patient quality of life coalition. http://patientqualityoflife.org/about-pqlc/. Accessed 15 May 2015

17. Chiu N, Cheon P, Lutz S, Lao N, Pulenzas N, Chiu L, McDonald R, Rowbottom L, Chow E (2014) Inadequacy of palliative training in the medical school curriculum. J Cancer Educ. doi: 10.1007/s13187-014-0762-3

Google Scholar

18. Gladieux JE, Basile M (2014) Jimmo and the improvement standard: implementing medicare coverage through regulations, policy manuals and other guidance. Am J Law Med 40(1):7-25

PubMed Google Scholar

Download references

Acknowledgments

The authors would like to thank Julie A. Poorman, PhD, for assistance with manuscript preparation.

Conflict of interest

Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article. Dr. Silver discloses that she is the founder of Oncology Rehab Partners, LLC that developed the STAR Program® (Survivorship Training and Rehabilitation). None of the other authors have disclosures.

Author information

Authors and Affiliations

1. Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, 300 First Avenue, Charlestown, MA, 02129, USA

Julie K. Silver

2. Department of Physical Medicine and Rehabilitation, Carolinas Rehabilitation, 1100 Blythe Boulevard, Charlotte, NC, 28203, USA

Vishwa S. Raj

3. Department of Palliative, Rehabilitation, and Integrative Medicine, MD Anderson Cancer Center, University of Texas, 1515 Holcombe Blvd. Unit 1414, Houston, TX, 77030, USA

Jack B. Fu

4. MedStar National Rehabilitation Network, 102 Irving St, NW, Washington, DC, 20010, USA

Eric M. Wisotzky

5. Department of Physical Medicine and Rehabilitation, University of Michigan, 325 E Eisenhower Pkwy, Ste 100, Ann Arbor, MI, 48108, USA

Sean Robinson Smith

6. American Cancer Society, 555 11th Street NW, Suite 300, Washington, DC, 20004, USA

Rebecca A. Kirch

Corresponding author

Correspondence to Julie K. Silver.

About this article

Cite this article

Silver, J.K., Raj, V.S., Fu, J.B. et al. Cancer rehabilitation and palliative care: critical components in the delivery of high-quality oncology services. Support Care Cancer 23, 3633-3643 (2015). https://doi.org/10.1007/s00520-015-2916-1
Download citation

Received:

Accepted:

Published:

Issue Date:

DOI: https://doi.org/10.1007/s00520-015-2916-1

Share this article

Anyone you share the following link with will be able to read this content:

Get shareable link

Provided by the Springer Nature SharedIt content-sharing initiative

Keywords

# data[].attributes.attachment_link.title
Cancer rehabilitation and palliative care: critical components in the delivery of high-quality oncology services - Supportive Care in Cancer

# data[].attributes.attachment_link.description
Palliative care and rehabilitation practitioners are important collaborative referral sources for each other who can work together to improve the lives of cancer patients, survivors, and caregivers by improving both quality of care and quality of life.

# data[].attributes.body
It has been noted that there is both decreased physical performance as well as functional deficits with oncology patients.

These deficits are modifiable.

Yet, these oncology patients and oncology survivors are not receiving the physiotherapy care they need.

THERE IS A GAP IN THE CARE of this patient cohort.

# data[].attributes.attachment_link.title
The prevalence of potentially modifiable functional deficits and the subsequent use of occupational and physical therapy by older adults with cancer - PubMed

# data[].attributes.attachment_link.description
The odds of having any potentially modifiable functional deficit were higher in patients with increasing age, comorbid conditions, and with less than a college degree. Few were referred for OT/PT services suggesting major underutilization of these potentially beneficial services.

# data[].attributes.body
In 541 oncology patients over the age of 70...

319 (21%) had impaired functional status.

507 (94%) had impaired physical performance.

314 (58%) were impaired in both.

# data[].attributes.attachment_link.title
Association of Oncologist-Patient Communication With Functional Status and Physical Performance

# data[].attributes.attachment_link.description
This secondary analysis of a cluster randomized clinical trial examines the association between providing oncologists with a geriatric assessment summary with recommendations and having oncologist-patient conversations about functional and physical performance.

# data[].attributes.body
Visual for the classification of burn injuries.

# data[].attributes.body
Visual of the anatomy behind burn injuries.

# data[].attributes.body
Talk on the psychological aspect of dealing with burns and scars.

# data[].attributes.attachment_link.title
Finding the Beauty in Your Scars | Audra Bryant | TEDxInglewood

# data[].attributes.body
Detailed podcast on scarring and burn injury anatomy, management, treatment, difficulty with same and outcomes.

# data[].attributes.attachment_link.title
Audio Factsheet: Scar Management After Burn Injury by MSKTC Radio

# data[].attributes.attachment_link.description
The Model Systems Knowledge Translation Center presents an audio factsheet on Scar Management After Burn Injury. The factsheet was developed by Sandra Hall, PT, Karen Kowalske, MD, and Radha Holavanahalli, PhD, in collaboration with the University of Washington Model Systems Knowledge Translation Center. The information in this factsheet is not meant to replace the advice of a medical professional. You should consult your health care provider regarding specific medical concerns or treatment.

Please see the content of this audio factsheet at: https://msktc.org/burn/factsheets/Scar-Management.

Visit msktc.org/burn and get the answers you need from experts who conduct innovative and high-quality research, provide patient care, and work to improve the health and overall quality of life for people with burn injury. That’s msktc.org/burn. This audio factsheet is funded by a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR; grant number 90DPKT0009). NIDILRR is a Center within the Administration for Community Living (ACL) in the U.S. Department of Health and Human Services (HHS). The contents of this factsheet do not necessarily represent the policy of NIDILRR, ACL, or HHS, and you should not assume endorsement by the Federal Government. Copyright 2022 Model Systems Knowledge Translation Center. This audio factsheet may be reproduced and distributed freely with appropriate attribution. Prior permission must be obtained for inclusion in fee-based materials.

# data[].attributes.attachment_link.title
The Bias behind Your Undiagnosed Chronic Pain | Sheetal DeCaria | TED

# data[].attributes.attachment_link.title
The mystery of chronic pain - Elliot Krane

# data[].attributes.body
Emphasises the psychological impact and toll of obesity.

# data[].attributes.body
Addresses the escalating issue of childhood obesity and advocates for community-driven solutions. She emphasises the importance of small, collective actions in creating significant, positive changes in children's health.

# data[].attributes.attachment_link.title
TEDxSoCal - Diana Hendel, PharmD - Childhood Obesity: Small Steps, Big Change

# data[].attributes.body
What has caused the decline of physical literacy/activity.

Ways/areas to resolve this.

# data[].attributes.attachment_link.title
Fixing the childhood obesity epidemic | Matt Young | TEDxStanleyPark

# data[].attributes.body
Medical and psychological impacts of childhood obesity.

Emphasis on building a healthier lifestyle.

Multi-targeted approach.

Needs engagement from the family.

# data[].attributes.attachment_link.title
The approach to treating childhood obesity | Anita Vreugdenhil | TEDxMaastricht

# data[].attributes.headline
The Predictive Validity of the Functional Assessment for Burns — Critical Care (FAB-CC) score for discharge outcomes in major Burns

# data[].attributes.subject
The Predictive Validity of the Functional Assessment for Burns — Critical Care (FAB-CC) score for discharge outcomes in major Burns

# data[].attributes.body
Summary

Evaluation of the effectiveness of the FAB-CC score - a tool designed to evaluate functional outcomes in burn patients.

It's valuable in predicting discharge outcomes.

Key Findings

The FAB-CC score demonstrated a significant correlation with discharge outcomes.

Was able to differentiate scores between those that needed to stay for more rehab and those that were able to be discharged.

Limitations

Smaller sample sizes limit the generalisability.

Data only collected from one burn centre which may not represent care on a national basis.

Implications for Practice

FAB-CC can aid clinicians in making informed decisions regarding discharge planning and the need for rehab.

FAB-CC can help with making care more efficient.

FAB-CC allows patients and families to form realistic expectations.

Smailes et al, 2021

# data[].attributes.attachment_link.title
The predictive validity of the Functional Assessment for Burns - Critical Care (FAB-CC) score for discharge outcomes in major burns - PubMed

# data[].attributes.attachment_link.description
FAB-CC2 is associated with, and FAB-CC1 has predictive validity for, patient hospital discharge outcome. These findings, in conjunction with our earlier work, confirm clinical utility of the FAB-CC for burns ICU patients.

# data[].attributes.headline
Use of Tape for the Management of Hypertrophic Scar Development: A Comprehensive Review

# data[].attributes.subject
Use of Tape for the Management of Hypertrophic Scar Development: A Comprehensive Review

# data[].attributes.body
Summary

Examination of the effectiveness of taping as a prevention measure against hypertrophic scars.

Analysation of the studies focusing on the application of timing, duration, and outcomes associated with taping.

Key Findings

Taping reduces scar height, redness and pliability.

Silicone tape hydrates the scar and modulates collagen production.

Initiating taping soon after wound closure and continuining for several months yields the best results.

Limitations

Small sample sizes.

Heterogeneity in studies.

Lack of consistent long-term follow up.

Implications for Practice

Implement taping soon after wound closure.

Education needed RE proper taping techniques and individualisation of taping strategies.

O'Reilly et al, 2021

# data[].attributes.attachment_link.keywords[]
national center for biotechnology information

# data[].attributes.attachment_link.title
Use of tape for the management of hypertrophic scar development: A comprehensive review - PubMed

# data[].attributes.attachment_link.description
Patients are often concerned about unsightly scars that form on their bodies after trauma, especially burn injuries. These scars can be thick, red and raised on the skin, and can impact on the patient's quality of life. For some scars, the process of skin thickening continues for up to two years aft ...

# data[].attributes.body
RF

Pre-existing mental health diagnoses.

Self-inflicted burn injury.

Assault by burn.

Acute Stress Disorder/PTSD.

Anxiety.

Sleep pattern.

Effects of pain.

Body image and disfigurement.

Social Considerations

Medico-legal capacity.

Advanced care planning & EoL.

Care of the family and peer support.

Income.

Housing arrangements.

Safeguarding issues.

Return to work.

Management

Work re-integration programme.

Promote re-engagement of social roles.

Support family/friends in adapting to social role changes.

BritishBurnAssociation - Standards of Physiotherapy and Occupational Therapy in the Management of Burn Injured Adults and Children 2022.

# data[].attributes.body
RF

Depth and location of burn.

Time to heal.

Complications.

Infection.

Skin type, fragility.

Scarring Hx.

Age.

PMHx.

Patient compliance.

SHx

Family/support network.

Dependants.

Occupation.

Hobbies.

Management

Pressure therapy.

Silicone gels.

Scar massage.

Splinting.

Positioning, stretching, exercise.

Steroid injections.

Taping, laser.

Dermarolling, microneedling.

Outcome Measures

POSAS - Patient Observer Scar Assessment Scale.

Photography.

BritishBurnAssociation - Standards of Physiotherapy and Occupational Therapy in the Management of Burn Injured Adults and Children 2022.

# data[].attributes.body
RF

Age.

Limitations.

PMHx.

Environment.

Family support.

Pre-Injury Function Considerations

Mobility, transfers, ADLs, hand dominance, level of activity.

SHx

Family support.

Dependants.

Occupation, hobbies and interests.

Management

Transfers/mobility practice and progression.

Social and family roles reintegration.

Work/study reintegration.

Discharge planning.

Driving.

Outcome Measures

CPAX - Chelsea Physical Assessment Scale.

TUAG.

Timed unsupported stand.

# data[].attributes.headline
ROM, CV Fitness and Strength with Burn Injuries 

# data[].attributes.subject
ROM, CV Fitness and Strength with Burn Injuries 

# data[].attributes.body
Risk Factors

Joint, facial involvement.

Age.

Long-term disabilities.

PMHx.

Hx of burns.

Grafting.

Exposed structures.

Pain and anxiety.

Pre-Injury Considerations

Mobility.

Management

Positioning, splinting, mobility.

Active/passive exercise, strengthening.

Optimising CV Fitness.

Education to patients and their family.

Functional exercise.

Proprioceptive neuromuscular training.

Outcome Measures

Goniometry.

Dynamometry.

Oxford Grading Scale.

Borg Scale.

Endurance tests.

BritishBurnAssociation - Standards of Physiotherapy and Occupational Therapy in the Management of Burn Injured Adults and Children 2022.

# data[].attributes.body
Risk Factors

Depth of burn.

Location of burn.

Infection.

Nutrition.

Pain.

Skin fragility - friction/shearing.

PMHx.

Patient compliance.

Fluid balance.

Heart/renal failure.

Assessment

Area affected.

Circumferential measurements.

ROM limitation.

Volume.

Pain.

Limb function.

Skin condition.

Management

Elevation and positioning.

Exercises.

Splinting.

Massage.

Pressure therapy.

Stretches.

Taping.

Outcome Measures

Photography.

Circumferential measurements.

Figure of 8 (hand).

BritishBurnAssociation - Standards of Physiotherapy and Occupational Therapy in the Management of Burn Injured Adults and Children 2022.

# data[].attributes.body
HPC

Cause of burn.

Location of where incident occurred.

Nature of incident.

Date and time of burn.

Date and time of admission to burn service.

Exposure to smoke or other respiratory irritants.

Additional injuries.

%TBSA, distribution, depth.

Treatment at scene/first aid given.

Treatment to date and details of surgical interventions.

Current meds.

PMHx

All PMHx.

Any psychiatric history.

Any learning disability.

Cognition pre-admission.

Level of physical function prior to admission.

Drug Hx pre-admission.

Allergies.

SHx

Hand dominance.

Smoking Hx.

Alcohol Hx.

Recreational drug Hx.

Patient's accommodation status.

Pre-burn level of support from family, friends and carers.

Pre-burn level of mobility.

Occupation.

Hobbies.

Language.

Religion.

Previous community input/other agencies.

BritishBurnAssociation - Standards of Physiotherapy and Occupational Therapy in the Management of Burn Injured Adults and Children 2022.

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Inhalation Injury information.

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An inhalation injury is caused by a direct thermal burn or chemical exposure. It is a clinical diagnosis and treatment ensures a patent airway. This article discusses these aspects of inhalational injury in burns.

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The Royal Children's Hospital Melbourne - Resource

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The Royal Children's Hospital Melbourne - Resource

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Outlines how children and adults are different when it comes to burn injuries.

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see also:

Key points

1. Burn injuries should be managed as a trauma case requiring primary and secondary survey

2. Accurate Total Body Surface Area (TBSA) estimation is essential for fluid resuscitation decision making - it does not include epidermal burn

3. Optimal fluid resuscitation is crucial - inadequate resuscitation contributes to intravascular hypovolaemia and organ failure; excessive resuscitation contributes to fluid creep with extension of the burn wound and systemic oedema causing cardiorespiratory compromise, intra-abdominal and limb compartment syndrome

4. Managing pain and preventing complications are an important part of burn assessment and patient care

5. Close supervision of children at all times will help prevent burns

6. Some minor burns will be able to be managed at non- Paediatric Burn Unit centres; some burns will require acute management then referral or retrieval to local Paediatric Burns Unit

7. Burn management requires multidisciplinary approach including psychosocial care which addresses the significant impact a burn can have on a child and their family

Background

Burns are common in children. Burns range from minor wounds that can be managed in an outpatient setting to moderate wounds, requiring transfer to Paediatric Burns Unit and surgical management, through to major wounds with associated traumatic injuries requiring retrieval to Paediatric Intensive Care and Burns Unit.

Scald burns in young children are the most common type of burn. Most burns are mild and can be managed in a community setting, however major burns require prompt and high quality management to optimise the cosmetic and functional outcome of potentially devastating injuries. The psychosocial impact of a substantial burn can be significant.

Burns in children are different to those in adults due to their differences in their physical attributes, developmental abilities and emotional maturity.

An accurate assessment of a burn depth is difficult, especially early post injury. All burn injuries should be considered part of a trauma assessment, and non-accidental inflicted injury should be considered.

Epidemiology

Burns are a significant cause of morbidity and mortality in children, and a common cause for hospital admission.

Most burns occur in the home, predominantly in the kitchen. Most burns are not very severe and are small; <10% total body surface area (TBSA). Most hospitalisations are short (<1 day), though many burns require community care and some for prolonged periods of time.

Globally, nearly 96, 000 children under the age of 20 were fatally injured as a result of a fire-related burn in 2004. Within all countries burn risk correlated with socioeconomic status. Regional differences in burns exist; in 2018 children under 5 years of age in African Region have 2 times incidence of burn deaths than their worldwide counterparts; boys under 5 years of age from low-middle income countries of the Eastern Mediterranean Region are nearly twice as likely to die from burns as similar boys from the European Region; burn injuries requiring medical care is almost 20 times higher in Western Pacific Region compares to the Region of the Americas.

In the developing world open cooking fires are a major source of burns; commonly hand burns. Burn injuries to hands are particularly disabling due to impaired functionality and lack of adequate rehabilitation/assistance devices in the developing world - even a small hand burn can affect an individual's ability to perform activities of daily living independently and perform physical labour for a family's livelihood.

The death rate in low-income and middle-income countries is eleven times higher than that in high-income countries - 4.3 per 100 000 as compared to 0.4 per 100 000[i].

The type and cause of paediatric burns are related to the age and developmental stage of the child. Young children are most likely to incur a burn injury: 70% paediatric burns occur in <5 year old children. Infants have the highest death rates. The highest rates of hospital admission are of children <4 years old which correlates with the period of time children are starting to walk, climb and explore. Three quarters of burns in children >9 years of age are due to flame injuries. Scalds from hot (instant) noodles is increasing in adolescents, and the death rate climbs again for 15 - 19 year olds when risk taking behaviour increases and work related burns are introduced.

Males are over represented in all age groups for burns and the gender imbalance increases with age. From 10-14 years of age males have a sharp increase in burn injuries from exposure to highly flammable liquid (eg petrol).

In Australia, burn and scald injuries are especially high for infants and children <4 years of age. Hot drinks, food, fats and cooking oils cause more than half of the scalds in this group, with face, trunk and arm burns being the most common sites of injury. Aboriginal and Torres Strait Islander people have higher rates of burns in all ages compared to other Australians, and whilst all Australians have the highest rate of burns in less than 4 year olds Aboriginal and Torres Strait Islander children of this age are more likely than other Australians to be burned (174 cases per 100,000 compared to 45 cases per 100,000 population).

Other risk factors for paediatric burns include poverty, overcrowding, lack of safety measures or adequate parental supervision including young girls being given a household role of cooking. Children with some underlying medical conditions are also at increased risk of burns such as epilepsy and physical or cognitive disabilities. Children are at risk of burns from neglect and inflicted burns as child abuse.

Pathophysiology

A burn is a thermal injury resulting in a wound characterised by an inflammatory reaction leading initially to local oedema from increased vascular permeability, vasodilation and extravascular osmotic activity. It is caused by direct effect of the burn agent on microvasculature and resultant chemical inflammatory mediators.

A burn is an injury with both local and systemic responses. There are three major types of burn: thermal, electrical and chemical. Changes in tissue after the burn trauma are very important. In large burns fluid loss from damaged tissue causes decreased plasma and increased haematocrit with decreased cardiac output which contributes to widespread cellular hypoperfusion resulting in multisystem damage.

Local response

Zone of coagulation - this is the primary site of injury and the site of maximum damage. This zone comprises irreversible tissue loss due to exposure to heat, electricity and/or chemicals.

Zone of stasis - this surrounding zone has decreased tissue perfusion and is a penumbra of potentially salvageable tissue. Good quality first aid and burn resuscitation aims to reverse ischaemia and minimise the size of this zone. Risks to increasing size include increased depth of burn, prolonged hypotension, infection and oedema. This zone changes making initial burn assessment difficult. The full extent of injury is only apparent after several days.

Zone of hyperaemia - this outer zone comprises an d area with increased perfusion and will recover unless there is an additional insult.

Skin loss decreases the body's ability to preserve heat and water and act as a barrier to prevent infection. Resuscitation and treatment aim to correct these consequences.

Figure 1: Jackson's Burn Wound Model, 1947. (Reproduced with permission: Figure 2 Hettiaratchy S, Dziewulski P. ABC of burns: pathophysiology and types of burns British Medical Journal. 2004;328(7453):1427-1429Ds).

Systemic response

Once TBSA >30% a systemic inflammatory response will occur.

The renal and hepatic systems are susceptible to dysfunction due to resultant fluid and protein loss and a decreased blood volume. In major burns the fluid state of the patient must be carefully managed. Adequate and timely fluid resuscitation due to excess losses from the burn are crucial in curbing the extent of systemic dysfunction from this mechanism. Similarly, over resuscitation with excess fluid can have detrimental effects on cardiorespiratory function and contribute to compartment syndrome in the limbs and abdominal cavity.

A widespread inflammatory response also occurs as the result of a burn injury with release of catecholamines, vasoactive mediators and inflammatory markers which can trigger a systemic inflammatory response syndrome (SIRS) resulting in multiple organ dysfunction syndrome (MODS).

Figure 2: Systemic response to burns

Reproduced with permission. (Figure 3 Hettiaratchy S, Dziewulski P. ABC of burns: pathophysiology and types of burns British Medical Journal. 2004;328(7453):1427-1429[v]).

SIRS also contributes to immunosuppression rendering a patient more susceptible to bacterial infection and sepsis. The systemic response worsens initial organ damage caused by shock and reduces the body's ability to fight infection; this leads to an increased risk of sepsis which further triggers inflammation, immunoparesis and infection.

Following a burn injury, a hypermetabolic state ensues where catabolism increases and anabolism decreases resulting in loss of muscle and bone mineral density. Wound healing may also be affected. This hypermetabolic state is sustained despite wound closure. Protein breakdown continues 6 - 9 months after the initial burn making nutritional support to sustain lean body mass and promote wound healing of crucial import. Bone growth can be delayed for 2 years after a burn injury in children.

How children are different to adults

Children have thinner skin than adults, therefore the time to burn, or the energy required to cause a burn is less. This means that a burn agent at any given temperature, will cause a deeper burn, at a faster rate, in a child compared to an adult.

Young children are at risk of hypothermia, especially during initial cooling of the burn and from increased evaporative loss due to their larger surface area to body mass ratio.

Children have an increased blood volume relative to their mass therefore fluid resuscitation needs to accommodate for this: large volumes per unit body weight are required compared to adults. Small children are more likely to become hypoglycaemic and maintenance fluids should incorporate glucose replacement in children <20kgs.

The risk of airway compromise in children following inhalation injury is greater due to a smaller airway opening and greater risk of closure from oedema.

The systemic inflammatory response in children tends to be stronger with more vulnerability to their effects, including am increased susceptibility to the resultant hypermetabolic state.

As children are still growing their need for skin growth and elasticity to accommodate this growth complicate wound and scar management.

Assessment: History of burn
Time of injury
Mechanism of injury, including circumstance for specific pattern of burn

Scald: estimate temperature and ask about the nature of the liquid

Recently boiled water?: likely to be close to 100 degrees Celsius,

Hot drink with milk?: likely to be a cooler than recently boiled water

A solute in the liquid?: eg boiled rice - raises the temperature of liquid

Viscous liquid? more viscous fluids result in more severe burns as they remain in contact with skin for longer
Common causes include scalds from hot drinks(tea/coffee), kettles, bath, noodles

Contact: estimated temperature and nature of the surface
Common causes include irons, hair straighteners, exhausts, campfires, metal clips on car seats

Radiant:
Common causes include sunburn - this may be associated with neglect. Some burns sustained during house fires or bush fires can be due to radiant heat.

Friction:
Common causes include falling on, or touching, moving treadmills, or road rash after a motor vehicle crash

Flame / explosion:

ask about the product that burned/exploded: to predict temperature and predict secondary effects

ask about the location where the patient was exposed: indoor flame injuries are more likely associated with inhalation injury as compared to those in open spaces; indoor explosions may be associated with greater traumatic injuries

ask about the duration of exposure: to predict extent of burn
Common causes include flash burns after pouring accelerants (kerosene, petrol) onto BBQ's / bonfires, as well as in house fires

Electrical:

Low voltage (<1000V - typically domestic), high voltage (>1000V - often industrial) and lightening have different patterns of injury and complications

Type of current: alternating current (AC) or direct current (DC). DC typically provides a single convulsion or contraction usually propelling person away from source, whereas AC causes repeated convulsions and cardiac arrhythmias such as VF and is considered more dangerous; a larger magnitude of DC is required to cause injury than AC
Was there a flash or arcing: more likely to cover a large surface area and be more superficial, time and duration of contact: to predict severity of burn
Common cause include young children chewing on electrical cords

Chemical:

ask about the type of product: to predict extent of burn and secondary effects (alkali vs acid burns)

look at clothing for stain colour

Cold:
direct contact with cold surface or exposure (frostbite)

Inhalation:
common causes include inhalation of hot gases during a house fire, or flame burns to the face. May be of greater consequence if they have occurred in enclosed space

First aid

Time started (was it within 3 hours)

Agents used - cool running water vs less effective agents (standing water, cold compress, ice, home remedies)

Duration - was it at least 20mins of cool running water?

If clothes and jewelry were removed

Decontamination method (for chemical exposure)

Any circumstances to implicate co-existing non-burn injuries Any circumstances to implicate non-accidental injury or vulnerable child
Assessment: Primary survey

Like all traumas, paediatric burn assessments require an initial primary survey with the aim of identifying and managing immediate life threats: do not be distracted by the burn injury until all immediate life threats have been addressed. The list below indicates some of the key examination findings to look for during the primary survey. These findings may signal the presence of an immediate life threat requiring management during the primary survey. Do not neglect to apply personal protective equipment (PPE) which is especially important to protect health care workers where the patient has a chemical burn.

Airway
Examination Management

If suspicion of airway burns apply high flow oxygen

If above present, consider early intubation by an experienced airway specialist

Protect the cervical spine with cervical spine motion restriction if there is associated trauma

Breathing
Examination

Signs of inhalation injury as above

Full thickness and/or circumferential chest burns

Tension pneumothorax secondary to an explosion / associated trauma

Management
Circulation
Examination

If early shock is present, consider causes other than the burn

For circumferential burns check peripheral perfusion (and need for escharotomy)

Management

IV or IO access (preferably 2 points of access)

Consider IV fluid resuscitation

Resuscitative Fluid management in burns >10% TBSA

This is required to compensate for excess fluid losses in the first 24 hours after burn

Calculate requirements from time of the burn, not time of presentation

Calculate fluid volume using Modified Parkland Formula (MPF) (below)

Hartmann's Solution is the fluid of choice - if unavailable, use 0.9% N saline

Glucose in maintenance fluid is required for children <20kgs

Patients with delayed fluid resuscitation, electrical conduction injury and inhalation injury have higher fluid requirements. Discuss with specialist team.

For burns >10% TBSA

In dwelling catheter (IDC) is recommended to monitor urine output

Nasogastric tube (NGT) is recommended with nil by mouth state to manage an initial gastroparesis associated with burns and later to ensure adequate caloric intake in the coming days

Fluid creep
Fluid creep refers to excessive fluid administration to patients with burns. Adequate fluid resuscitation is a crucial part of managing children with major burns; if provided early it restores intravascular volume and maintains tissue perfusion both to the burn wound which avoids extension of the injury into the zone of stasis, and to the body which evades more widespread complications such as renal failure and reduces mortality.

The Modified Parkland formula above should be used as an initial guide to fluid resuscitation but the ongoing fluid replacement in a child with a major burn must include regular and in-depth fluid assessment beyond the urine output alone. If a child with a major burn is overhydrated it can lead to the development of systemic interstitial oedema which independently cause complications such as limb ischaemia from increased limb compartment pressures, renal failure from intra-abdominal compartment syndrome and respiratory failure from airway swelling and trauma.

To avoid fluid creep, avoid over estimation of TBSA, include all resuscitation fluids received by patient when calculating the appropriate resuscitation volume. If the fluid volumes appear greater than the predicted requirements from the modified Parkland formula alternative causes should be sought and managed. A fluid assessment of a patient with major burns includes not only the urine output but clinical fluid examination, biochemical markers, ventilatory parameters and end organ perfusion markers.

Disability

Exposure

Fully expose the patient in order to assess the extent of injury in terms of:

1. the percentage of Total Body Surface Area (TBSA) that is affected by the burn and

2. the burn depth

Check the patient's temperature (it is easy for small children to become hypothermic after cooling). The principle is to keep the patient warm, but the burn cool. The 20 mins of cool running water during first aid can be split into shorter sessions, with warming of the patient in between, as long as all the cooling occurs within the first 3 hours.

Assessment of TBSA

Expose whole body - remove clothing and log roll to visualise posterior surfaces

Keep patient warm

Estimate burn area with the Lund & Browder Chart

Do NOT include area with epidermal burn (erythema only)

TBSA determines need and volume of fluid resuscitation, hospital admission and transfer to Paediatric Burns Unit

Reproduced with permission. (Appendix 1. CHQ-GDL-06003 - Management of a paediatric burn patient within the Pegg Leditschke Children's Burns Centre. Children's Health Queensland Hospital and Health Service).

Assessment of burn depth

Burns are dynamic wounds: it is difficult to accurately estimate the true depth and extent of the wound in the first 48-72 hours

Burns are described as epidermal, dermal (superficial/mid/deep) and full thickness

Speed of capillary refill is a good indicator of burn depth, although burn wound evolution results in increasing depth therefore examination can change over time

Most burn wounds are not a homogenous depth

Assessment: Other considerations
Consider co-existing injuries
Especially in motor vehicle crashes, blasts/explosions, electrical injuries or jumps/falls from significant heights.

Consider alternate diagnosis: scald burn mimics

Consider non-accidental injury (see below)

Burn Wound Management

Like all traumas paediatric burn injuries require recognition and management of all injuries following the primary and secondary survey.

Acute management of superficial burns with erythema only

Can be treated without dressing

Infants who show a tendency to blister or scratch, a protective, low-adherent dressing with crepe bandage may be helpful.

Acute management of minor burns (isolated, <10% TBSA)

Acute Management of major burns (>10% TBSA) or complex burns

First aid

Remove jewelry and clothing in contact with burn source

Do not remove bitumen stuck to a burn

Cool affected area as soon as possible (within 3 hours from time of burn) for a total of 20 minutes with cool running water

If cool running water is unavailable, other options include: frequently changed cold water compresses/towels, immersion in a basin, irrigation via an open giving set

Never apply ice and avoid use of hydrogel burn products

Do not use butter, sugar, oil, toothpaste, potato, egg white or other traditional remedies

Prevent hypothermia: cool the burn not the child

Remove wet clothes/dressings after initial cooling

Try to keep child otherwise warm

Cover the wound and the child after assessment

When possible, warm the intravenous fluids and the room

Cover burn with plastic cling film lengthways along the burn (do not wrap circumferentially) - this helps maintain burn wound moisture and protect exposed nerve endings which contributes to pain management

Do not apply plastic cling film to face (use paraffin ointment)

Do not apply plastic cling film to a chemical burn

Discuss Chemical burn decontamination with Poisons Information (Tel: 131126)

Appropriately consented photos of burns should accompany a referral if possible

Analgesia

Clean

Assess

Assessment of burn injury TBSA and depth as above

Take photos with appropriate consent

Dress

Apply appropriate occlusive non-adherent dressing; if these products are not available, refer to local Burns service for alternative options

If there is anticipated delay or time until definitive care, consider use of multiple layer non-adhesive paraffin antiseptic dressing.

Facial and perineal burns

Epidermal or superficial dermal

Apply white soft paraffin twice daily after cleaning face

Chloramphenicol ointment to eye and ear burns

Perineal burns are at risk of contamination - after bowel action, area should be cleaned with soapy solution; consider catheterisation; 4% chlorhexidine skin wash

Mid or deep dermal

Consider silver-impregnated dressing (discuss with Burns service)

Other body regions

Epidermal

May not require dressing

Consider covering with protective, low-adherent dressing for comfort

Mid or deep dermal

Dressing product used depends on the expected duration required before removal or wound review

In general:

- for small, superficial partial thickness burn wounds use a low adherent dressing then crepe bandage/tape

- for more extensive or deeper partial thickness burn wounds use a low adherent silver dressing then crepe bandage.

Elevate
Operative management

Superficial wounds should heal by regeneration within 2 weeks and need only cleaning, dressing and review to optimise healing. If a burn has not healed within 2 weeks it should be referred for assessment and may require surgery.

Deep partial thickness or full thickness burns are likely to require operative management which includes excision of the deep burn and skin grafting within 5-10 days to expedite healing and minimise scarring. Sometimes artificial dermis is used as a bridge to skin grafting. Skin grafts can be autografts or allografts.

Grafting consists of 4 steps

1. The removal of injured tissue

2. Selection of a donor site, an area from which healthy skin is removed and used as cover for the cleaned burned area

3. Harvesting, where the graft is removed from the donor site

4. Placing and securing the skin graft over the surgically-cleaned wound so it can heal

For large burns multiple operations may be required to complete the grafting process.

Investigations

Major burn (≥10% TBSA)
Haemoglobin, electrolytes, BGL, group and hold, VBG

Suspected inhalation injury
ABG for carbon monoxide, lactate, cyanide level

Electrical burn
Cardiac monitoring, urine myoglobin

Special considerations

Circumferential deep burn (deep dermal or full thickness)

Elevate part of limb distal to burn to minimise swelling and oedema. Assess and monitor for neurovascular compromise of tissue distal to the burn; escharotomy may be required.

Limb burns

Elevate the limb and monitor perfusion distal to burn.

Hand burn

Hand burns in children are common due to the inquisitive nature of children and their developing motor skills. Assessment and management of hand burns in children are as above. Special priority must be given to early active rehabilitation to optimise hand function. See Rehabilitation below.

Treadmill injury

Exercise equipment is becoming commonplace in homes. Children should not have access to treadmills at any time: switch off power at wall and unplug, keep behind closed toddler gate or locked door. A friction injury caused by a treadmill is a type of burn, which should be assessed and treated as a burn. Friction injuries from treadmills are commonly on children's hands and cause serious burns often requiring surgical intervention and lengthy rehabilitation.

Head and neck burns

Nurse head up to reduce swelling and oedema.

Ocular burns

Signs of ocular burns include blepharospasm, tearing and conjunctivitis. All facial burns should have ophthalmological assessment including visual acuity, external ocular exam and Fluorescein 2% eye drops to assess for corneal damage. Full thickness facial burns propose high risk of ocular damage.

Both thermal and chemical corneal burns threaten vision; alkalis penetrate deeper and have greater potential for serious and delayed burns.

Treat all ocular chemical burns with copious irrigation using 0.9% NaCl as soon as possible. Ensure the unaffected eye is uppermost during irrigation of effected eye to avoid further contamination. Use topical anaesthetic on effected eye for analgesia and to aid tolerance of irrigation.

Use topical Chloramphenicol to prevent secondary infection.

Urgent paediatric ophthalmology review is required to for:

Electrical injuries

Degree of injury is related to the voltage of the electrical source. Electrical injuries can be associated with other injuries: consider spinal precautions. Electrical injuries can also cause cardiac dysrhythmias - consider 24 hours ECG monitoring. Monitor and manage elevated CK, urine haemoglobin/myoglobin and haemochromogen. Monitor for compartment syndrome.

Reproduced with permission. Clinical Guideline, Statewide Burn Injury Service - NSW Burns transfer guidelines (4th edition) Page 12 Electrical burns: table Overview of electrical injuries © Copyright - Agency for Clinical Innovation 2020

Electrical injury: labial artery erosion

Children can suck on or chew through power cords, or can chew on damaged/frayed power cords, resulting in an electrical burn. Even low voltage electrical burns can be serious causing deep injury with muscle tendon and vessel involvement. Electrical burns occurring at the edge of the mouth can be associated with acute or delayed (up to 21 days) labial artery involvement and significant haemorrhage.

Chemical burns

Chemical burns are caused by caustic agents:

First aid of chemical burns with irrigation of cool running water is extremely important and is often forgotten. Personal protective equipment for first aid givers should be worn (gloves, mask, gown, eye protection. Ensure contaminated clothing is removed and brush any powdered agent off skin onto a collection sheet to be disposed of appropriately.

Irrigate from the top of the wound down to the floor with appropriate drainage so contaminated water does not cause further injury.

Consider systemic symptoms from metabolic and electrolyte disturbance from absorbed agent.

Chemical burn: oesophageal injury

Many harmful agents are found in everyday households eg toilet cleaner, bathroom cleaner, hair products, laundry and dishwasher detergents, batteries, drain and oven cleaners. Ingestion of caustic agents can lead to oesophageal burns, strictures and perforation. Children with significant injury may have no-mild symptoms only. Symptoms include dysphagia, drooling, chest/abdominal pain, refusal to eat, respiratory compromise. The injury tends to worsen over time.

Tetanus prone wounds

Consider if prophylaxis with vaccination or tetanus immunoglobulin is required.

Inhalation injury

These occur with flame burns in enclosed spaces. Direct inspection of the oropharynx should be performed on arrival and consideration of early intubation by an experienced airway specialist.

Inhaled smoke is cool upon reaching the lungs but products of combustion are irritating leading to bronchospasm, inflammation and swelling. This predisposes an individual to atelectasis and pneumonia, and can be worse in asthmatics. Patients may require non-invasive positive pressure ventilation or invasive ventilation and airway toileting.

Carbon monoxide and cyanide poisoning

If suspicion of associated Carbon monoxide (CO) poisoning or cyanide poisoning liaise early with Paediatric Burn Unit, Critical Care and Poisons Information (Tel: 131126).

Carbon monoxide is a toxic gas inhaled during a fire, such as a patient enclosed in a house fire. Carbon monoxide binds very strongly to haemoglobin and intracellular proteins contributing to intracellular and extracellular hypoxia. Toxicity is dose dependant involving no or few symptoms through to cardiovascular compromise with seizures and death.

Symptoms include:

Pulse oximetry cannot differentiate between haemoglobin and carboxyhaemaglobin so will not read low even when a patient is hypoxic. Blood gas will show metabolic acidosis and raised carboxyhaemaglobin. These patients require 100% oxygen and may require ventilation. Unborn foetus can be affected by toxicity: specifically discuss care of pregnant women with specialist teams.

Cyanide is a potentially lethal toxic poison that is produced in gaseous form from burning natural and synthetic fibres such as plastics and wools such as occurs in in domestic/industrial fires. Cyanide poisoning occurs from inhalation of this gas and often occurs with carbon monoxide poisoning. Toxicity is dose dependant and incudes multisystem involvement[ii].

Initial symptoms include:

More severe symptoms include end organ damage form anaerobic metabolism with associated hypotension, bradycardia and cardiovascular collapse, respiratory depression and reduced GCS.

Blood gas will show metabolic acidosis with high lactate, serum level cyanide should be taken.

Treatment includes ABC resuscitation, high flow oxygen and administration of antidote hydroxocobalamin then sodium thiosulfate.

Frostbite

Frostbite is a type of burn injury to the skin and underlying tissues by freezing. It most commonly effects the extremities and can be divided into superficial or deep. It can occur through exposure to cold-weather conditions or direct contact with cold ice, liquid or metal. Minor frostbite injuries can be managed with simple first aid involving analgesia and rewarming followed by simple wound care. More serious injuries may require review with a burns service for more intensive wound care management.

Non-Accidental Injury

Non-accidental burn injuries can occur in the setting of neglect or physical abuse. Inflicted burn injuries are under recognised; it is difficult to estimate the incidence. They effect children of all ages and incur significant mortality and morbidity[iii].

Concerning features on history

Scalds are the most commonly inflicted burn injury. Certain locations or patterns of burn are more suspicious for an abusive cause:

Burns concerning for inflicted injury

Submersion burns

Circumferential

Symmetrical

Uniform depth

No splash marks/satellite burns

Buttocks, perineum, extremities

Sparing on buttock cheeks "donut sign" (held down on bath), in flexures (groin, knees) and abdominal creases (as trunk is flexed forward when child tries to protect them self)

Glove and stocking distribution for limb submersion

Contact burn

Very young child

Patterned burn >1 lesion

Cigarette burn: clustered, sharply demarcated, ~1cm punched out, deep, circular, hands and feet

Iron

Lighter - classic "smiley face" patterned burn

Trunk or buttock

Bilateral foot sole burns from being held on hot pavement

What to do if you are concerned a burn injury was caused by neglect or abuse

Consider consultation with local paediatric team when

Consider transfer to a Paediatric Burn Unit when

Child requiring care beyond the comfort level of the hospital

Following burns:

>10% TBSA

All full thickness burns

Special areas: face, ears, eyes, neck, hands, feet, genitalia, perineum or a major joint, even if <10%

Circumferential

Chemical

Electrical

Associated with trauma and/or spinal cord injury

All inhalation/airway

Children <12 months

Discharging a patient with a burn wound

Minor burns may be discharged at initial presentation and referred to outpatient burns follow up of local service with 1-2 visits per week initially.

Moderate or large burns or patients with multiple injuries will have required in patient admission or transfer to a Paediatric Burns Unit and may require Paediatric Intensive Care. As part of acute care - once discharged will require multiple follow up appointments as an outpatient.

The ability of a family to provide adequate care for a child with a burn and attend appointments should be taken into account when deciding the child's disposition. These include geographical isolation and concern for social welfare of child; delayed presentation, suspicion of non-accidental injury or concern family will not care for wound or attend appointments.

Follow up

Burns can evolve over time. Consider a follow up within 3 days of initial presentation to reassess depth, monitor healing and determine ongoing management. On reassessment referral to Paediatric Burn Unit is necessary:

Depth is unclear after 3 - 5 days

Slow to heal - poor progression at 5-7 days

Post Acute Care of Burns

The type of care a child requires depends on the type, depth and extent of burn, involvement of burn in special areas premorbid health, additional injuries and psychosocial situation (eg concern of neglect or non-accidental injury). A multidisciplinary team is required.

Burn Dressings

The burn wound dressing will depend on the type and severity of the burn wound.

Principles of burn wound management

Daily dressing change is not advised. Timing of dressing changes depends on the product used. Dressing advice can be obtained from your local Paediatric Burns Unit.

Many burn dressings are available. Dressing choice will depend on what is stocked at your local service. Below is an example of a safe and effective initial dressing.

Primary Dressing/Contact Layer

Application of silver dressing as per local methods. A typical burn dressing may include 7 day Acticoat (alternatives include 3 day Acticoat, Mepliex Ag, Aquacell Ag).

Secondary Dressing/Fixation

Provides a final layer to absorb exudate and secure primary dressing/contact layer in place (Melolin, Hyperfix).

Analgesia

Pain management is an important part of paediatric burn care - uncontrolled stress and pain contribute to poor healing. All procedures should be performed with adequate sedation and analgesia. Multimodal analgesia is often necessary to achieve adequate analgesia. Consult local pain service for advice or opioid infusions/patient controlled analgesia as required for in patients with severe burns. For minor burns including those managed in the community consider nitrous oxide or intranasal fentanyl during burn review and dressing changes. Consider additional analgesia requirements for children who have had previous distress during dressing changes or ongoing anxiety.

Utilisation of child life therapy, music therapy teams and non-pharmaceutical distractions (eg iPad, breast feeding, reading, limiting child's ability to watch wound care) should complement chemical analgesia and sedation.

Preventing Infection

Standard infection control measures apply to children with burn injuries

Burns >10% TBSA require additional infection control measures which aim to limit child's exposure to bacteria via isolation and limiting transmission via contact - follow local Paediatric Burns Unit infection precautions.

Nutrition

Nutrition is an important part of burns care. Children have an increased metabolic requirement, and increased nutritional requirement for growth, limited energy reserve and an increased body surface area to mass ratio compared to adults.

Children who are unable to drink due to facial burns or other injuries or medical issues should have a nasogastric tube inserted and commence enteral feeds. A dietician should be involved to ensure adequate nutrition is met including an assessment of increased macronutrient and micronutrient requirement (consider supplementation vitamin A, vitamin C and zinc to promote wound healing). Regular weight measurements aid assessment of adequate nutrition.

In burns >15% TBSA NGT feeds should be commenced within 6 hours of the burn.

Positioning

Burn areas should be elevated to limit oedema (monitor for compromise of peripheral circulation). When a burn crosses a joint, joint should be positioned to maintain optimal functional range of movement with consultation with occupational therapy and physiotherapy team.

Post Acute Care Complications

Itch

Healing wounds are often itchy. Non sedating antihistamines are a safe option for symptomatic management.

Oedema

Circumferential burns inhibit lymphatic drainage and venous return resulting in oedema which may take 1-2 weeks to resolve. Elevation of the area will limit amount of oedema and accelerate resolution of oedema and minimise neurovascular compromise.

Fever

Fever is a common reaction to hypermetabolic state and immune response following a burn injury however the child must be assessed for other causes. Prophylactic antibiotics are not recommended in burns.

If there is concern the burn wound is infected send a swab for MCS and treat with empiric antibiotics as per local guidelines.

Toxic shock syndrome (TSS) is a rare complication of an infected burn and can be life threatening.

Signs/symptoms TSS

Shock (tachycardia, hypotension)

Fever >38.9 degrees

Erythematous rash

Diarrhoea and vomiting

Lethargy

Irritability

Treatment includes active resuscitation with IV fluids, IV antibiotics and urgent paediatric and burns specialty care.

Psychosocial care

The consequences of a child sustaining a burn can be profound on the child and their family's psychological, emotional, social and financial wellbeing. Children have evolving development with different physical, cognitive and emotional abilities. Children are dependent on carers and of children presenting with burn injuries a significant portion are vulnerable children. Treating a child with a significant burn injury can involve multiple invasive frightening procedures, protracted treatments and regular engagement with a health facility. Treatment compliance is important to achieve the best outcome possible. Caring for the child includes support for family members which includes multidisciplinary team approach noting a family's needs may change from acute care to rehabilitation and the child's transition back to community and school.

Rehabilitation

Depending on the size and site burn injuries can be associated with a significant risk of limited functioning. Appropriate burn care includes optimising function after a burn to achieve the best possible outcome.

Some burns may require review by occupational therapy or physiotherapy team, including:

Ongoing OT requirement may be necessary to optimise patient function and minimise risk of irreversible complication such as contracture and deformity

Rehabilitation is a long and intensive process and will commence as early as possible (often in hospital) and continue at home with community supports. Therapy may involve a comprehensive plan including passive and active exercises as well as resting splints. Patients and their family are required to take on responsibility for and play an active part in ongoing rehabilitation.

Scar management

Pressure dressings are utilised to minimise scarring post burn. Therapists may tailor pressure garments unique to the patient's requirements and provide exercises to optimise a patient's functional outcome.

Skin is altered after a burn and requires regular moisturising to prevent cracking and breaking down which can lead to secondary infection.

Burn reconstruction

Most burns managed well initially will not require reconstruction. Sometimes burn reconstruction will be recommended to optimise comfort, function and appearance. This occurs many months after the initial burn.

Ensure cups of hot liquid are always out of reach of children

Thick soup is more viscous and remains on a child continuing to burn them - wash soup or hot food off with cool running water and continue first aid for 20 minutes

Avoid table clothes as children can pull hot food/drinks down

Always ensure handles of pots on the stove are angled in and out of reach of children

Ensure cords in kitchen not long or hanging down into child's reach (eg kettle/toaster able to be pulled down by loose cord)

Install a guard around hot plates on stove

Ensure deep fryers are OUT of reach of children

Block off entry to kitchen with childproof gate

Always check bathwater before putting child in bath

Put in cold water first, then add hot water, temperature should not exceed 50 degrees

Do not leave children unattended in bath

can turn on hot tap directly causing burn

can electrocute self in bath with bathroom electronic equipment (hairdryer, shaver etc)

Always run some cold water through the tap last so faucet is not hot

Ensure smoke alarms installed and functioning to the Australian Standard, replace batteries each year with daylight savings

Always supervise children around any naked flame (candle, fireplace, BBQ)

Ensure children cannot access matches/lighters

Do not use accelerants on an open fire (eg petrol, grappa, methylated spirits)

Ensure secure storage of flammable material within the home

Do not set off fireworks/flares

Do not smoke around children, do not smoke whilst carrying child in baby carrier (ash and cigarette can burn child's face)

Place guards around heaters and teach children not to touch or stand too close

Do not leave power cords plugged in and accessible to children

Place safety blocks into unused power points

Do not use electric blankets in children's bed (risk of overheating, risk of electrocution if wet bed)

Replace any electrical cords that are frayed/broken down

Lock up all cleaning materials and ensure children have no access

Do not store cleaning materials or other home maintenance materials in old food containers (eg coolant in soft drink bottle, snail bait or rat poison in ice-cream container)

Ensure batteries are stored away from access to children

Limit use of toys/devices requiring button batteries and if used ensure safety cap over battery compartment are always securely screwed in

Ensure running treadmills are inaccessible to children

Electricity switched off at power and unplugged

In separate room child cannot get into

Walled off with child's playpen

[i] World Health Organisation, Children and Burns, 2004.
https://www.who.int/violence_injury_prevention/child/injury/world_report/Burns_english.pdf
[ii] World Health Organisation, Burns, 2018.
https://www.who.int/en/news-room/fact-sheets/detail/burns
[iii] Australian Institute of Health and Welfare, Burns and Scalds.

https://www.aihw.gov.au/reports/injury/burns-scalds/contents/table-of-contents

[iv] AIHW: Pointer S & Tovell A 2016. Hospitalised burn injuries, Australia, 2013-14. Injury research and statistics series no. 102. Cat. no. INJCAT 178. Canberra: AIHW.

[v] Hettiaratchy S, Dziewulski P. ABC of burns: pathophysiology and types of burns British Medical Journal. 2004; 328(7453): 1427-1429.

[iv] Rogers AD, Karpelowsky K, Millar AJW, Argent A, Rode H. Fluid Creep in Major Pediatric Burns European Journal of Pediatric Surgery 2010; 20(2): 133-138.

[vii] CHQ-GDL-06003 - Management of a paediatric burn patient within the Pegg Leditschke Children's Burns Centre. Children's Health Queensland Hospital and Health Service.

[viii] Clinical Guideline, Statewide Burn Injury Service - NSW Burns transfer guidelines (4th edition). Page 12 Electrical burns: table Overview of electrical injuries

[ix] Life in the Fast Lane. Carbon Monoxide Inhalation [online]. Dr Neil Long, last update August 25, 2019. Viewed 13 th May 2020. https://litfl.com/carbon-monoxide-inhalation/

[x] Life in the Fast Lane. Cyanide Poisoning [online]. Dr Chris Nickson, last update April 2, 2019. Viewed 13 th May 2020. https://litfl.com/cyanide-poisoning-ccc/

[xi] Victorian Forensic Paediatric Medicine Service. Burns Including Scald Burns [online]. Viewed 20 th April 2020. https://www.rch.org.au/vfpms/guidelines/Burns_including_scald_burns/

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see also: Burn injuries should be managed as a trauma case requiring primary and secondary survey Accurate Total Body Surface Area (TBSA) estimation is essential for fluid resuscitation decision making - it does not include epidermal burn Optimal fluid resuscitation is crucial - inadequate resuscitation contributes to intravascular hypovolaemia and

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British Association of Plastic Reconstructive and Aesthetic Surgeons - Resource

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British Association of Plastic Reconstructive and Aesthetic Surgeons - Resource

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Great resource for in depth information on burn injuries.

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Article resource with lots of key information RE burns.

Useful schematic for visualising the different burn degrees.

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Introduction

In addition to determining the cause of a burn injury it is imperative to classify the injury according to its severity - its depth and size. Burns that affect the uppermost layer of the skin (epidermis only) are classed as superficial (first-degree) burns (Fig. 1); the skin becomes red and the pain experienced is limited in duration. Superficial partial-thickness (second-degree) burns (formerly known as 2A burns) are painful, weep, require dressing and wound care, and may scar, but do not require surgery. Deep partial-thickness (second-degree) burns (formerly known as 2B burns) are less painful owing to partial destruction of the pain receptors, drier, require surgery and will scar. A full-thickness (third-degree) burn extends through the full dermis and is not typically painful owing to damage to the nerve endings, and requires protection from becoming infected and, unless very small, surgical management. Finally, a fourth-degree burn involves injury to deeper tissues, such as muscle or bone, is often blackened and frequently leads to loss of the burned part. Although superficial and superficial partial-thickness burns usually heal without surgical intervention, more severe burns need careful management, which includes topical antimicrobial dressings and/or surgery. Importantly, burns are classified as either minor or major. A minor burn is usually a burn that encompasses <10% of the total body surface area (TBSA), with superficial burns predominating. By contrast, the burn size that constitutes a major burn is not commonly well-defined; some guidance to classify severe burn injuries are: >10%TBSA in elderly patients, >20%TBSA in adults and >30%TBSA in children. Alongside injuries to the skin, burns can be accompanied by smoke inhalation or other physical trauma to other organs.

The uniqueness of a severe or major burn injury is anchored in the body responses to it. After the injury, an immediate systemic and local stress response is triggered that, unlike sepsis or trauma, does not recover quickly. Severe burns cause a complex pattern of responses that can last up to several years after the initial insult. In general, immediately after the insult, an inflammatory response is triggered to promote the healing process. However, in severe burns, this inflammatory process can be extensive and become uncontrolled, leading to an augmented inflammation that does not induce healing but rather causes a generalized catabolic state and delayed healing. This response is almost unique to burns and is referred to as the hypermetabolic response; it is associated with catabolism, increased incidence of organ failure, infections and even death.

Once the burn injury severity has been established, the patient needs to be appropriately referred and triaged. Care of a patient with major burn injury is resource-intensive, often takes place in a specialized centre, and has a substantial impact not only on the life of the patient but also on the lives of caregivers and families - often for a long period of time. A recent study demonstrated that burn injuries affect morbidity and mortality for at least 5-10 years after the injury. Thus, those involved in burn care must adapt their goals to move away from immediate survival as the main goal towards goals that address scarring, long-term well-being, mental health and quality of life. Indeed, the trauma care community recently adopted the goals of no death, no scar, no pain.

In this Primer, we discuss key aspects of burn injury and provide an up to date description of the epidemiology and clinical care of patients with burn injuries. Mechanistically, we focus our discussion on severe burns, as these injuries exhibit profound inflammatory and metabolic effects that increase the risk of long-term sequelae and death, but principles of wound care and acute management can also be applied to minor burn injuries. The goals to reduce scarring and safeguard mental health are also described alongside other long-term outcomes of quality of life. We also discuss promising future therapies.

Epidemiology

Burn injuries result in lifelong physical and psychological scarring, causing pain and influencing mental health, quality of life, ability to return to work and subsequent mortality. Although information on burn epidemiology is essential for resource allocation and prevention, the available data are variable and inconsistent. The majority of data are from high-income countries and are directly related to access to health-care resources, differences in environments and the resources of the various health-care systems. In lower income countries, fewer resources, geographical constraints and cost limit data collection and access to health care. Additionally, cultural factors such as open-air cooking areas and loose clothing (for example, saris), domestic violence and dowry deaths contribute to regional variation. To address the significant gap in information, the WHO is piloting an online, checkbox-based Global Burn Registry that aims to standardize reporting.

Although burn injuries are decreasing in high-income countries, the prevalence of burn injuries remains high elsewhere, with ~90% of burns occurring in low- and middle-income areas. The WHO estimates that 11 million burn injuries of all types occur annually worldwide, 180,000 of which are fatal. There is a wide variability in the incidence of burn injury. For example, the number of burn-related deaths per 100,000 population ranges from 14.53 in Cote D'Ivoire to 0.02 in Malta. Burn-related deaths of children are 7 to 11 times higher in low-income than in high-income countries.

In the USA, a bimodal age distribution of all burn injuries is evident, with the majority of injuries occurring in young children (1-15.9 years of age) and in those of working age (20-59 years of age). Regardless of country, burns in children are more equally distributed between boys and girls, especially in toddlers. However, this ratio changes as age increases; in most countries, nearly twice as many men are injured as women. An exception to this trend has been noted in Ghana and India, where up to three times more women are injured and die from burn injuries than men.

The American Burn Association (ABA) National Burn Repository 2019 reports that, overall, flame burns are still the majority of injuries in the USA (41%), with scalds second at 31%. Chemical (3.5%) and electrical burn injuries (3.6%) occur much less commonly. Burns in children <5 years of age tend to be scald injuries, with increasing flame-related burns as age increases. Around the world, burns in the elderly population are increasing, and are predominantly flame-related. However, scald injuries are increasing substantially as well. Finally, depending on the environment, burn injuries are more frequent in some vulnerable populations, such as those with epilepsy.

Mechanisms/pathophysiology

Experimental and clinical studies have demonstrated that severe burns (regardless of the cause) result in the development of an extremely dysregulated inflammatory host response within a few hours of injury. The inflammatory and stress responses are characterized by elevated levels of cytokines, chemokines and acute phase proteins as well as a hypermetabolic state that is driven by a sustained sympathetic tone that can persist beyond the acute phase of care. A number of factors contribute to the magnitude of the host response: burn severity (percentage TBSA and burn depth); burn cause; concomitant inhalation injury; exposure to toxins; other traumatic injuries; and patient-related factors such as age, pre-existing chronic medical conditions, drug or alcohol intoxication, and timing of presentation to medical aid. Depending on the magnitude of the injury, the initial host response immediately after severe burn injury is similar to that after many other inflammatory conditions triggered by tissue destruction such as trauma or major surgery, which is helpful in initiating tissue repair and overall wound healing. However, after severe burns, the inflammatory cascade may be triggered multiple times during the course of clinical care after initial resuscitation, for example, during burn surgery or subsequent infectious complications. When the inflammatory cascade occurs repeatedly or remains uncontrolled, it can destroy host tissue and contribute to organ dysfunction and death. Although various pieces of the complex response after burn injury have been identified, how and in what sequence these pieces interact have not been resolved.

Initial injury

Immediately after injury, the burn wound can be divided into three zones: the zone of coagulation (with the most damage in the central portion); the zone of stasis or zone of ischaemia (characterized by decreased perfusion that is potentially salvageable); and the zone of hyperaemia (the outermost region of the wound characterized by increased inflammatory vasodilation). The degree of cellular injury varies depending on the zone of injury and spans the spectrum from immediate cellular autophagy within the first 24 hours following injury, delayed-onset apoptosis ~24-48 hours after the burn injury and the presence of reversible oxidative stress. The natural healing of these wounds involves dynamic and overlapping phases (Fig. 2) that include an inflammatory phase, which is initiated by neutrophils and monocytes homing to the injury site via localized vasodilation.

Shock

Alongside cytokines and other inflammatory mediators at the site of injury, stress hormones such as catecholamines and cortisones are released by the adrenal glands, all of which have systemic effects. Burn injury usually results in a distributive shock, an abnormal physiological state in which tissue perfusion and oxygen delivery is severely compromised owing to marked capillary leakage of fluid from the intravascular to interstitial space, that contributes to profound tissue oedema and fluid accumulation. The marked capillary leakage can be attributed to oxidative stress that is characterized by increases in the levels of nitric oxide and inflammatory mediators, which damages the vascular endothelium. Burn injury also depresses cardiac function within a few hours of injury, lasting ~24-48 hours, via oxidative stress, the release of inflammatory mediators (such as IL-6 and tumour necrosis factor (TNF)) and cellular alterations (such as apoptosis and necrosis). The decrease in cardiac function and relative hypovolaemia, along with low blood flow caused by vasoconstriction, affects perfusion of tissues and organs (that is, distributive shock), including the lungs, liver and gastrointestinal tract - augmenting tissue and organ dysfunction and damage. The state of shock continues even if hypovolaemia is corrected. Furthermore, the cardiovascular dysfunction can further exacerbate the systemic inflammatory response into a vicious cycle of accelerating organ dysfunction (summarized in ref.).

Hypermetabolic state

After an initial (~72-96 hours) hypometabolism (ebb phase) - which is potentially caused by intracellular processes, e.g. increased endoplasmic reticulum stress and mitochondrial dysfunction and characterized by decreased metabolic rate and intravascular volume, poor tissue perfusion and low cardiac output - a hypermetabolic state is typically observed after injury in patients with severe burns (flow phase). The hypermetabolic state after burn injury persists for up to 36 months after the initial insult. Stress hormones such as catecholamines, glucocorticoids (produced by the adrenal glands) and glucagon (produced by the pancreas) increase blood pressure, peripheral insulin resistance and breakdown of glycogen, proteins and lipids. The results of these effects are increased resting energy expenditure, increased body temperature, total body protein loss, muscle wasting and increased stimulated synthesis of acute-phase proteins (such as insulin-like growth factor 1 (IGF-1), which has anabolic effects), ultimately resulting in organ catabolism associated with organ dysfunction and death.

Although these responses are reported in patients with other types of trauma or critical illness, their magnitude and duration in patients with severe burn injury is of consequence. Sustained release of catecholamines, glucocorticoids, glucagon and dopamine (released from the brain) seem to initiate a cascade of events leading to an acute hypermetabolic response and an ensuing catabolic state (Fig. 3). The mechanism(s) underlying this complex response remain to be established, but studies have suggested that the continuous and sustained release of pro-inflammatory mediators such as cytokines, chemokines and acute phase proteins (namely, IL-1, IL-6, TNF and IGF-1) may further contribute to the hypermetabolic state in patients with moderate to severe burn injury. Regardless of the underlying mechanistic detail, an effective treatment to abolish or reduce the hypermetabolic response is not available. However, the recent discovery of the browning of the white adipose tissue due to inflammation or upregulation of mitochondrial brown fat uncoupling protein 1 (which is responsible for thermogenic respiration) after burn injury seems to induce metabolic and immune changes that further augment hypermetabolism and immune dysfunction - an avenue that may lead to new treatment options.

Immune dysregulation and infection

In addition to hypovolaemic and hypermetabolic responses, burn injury has a profound effect on the immune system. Immune cells, including monocytes, macrophages and neutrophils, which are activated in response to burn injury within a few hours, recognize endogenous factors such as damage-associated molecular patterns (DAMPs) or alarmins that are generated as a result of burn-mediated tissue damage. DAMPs and their exogenous counterparts, pathogen-associated molecular pattern molecules (PAMPs), are recognized via pattern recognition receptors, namely Toll-like receptors (TLRs) and NOD-like receptors (NLRs). The ligation of TLRs and NLRs by their specific ligands results in the activation of downstream inflammatory pathways, leading to activation of NF-κB, a master transcription factor involved in the release of multiple inflammatory mediators (such as IL-1, IL-6, IL-8, IL-18 and TNF). The release of these cytokines and chemokines furthers the cycle of inflammation leading to systemic inflammatory response syndrome (in which uncontrolled cytokine release leads to excessive leukocyte recruitment, fever or hypothermia, tachycardia and tachypnoea). Interestingly, other immune functions are severely compromised, including macrophage antigen presentation or neutrophil killing of invading pathogens. Moreover, T cell proliferation and IL-2 production are also suppressed. Together, these events lead to the development of a compromised adaptive immune response, resulting in enhanced susceptibility to infection (Fig. 4).

Tissue injury following severe burns results in release of endogenous damage-associated molecular patterns (DAMPs) such as mitochondrial DNA and double-stranded RNA (dsRNA), which along with exogenous pathogen-associated molecular pattern molecules (PAMPs) such as lipopolysaccharides (LPS) and peptidoglycans, can induce vascular leak, an inflammatory response and metabolic changes. Vascular leak and transfer of intravascular fluid to third spaces leads to tissue oedema and further injury. The inflammatory response can result in immunosuppression and ineffective response to bacterial invasion. Metabolic changes include increased muscle protein degradation, insulin resistance and increased cardiac load. The culmination of these events is often systemic inflammatory response syndrome (SIRS), an inflammatory state affecting the whole body, which can lead to multiple organ failure, and ultimately, death. MHC, major histocompatibility complex; PGE ₂, prostaglandin E ₂; TNF, tumour necrosis factor. Adapted from ref., Springer Nature Limited.

Indeed, patients with severe burn injuries are at higher risk of developing infectious complications. Ventilator-associated pneumonia is also a common finding in patients with severe burn injuries. Additional sources for infection in these patients can be their own microbiota associated with skin, respiratory tract and intestines. Compromised host defence from the disrupted skin barrier in patients with burn injury leads to increased susceptibility to infection (predominantly bacterial, but also yeast, fungal and viral), increase virulence from specific pathogenic organisms and the subsequent development of organ failure. Indeed, in a recent autopsy study, >60% of deaths in patients with burn injury were attributable to infectious complications and nearly all had at least one associated organ failure, with many having multiple organ failure. Each episode of sepsis (Box 1) can lead to organ dysfunction, which eventually leads to organ failure that affects different organs, including the kidneys, lungs, liver, gastrointestinal tract, heart and bone marrow.

Various studies support the suggestion that the gut, being the major source of bacteria and bacterial products, also plays an important part in pathogenesis after burn injury. Previous studies have shown an increase in intestinal bacterial growth after burn injury, resulting from diminished gut immunity, hypoperfusion and gut dysmotility. Furthermore, an increase in intestinal permeability (due to hypoperfusion and subsequent tissue inflammation and damage) has also been documented in patients and in animals within a few hours of burn injury and enables the gut bacteria to enter extra-intestinal sites such as mesenteric lymph nodes, liver and lungs. Indeed, increased bacterial translocation has been noted within the first few days after burn injury. However, this process becomes recurrent when the burn injury is followed by additional triggers that lead to gut hypoperfusion, such as peri-operative haemorrhagic shock and infectious complications. The microbial communities in faecal samples from patients with burn injury have been shown to be different from those observed in faecal samples from healthy controls. Specifically, the faecal microbial communities of controls were dominated by the Bacteroidaceae, Lachnospiraceae, and Ruminococcaceae families. The faecal samples from patients with burn injuries exhibited a marked decrease in the relative abundance of these three families, but also demonstrated sharp increases in the relative abundance of the Enterobacteriaceae, a finding that has been replicated in mice. Furthermore, results obtained using in situ hybridization suggest large populations of Enterobacteriaceae in close proximity to the villi in the small intestine of mice receiving burn injury. This observation provides further evidence that intestinal bacteria and their products (such as endotoxin) can cross the intestinal epithelial barrier into the systemic or lymphatic circulation and contribute to the pathology after burn injury. Changes in the microbial community or diversity have been implicated in the development of many diseases including allergies, obesity, inflammatory bowel disease and many infectious diseases. However, a more systematic approach is needed to better appreciate the role of gut-derived bacteria or the microbiome in pathogenesis after burn injury.

Other injuries

Burn injuries can also lead to alterations and injuries in other organs. A common injury occurring with burns is inhalation injury (respiratory tract or lung tissue injury), caused by heat or inhalation of smoke or chemical products of combustion and leading to various degrees of damage (Box 2). Usually, inhalation injury is present in conjunction with the burn and can range from a minor injury to a very severe and necrotic injury pattern. Inhalation injury increases the risk of pulmonary complications, including ventilator-associated pneumonia, fluid requirements and mortality. However, measurement of the severity of inhalation injury is currently not well defined, despite some efforts and an existing grading system based on bronchoscopy, making assessment of the true effect of inhalation injury challenging.

A small percentage of burn injuries are associated with concomitant trauma, which commonly includes traumatic brain injury, injury to the abdominal or thoracic cavities, fractures or complex soft tissue injury (such as crush injury or degloving injury, with multiple layers of tissue involved). In general, patients with burns and traumatic injuries have worse outcomes than those without trauma. A comprehensive assessment of patients by trauma and burn teams needs to be conducted to optimize outcomes in these patients with complex and challenging injuries.

Additionally, burn injury affects all organs to some degree, owing to the systemic response to the burn. Possible effects include brain atrophy, pulmonary damage leading to pneumonia and/or acute respiratory distress syndrome (ARDS), acute renal failure, liver failure, hepatic fatty infiltration, gut atrophy, lipolysis and fat catabolism, cardiac dysfunction, and thymus and immune dysfunction and depletion. These effects lead to immunocompromise, loss of bone mineral density, hormone depletion and dysfunction, and thyroid dysfunction, all of which are common in the complex picture of burn-associated hypermetabolism. In an autopsy study, for example, multiple organ failure was a primary cause of >70% of all burn-related deaths.

Although very rare, a potential complication that has been documented in patients with burn injuries is irritation of the eye. Exposure to hot air, steam or flames can burn the face and eyes or eyelids, which can affect the normal function of the eye. Furthermore, injury to the eyelid can compromise the barrier and predispose the burn wound to foreign bodies and infection.

Box 2 Inhalation injury

Diagnosis, screening and prevention

Prevention

Burn injuries result in permanent scarring and adverse long-term sequelae that affect burn survivors and their caregivers. Unfortunately, as vulnerable populations are disproportionately injured, the burden from these injuries further marginalizes already disadvantaged groups. A central tenet of modern burn care is that the majority of burn injuries are preventable. As a result, the ABA encourages participation in prevention programmes as part of burn centre verification, and the WHO has proposed a plan for burn prevention and care at a global level. To encourage prevention implementation globally, the WHO published a collection of successful strategies from high-, middle- and low-income countries. These strategies range from grassroots changes of lifestyle (for example, safe wood burning stoves) to legislative regulation (for example, on children's sleepwear flammability).

Alongside legislative strategies, successful implementation of prevention programmes (for example, the introduction of fire-safe cigarettes and reduced flammability of children's clothing) has reduced the incidence of burn injuries in high-income countries. However, these efforts may not be as effective in low- and middle-income countries. In these settings, local social factors must be taken into consideration, for example, most low-income countries do not have water heaters or the resources for smoke detectors in each home. The Haddon Matrix (assessing pre-event, event-related and post-event factors) should be considered when constructing prevention programmes as the matrix helps to organize interventions for appropriate upstream, midstream and downstream targets. This approach can be applied at a regional level or even at a case level. Figure 5 provides an example of a Haddon Matrix under development by the authors (S.L.) to guide a programme for prevention of paediatric burn injuries.

The Haddon Matrix is a means of understanding traumatic injury that examines aetiological relationships instead of using descriptive terms. This approach is essential to transition from the concept of burn injury as an 'accident' that is unpreventable, to the concept of injury being related to factors that can be modified. For example, we shift the concept from a child 'accidentally' turning on the hot water in a bathtub, to an unsupervised (change supervision) child turning on the hot water (control the water temperature at the boiler, or with a mixing valve). In using this approach, it is important not to assign blame, but to recognize the resources needed or factors that influence the cause of the traumatic event. For example, by examining the reasons why the child was unsupervised (parental mental health, other young siblings in the family, overstretched parents) and how to control the hot water (turn down the water heater, child-proof lockable tap, preset water temperature at the tap), programmes can be established to address them.

To be successful, regional burn prevention programmes should concentrate on factors that influence the incidence of burn injury in the local environment, knowledge dissemination strategies and data collection methods to identify the areas of focus and evaluate programme effectiveness. For example, in some countries, factors such as loose clothing and cooking on open fires are important areas of focus. In other regions, the occurrence of electrical burns has increased substantially as industrialization has taken place. Prevention strategies can also be applied at a more personal level. For example, a review of injuries sustained by firefighters identified that burns occurred in common patterns associated with gaps in equipment, which can guide future equipment modifications and improvements. Development of prevention programmes must also take into consideration knowledge access and engagement with the selected media. For example, strategies to 'gamify' knowledge acquisition using mobile phone applications could reach a wider audience than a television commercial in some regions and for certain age groups. Literacy patterns, cultural appropriateness (which is particularly challenging to address in countries with more than one official language and no clear common language) and access to the recommended technologies can be barriers to this approach; for example, it is not possible to avoid open fire cooking until a cheap, safe, readily available alternative is identified. Furthermore, correction of one risk factor might introduce another; for example, use of liquefied petroleum gas burners as an alternative to open fire cooking without proper training can result in more injuries. Robust data collection and reporting and evidence-based decision making is needed to provide the information to drive this process. Although this information is more readily available in high-income countries, the countries with the highest rates of burn injury may not currently have the infrastructure to collect these data. To address this need, the WHO has started the Global Burn Registry to aid data collection in low-resource settings and address this knowledge gap.

Diagnosis

Accurate assessment of the severity of a burn injury is paramount because it forms the basis for all subsequent treatment decisions, triage plans and assessment of medical futility. Whenever possible, decisions about how to proceed after diagnosis and screening should incorporate patient preferences and expectations about quality of life. Optimal assessment of the severity of burn injury must involve a systematic methodical approach, such as that described in course materials for the Advanced Trauma Life Support (ATLS) by the American College of Surgeons Committee on Trauma, Emergency Management of the Severe Burn (EMSB) by the Australian and New Zealand Burn Association, and Advanced Burn Life Support (ABLS) by the ABA. Such diagnostic approaches must involve an orderly sequential evaluation (phase I of management), including the primary and secondary survey, that considers the need for further consultation and possible transport to optimize outcomes at specialized centres.

Primary survey

The primary survey at the scene of the injury or in the emergency department comprises immediate standardized assessment - in this order - of: the airway, breathing, ventilation, circulation and cardiac status, disability, neurological deficit, gross deformity and degree of exposure (requiring complete disrobing to enable identification of associated injuries). To avoid hypothermia, especially in children and the elderly, this assessment must be conducted while maintaining a warm environment. A preliminary estimate of the size of the burn using Lund and Browder diagrams for children and, for adults, the Rule of Nines (Fig. 6) is essential at this time because the amount of oral or intravenous fluid resuscitation is based on the burn size (percentage TBSA). Given the life-threatening nature of respiratory failure, assessing burn severity must also include early determination of whether the patient has a smoke inhalation injury (Box 2). Exposure to products of combustion in a closed space, facial burns and soot in the oral cavity do not in themselves indicate an inhalation injury but strongly necessitate further physical examination of the posterior pharynx for evidence of thermal injury, including mucosal erythema, sloughing and swelling or soot in the vocal cords. Clinical signs such as stridor, hoarseness, carbonaceous sputum and dyspnoea also suggest inhalation injury and warrant further work-up. However, even in resource-rich settings, in the majority of patients, diagnosis is made primarily on clinical appearance.

In adults, the 'Rule of Nines' (that is, using multiples of 9) is used to assess the proportion of the total body surface area (TBSA) affected and to help guide immediate treatment decisions, such as amount of fluid resuscitation, that are based on the size of the burn injury. However, owing to different head to body size ratios, the proportion of the TBSA affected in children is estimated differently; the Rule of Nines is inaccurate. Another challenge is the body habitus. For example, the Rule of Nines and the estimate that each hand comprises 1% of the TBSA are inaccurate in patients who have obesity or cachexia. The body areas are separated by colour and the numbers are percentages of the TBSA and include front and back coverage; for example, '32' in the diagram of the trunk relates to the chest, abdomen and back that make up 32% of the TBSA. The hand, including the palm, fingers and back of the hand, represents 2% of the TBSA and can be a useful tool for quick calculation of the size of a burn - especially irregularly shaped scald burns.

Secondary survey

The secondary survey, often in the emergency department or the burn centre, includes laboratory analyses and imaging, as indicated by evidence of other trauma or comorbidities. The secondary survey includes ensuring adequate tetanus prophylaxis, as burns are open wounds. The initial laboratory analyses in patients with burn a size of ≥15%TBSA include complete blood count, electrolyte assessment, coagulation profile and arterial blood gas measurement. In patients with suspected smoke inhalation injury, normal oxygenation and chest radiographs do not rule out the diagnosis as the pulmonary inflammatory response may take time to develop.

The secondary survey importantly includes a definitive evaluation of the burn severity including depth (Fig. 1) and size based on TBSA (Fig. 6). Understanding which burn wounds will heal and which will benefit from early excision and grafting can be challenging, owing to a lack of widely accepted validated noninvasive imaging techniques to estimate burn depth. Furthermore, estimates of burn size and depth made before admission to a burn centre - and even by experts - have consistently been shown to be inaccurate in spite of standardization attempts and the availability of tools such as the Lund and Browder diagrams and the Rule of Nines. Given the unreliability of burn size and depth assessment by clinicians who are not burn experts and the expense and logistics of transferring patients to higher levels of care, development of creative technological solutions for consultations is essential. New approaches in development include the use of computer-assisted programs to improve burn size estimation and enable focused and accurate telemedical consultation. Telemedicine programs encompassing either real-time video conferencing or store-forward pictures of the wounds provide an option for burn experts to facilitate triage by assessing injury severity prior to transfer. Precise burn depth assessment can be challenging especially in patients at extremes of age and with thinner skin. To address this issue, several innovative devices incorporating laser Doppler imaging, harmonic ultrasound imaging, optical coherence tomography and high-resolution infrared thermography have been developed and introduced into preclinical and limited clinical trials. Validation of these modalities requires both comparison of digital images with histological specimens of burned skin as well as objective correlation of the data with burn depth assessments by clinical experts. Unfortunately, the expense of integrating these into daily practice has presented a barrier to widespread use.

Screening

The concept of screening in a patient with a burn injury is multifaceted given the complexity of the different physical and psychological elements involved and our growing understanding of functional recovery after injury. For example, screening for multidrug-resistant microorganisms early after admission can inform antimicrobial choice in the event of an infection. Standardized predictive formulae can provide estimates of the risk of developing complications such as acute kidney injury and ARDS after burn injury, but success with their use has been variable. The optimal smoke inhalation screening tool should be highly sensitive to avoid airway loss or respiratory failure due to missed diagnosis but must also be specific to avoid unnecessary intubation. Indeed, unnecessary intubation is associated with increased rates of ventilator-associated pneumonia and other upper airway complications including vocal cord and tracheal injury. Identifying which patients require early intubation to prevent loss of airway after smoke inhalation represents an ongoing area of equipoise. Unfortunately, biomarker identification for the development of predictive clinical decision support tools has so far eluded us.

Management

Over 95% of fire-related burn deaths occur in low- and middle-income countries, where centres with burn expertise are sparse (Box 3). Even in the USA, access to specialized burn care has been repeatedly found to be limited, with up to 20% of the US population living >2 hours by ground or air from a verified burn centre. As such, training of health-care workers at basic-level facilities is essential to reduce death and disability from inadequately treated burns, especially under austere and low-resource conditions, including in low- and middle-income countries, war zones and mass-casualty incidents.

For all minor burn injuries, the steps of first aid (Box 4) are sufficient treatment; these steps are also recommended for the immediate treatment of more severe burn injuries. Indeed, in patients with more severe burns, phase I of the acute management includes the aforementioned primary and secondary surveys. After the acute management phase, four major components of care follow upon admission to a burn centre: resuscitation, burn wound coverage, critical care and/or supportive care, and rehabilitation (Fig. 7). Another important aspect of planning burn care is predictors of outcome. One of the unique characteristics of burn injury is its reliable dose-response between the extent of the burn and outcome (that is, the larger the burn size, the worse the outcome). The Baux score combines the effect of the extent of the burn injury with patient age, and was described half a century ago. The Baux score is used to predict mortality following burn injury, with patient age and burn size (percentage TBSA) being equal contributors to predicted mortality. The Modified Baux score includes inhalation injury (present or absent), and is now the most widely accepted outcome predictor to date; it is applicable to patients of a wide range of age, including children.

Burn outcomes should be validated against benchmarks and this concept was introduced by a multicentre trial (Glue Grant study). More importantly, the ABA is actively working on a prospective database that will assess outcomes and compare the outcomes of a single centre against those of other burn centres within the ABA burn centre community, enabling objective evaluation of outcomes following burn injury.

Box 3 Burn care in low-resource areas

Special considerations

Paediatric patients

In general, the care path of a paediatric patient with a burn injury is similar to that of an adult. The initial approach is based on the principles of primary and secondary survey. However, the predominant differences in the care of a paediatric patient with a burn injury stem from the fact that, in children, the head represents a larger proportion of the TBSA and from the reduced overall physiological reserve of children. Newborn babies, for example, have a bigger head to body ratio with correspondingly smaller legs. Additionally, because children have limited glycogen stores, they should be given weight-based maintenance intravenous fluid in the form of 5% dextrose in 4.5% normal saline in addition to burn resuscitation fluid. The most important aspects of the care of a paediatric patient, as in adults, are to close the wound, treat hypermetabolism and plan for the long-term outcome.

Elderly patients

Phase II: resuscitation

Burn shock, which combines hypovolaemic, distributive and cardiogenic features, occurs in the initial 48 hours secondary to the dysregulated inflammatory response after burn injury, and is characterized by a diffuse capillary leak wherein losses of proteins, electrolytes and plasma further reduce intravascular volume, impair end-organ perfusion and produce cellular dysoxia (aberrant cellular oxygen metabolism). As discussed previously, a number of factors contribute to the magnitude of the response, the combination of which contributes to considerable complexity and requires an individualized approach. In general, those with burn sizes >20%TBSA will require fluid resuscitation. However, patients with smaller burns may also require fluid resuscitation under circumstances in which other insults exists, such as electrical injury, smoke inhalation or concomitant trauma. The ultimate goal of fluid resuscitation is to maintain end-organ perfusion while avoiding resuscitation-related morbidity such as extremity, abdominal and orbital compartment syndromes (conditions characterized by acute increases in pressure in specific compartments, requiring emergent decompression to avoid cell death).

Colloids: albumin or plasma

A recent meta-analysis of burn resuscitation outcomes indicated that albumin-augmented resuscitation with 5% albumin as early as 8 hours after burn injury in those who are projected to receive a massive resuscitation (defined as those needing >1,500 ml per hour for 2 hours or >250 ml/kg in 24 hours) enables the infusion of a lower total volume of crystalloid in the first 24 hours. A previous randomized controlled trial has shown that the use of plasma, an alternative to albumin, reduces 24-hour fluid volumes, decreases intra-abdominal pressure and reduces subsequent development of abdominal compartment syndrome compared with administration of crystalloid. Additionally, plasma seems to have important advantages related to preserving the microvascular endothelium by maintaining the cell wall glycocalyx compared with other resuscitative fluids. Unique to the use of plasma are the known risks of pooled blood product transfusions, which include transfusion-related lung injury. However, recent improvements in screening have mitigated this risk.

Vitamin C

The antioxidant and reactive oxygen scavenging ability of vitamin C prompted interest in its use during burn resuscitation. Initial animal studies were favourable, with decreased fluid requirement, oedema and capillary leak, and reduced lipid peroxidation, compared with crystalloid alone. In a small randomized trial in humans, high-dose vitamin C reduced 24-hour crystalloid fluid volumes and improved some ventilation and oxygenation parameters without a significant difference in mortality. Recent clinical data on vitamin C in patients with ARDS also seems positive, suggesting that vitamin C might have a beneficial effect in patients with burn injury. However, conflicting data on renal safety and falsely elevated point-of-care glucose levels have prevented adoption of resuscitative vitamin C and highlight the need for robust clinical trials of its use in patients with burn injury.

Blood purification strategies

Blood purification strategies are appealing because they aim to remove circulating inflammatory mediators. Indeed, retrospective studies of therapeutic plasma exchange (TPE) have demonstrated reduced resuscitative volume needs, improved mean arterial blood pressure, increased urine output and decreased lactate levels. Unfortunately, a single TPE treatment requires high volumes of either donor plasma or colloid, and consequently TPE is used by few centres due to cost and the resources required.

A more practical alternative to TPE may be haemofiltration. High-volume haemofiltration (HVHF) (doses >70 ml/kg per hour) may benefit patients in shock and can be used as an adjunct in those with burn shock. A recent multicentre trial in patients with burn injuries demonstrated that HVHF was effective in reversing shock and improving organ function. Another trial demonstrated that HVHF decreased the incidence of sepsis, duration of vasopressor treatment needed and mortality in patients with severe burn injuries. This study demonstrated a significant decrease in circulating inflammatory markers in the HVHF group compared with controls. These blood purification strategies may not be practical in a resource-constrained environment.

Phase III: burn wound coverage

In the first half of the 20th century, burn injuries were managed expectantly and, unfortunately, patients frequently succumbed to overwhelming sepsis while waiting for their burn eschar (scab) to slough, or for their open wounds to close by secondary intention (that is, allowing the burn injury to heal on its own). Topical antimicrobials slow the septic process and have been instrumental in preventing those with larger, more-severe burns from succumbing to sepsis. However, improvements in survival and shortened length of hospital stay were only realized after the introduction in the 1970s of early excision and grafting.

Early excision, the gold-standard treatment, attenuates the hypermetabolic state and removes the biological nidus for infection, thereby reducing the risk of burn wound sepsis. Early autografting (that is, where skin is transplanted from a healthy (donor) site on the patient to the burned part) then builds on these improvements by rapidly closing excised wounds, further reducing infection risk, decreasing pain and enabling earlier mobilization. However, the optimal timing for 'early' excision is debated; for example, whether a patient undergoes surgery during the first day after burn, or 2-3 days later after completion of the 24-hour resuscitation, remains unclear. Regardless, the principle of excision and grafting is clear: close the wound. If a patient has good donor skin sites and is stable in resuscitation, autografting should be conducted while the wound bed is fresh and uncontaminated. If there are concerns about the viability or bacterial load on the wound bed and/or the patient's stability, allografting (that is, using skin from another person (usually cadaveric)) should be used to temporarily cover the debrided wound. The surgical approach is to leave no full-thickness burned tissue behind and debride down to viable tissue.

Although many surgeons believe excising and covering the largest areas, such as back and trunk, should be performed first, in some centres the face and hands are covered first before transitioning to the body. We (M.G.J., S.L. and N.S.G.) believe that excision and coverage of the back and trunk have priority followed by the joints, legs and arms. Occasionally, valuable uninjured patches of potential donor sites can be 'saved' for use on important functional and cosmetic areas such as the hands and face. Our approach is based on the hypothesis that large burned areas contribute most to and augment hypermetabolism and inflammation and are, therefore, directly linked to poor outcomes. Once the larger areas have been covered, 'healed' skin can be harvested for delicate areas such the face, eyelids and hands; although cosmetic outcomes may not be optimal (owing to the reduced thickness of the skin), later reconstructions can be addressed once the patient is stabilized and out of hospital. Regardless of the order, skin grafts are usually meshed (that is, processed to 'punch' apertures onto the graft, allowing it to expand in size and permit ingress of topical agents and egress of serous fluid or blood) for the back trunk, legs and arms; sheet grafts (that is, donor sites that are excised and used as-is) are used for cosmetic areas such as the hands, face and neck.

Autologous split-thickness skin grafts

The gold-standard burn coverage is autologous split-thickness skin grafts (STSGs). Uninjured skin is harvested using a dermatome instrument, and the STSGs are transferred to an excised burn site. In burns covering >30-40%TBSA, available uninjured skin may be insufficient to allow definitive coverage in a single operation. In such cases, STSGs are frequently meshed and expanded to cover a larger excised area (Fig. 8); this approach trades aesthetic and functional outcomes for rapid closure and reduced donor site morbidity. For larger burns, usually >60%TBSA, mesh ratios >1:3 may be required, but are very technically challenging to use owing to fragility of the meshed skin, often resulting in substantial portions of the 'grafted' areas remaining open, necessitating overgrafting with allograft to functionally close the wound. A solution to this issue is provided by Meek meshing technology, which expands the skin graft up to a ratio of 1:9 (Fig. 8). The expanded mesh can cover larger areas and the morbidity of poor scarring (see below) can be alleviated by combining the Meek technique with a dermal regenerative matrix and/or spray of a cell suspension, which can assist in closing the wound.

For a patient with a severe burn injury to survive, the burn wounds need to be excised and covered. Temporary measures using allograft or various biological substitutes are available but, at this time only the patient's skin (autologous) can permanently accomplish coverage. Several graft methods are available to cover burn wounds using autologous skin. a | Sheet grafts are the most aesthetically pleasing but require a lot of skin to cover wounds and, therefore, are usually reserved for small burns or for skin grafts to complex and important areas such as the face, hands and breasts. Full-thickness sheet grafts are reserved for smaller defects (usually lower eyelids and re-occurring upper eyelids) and play a more important part during the reconstructive phase. These are harvested using a dermatome. A split-thickness graft can be placed as a sheet graft or used for meshing. b | Use of meshed split thickness skin grafts is usually the method of choice to cover larger areas. The goal of meshing skin is to expand the donor skin to obtain greater coverage; skin can be meshed in ratios of 1:1.5, 1:2, 1:3, 1:4 or 1:6. Although increased meshing increases the coverage size, meshed skin becomes increasingly fragile. c | An alternative technique is the Meek technique, in which skin squares can be spread out to a large extent and added to the wound bed, covering large areas (up to a ratio of 1:9). This technology is reserved for extensive burns for which donor sites are sparse. d | A freshly meshed split-thickness skin graft (left) and its healing over time (right). Images in part c courtesy of R. Nijlant, Humeca B.V., Netherlands.

Artificial skin substitutes

In cases in which autologous skin is insufficient, thin and/or frail, artificial skin substitutes can be used (Fig. 9). Composed of various biological, synthetic and biosynthetic materials, artificial skin substitutes can provide either temporary or permanent coverage of open wounds. In manufacturing skin substitutes, the scaffold is always taken into consideration. Scaffolds are 3D structures that act as a substitutes for extracellular matrix, providing the framework for neovascularization, cell adhesion, proliferation and differentiation. In addition, growth factors and cells can be added to the scaffold to enhance healing. Many variations are available, although all skin substitutes should demonstrate the following: resistance to shearing forces when handled; structure and function of normal skin that protect from fluid loss and infection; ability to act as a scaffold and enable cells to proliferate for wound healing; non-inflammatory, nontoxic and non-immunogenic composition; and affordability. For example, Skin TE (Polarity) is a technology where a skin biopsy is digested, sent to the manufacturer and then incorporated into a gel that contains epidermal and dermal elements, as well as skin appendages, that is directly applied to the burn wound. Additionally, there are different classification systems for skin substitutes. The Davison-Kotler classification categorizes skin substitutes based their composition (cellular or acellular), whether they are single layer or bilayer, their structure (epidermal (derived from human placenta), dermal or composite (for example, a composite skin substitute composed of a bovine collagen, glycosaminoglycan bilayer and with a silicone layer that acts as the epidermis)), the type of biomaterial used (synthetic, biosynthetic or biological), and the duration of cover (permanent, semi-permanent or temporary).

Skin substitutes have undergone development over the past decade from temporary materials used to induce wound healing towards permanent tissue-engineered materials that offer definitive healing. This figures reflects a summary of some promising skin substitutes or treatments to induce wound regeneration. a | The common principle of skin substitutes is to the deliver proteins, growth factors and/or cells via a delivery vehicle or matrix that will then be integrated into the wound and form new autologous skin. b | ReCell is not a composite skin substitute, but a device that sprays a cell suspension of skin cells including epithelial cells, fibroblasts melanocytes and other resident cells onto the wound or grafted area to improve healing and scarring. c | The skin gun (RenovaCare) delivers autologous cells and/or stem cells to wounds to improve wound healing. Although this is a promising approach, no clinical trials or substantial evidence have been reported that indicate that the skin gun will enter the clinical arena. d | Recently, a hand-held device has been designed that can print 3D autologous skin. This device is based on microfluidic technology and can deliver cells specifically and accurately in an 'ink', which serves as a matrix. e | A skin substitute using autologous cells from a healthy donor and a matrix shows self-assembly of dermal and epidermal structures. Although the ideal tissue-engineered skin derivative has not been described, this technology will change the way burn care is delivered and will improve acute and long-term outcomes. Image in part b courtesy of Avita Medical. Image in part c courtesy of RenovaCare Inc. Part d provided by A. Guenther (University of Toronto, Canada), and adapted with permission from ref., Royal Society of Chemistry. Panel e is reprinted from ref., CC BY 4.0 ( https://creativecommons.org/licenses/by/4.0/).

Table 1 Example commercially available skin substitutes

Scarring

A central part of the long-term outcome after burn injury is scarring; scars are optimally flat and minimally discoloured. After burn injury, normal scars are characterized by increased collagenase activity, lower TGFβ expression and macrophages with a predominantly M1 phenotype, which promotes T helper 1 cell subsets. However, burns can result in the development of a pathological scar. In particular, deep partial-thickness or full-thickness burns take longer to heal, which results in an increased risk of pathological scarring, especially when combined with a prolonged acute inflammatory phase. Pathological scars are characterized by excess collagen deposition, resulting in a thick, non-pliable defect that can cause itch, pain and contractures, limiting functionality.

Two primary subtypes of pathological scars occur after thermal injury - hypertrophic scars and keloids. Hypertrophic scars are more common in burn injuries and occur in 30-90% of patients with burn injuries. Delay (>3 weeks) in wound healing increases the risk of hypertrophic scarring, which is typically restricted to the confines of the initial injury and does not recur after excision. Decreased collagenase activity in hypertrophic scars leads to perturbed collagen production and degradation, resulting in bundles of crosslinked collagen oriented parallel to the epidermal surface. In particular, mature type I collagen expression is reduced and type III collagen is over-synthesized. Additionally, hypertrophic scars have higher TGFβ and PDGF expression, macrophages with a predominantly M2 phenotype, which promotes T helper 2 cell subsets, and increased myofibroblasts compared with normal scars. Hypertrophic scar colour ranges from hypopigmented to hyperpigmented.

By contrast, keloid scars are occur mainly in those with darker skin pigmentation and develop several months or years after the initial insult. Keloid scars are raised fibroproliferative lesions composed of disorganized bundles of type I and type III collagen. They exhibit tumour-like properties and are characterized by a dependence on anaerobic glycolysis to produce metabolites necessary for cell proliferation. Furthermore, keloid scars demonstrate uncontrolled growth, invasion of normal tissues and recurrence despite treatment. Importantly, persistence of the inflammatory and proliferative phases of wound healing are likely to predispose patients to keloid scarring and results in a scar that grows beyond the initial burn wound. Keloid scar pigmentation can be increased or decreased compared with normal skin but is typically increased compared with the normal 'baseline' skin pigmentation of the patient.

Both keloid and hypertrophic scars detrimentally affect quality of life and are managed with a combination of intralesional pharmacological therapy, contracture release, scar excision, scar massage and laser therapy depending on the scar presentation.

Phase IV: supportive care

Phase V: rehabilitation

Not surprisingly, the psychosocial cost of severe injury is high on patients and their families. For this reason, it is advisable to fully integrate social workers, vocational counsellors and psychologists into the multidisciplinary burn team. Phase V has been neglected or even ignored for some time; it was only recently that we learned about the essential importance and value of good quality long-term outcomes after burn injury.

Quality of life

Health-related quality of life (HRQOL) is a multidimensional concept that reflects an individual's perception of how a condition affects health-related domains for physical, psychological, emotional and social wellbeing that considers quality of life in relation to other health-related components (personal and environmental factors). HRQOL is an increasingly studied outcome after burn injuries, in both the short and long term. Indeed, several tools can assess HRQOL in adult patients after burn injuries. For example, the Burn-Specific Health Scale-Brief (BSHS), Medical Outcomes Survey Short Form-36 (SF-36) and EuroQol (EQ-5D) questionnaires are often used. The use of both burn-specific and generic instruments provides insight into consequences of burn injuries in themselves and also in reference to other conditions. However, emerging data cast doubt on the psychometric quality of several burn-specific instruments. For example, the SF-36 domains were shown to be more sensitive to change than BSHS-B domains 1 month after burn injury in one study. In addition, the specific psychometric properties of the BSHS-B are not yet available, including test-retest reliability (whereby repeated measurements over time show similar results in unchanged patients), validity of hypothesis testing and item-total correlations (whereby all items of a domain measure the same construct). Thus, the optimal burn-specific instrument is not yet available. Several new instruments, including the Brisbane Burn Scar Impact Profile, the CARe burn scale and the LIBRE survey, warrant further validation. Of special note, instruments developed for surveying patients in high-income countries may not pertain to burn survivors in lower income countries or those living in rural or remote areas.

Models that can predict recovery of quality of life after burn injury can inform patients and health-care professionals on the expected outcomes, identify patients with expected suboptimal outcomes and enable the tailoring of treatment to optimize outcomes. Also, such models can be used for benchmark purposes. Indeed, prognostication models for HRQOL after burn injury have been developed for use in children and adolescents. Spronk et al. have recently developed a prognostication model for use in adult patients (submitted for publication), which should be further validated in different burn populations.

Adults

Two studies have indicated that women report worse HRQOL 1 year and 10 years after a burn injury, but other reports suggest less consistent correlations between female sex, pain and post-burn substance use disorder and poor HRQOL. Furthermore, although HRQOL improves over time overall, some domains, including physical and emotional role participation, anxiety, depression and pain or discomfort, demonstrate delayed return to baseline after a burn injury. Compared with the general population, patients who sustain severe burn injuries report lower quality of life, especially related to anxiety and depression, and pain and discomfort.

With increasing focus on post-intensive care syndrome, an increasingly understood condition in which critically ill patients are recognized to have longstanding physical and cognitive conditions, health systems must consider the long-term effects of hospital-acquired complications on functional recovery. Patients with burn injuries who experience a urinary tract infection, venothromboembolism, pulmonary complication or acute kidney injury during hospitalization reported lower physical component summary scores on the SF-12 for up to 24 months after the injury. Although in most quality of life studies, follow-up has been limited to 24 months after burn injury, emerging data suggest that patients struggle with functional recovery and HRQOL for as long as 10 years after the injury is sustained. As we become more familiar with the issues that drive long-term functional recovery, use of additional instruments such as Satisfaction with Life (SWL, which measures global cognitive judgments of satisfaction with life), Satisfaction with Appearance (SWAP, which measures body image dissatisfaction in persons with visible disfigurement), and the Community Integration Questionnaire (CIQ, which measures levels of community integration) provide alternative options for assessing patient perceptions of their HRQOL.

Children

In children after burn injury, the Burns Outcome Questionnaire for children 0-5 years of age (BOQ ₀₋₅) and the BOQ ₆₋₁₈ (ref.) are valuable resources for quality of life assessment. The BOQ ₀₋₅ consists of ten scales, ranging from play to appearance, whereas the BOQ ₆₋₁₈ consists of 12 scales addressing physical functioning, emotional health and social functioning including school re-entry. However, the domains in these questionnaires correlate poorly with those of the WHO International Classification of Functioning, Disability and Health, suggesting that further development and validation of the BOQ surveys is required. Indeed, few studies have addressed HRQOL in paediatric patients after burn injuries, especially in young children up to 4 years of age. Burn size and depth, length of hospital stay, presence of facial and hand burns, comorbidity and long recovery time predict suboptimal HRQOL following burn injury in children. Studies in paediatric patients have shown improvements in HRQOL over the first 6 months after injury. However, some domains, including 'concern/worry' and 'appearance' in young children and 'appearance' and 'parental concern' in children 5-18 years of age, show persistent lack of improvement. Thus, children and adolescents seem to have continuing problems with changes in appearance, and parents have concerns related to their children after burn injury.

Assessing quality of life in children, especially those <12 years of age can be challenging. However, using parents as surrogates may in fact not reliably predict individual perception of quality of life. For example, using the validated questionnaire designed for adolescents (BOQ), adolescents and parents' assessments of appearance, itch and school re-entry differed. Thus, results on parent-reported quality of life should always be interpreted with caution and should ideally be checked with the child.

Employment and school after injury

Return to work and school are acknowledged to be important outcomes after burn care. Beneficial for individual health, social and societal aspects for individuals, work is not only a source of income but represents evidence of community integration and participation. Two systematic reviews showed that 66-74% of burn survivors returned to any form of work 1-24 months after the burn injury. Several factors predicted return to work, including burn severity, length of hospital stay, age, psychosocial and work-related factors. For example, one single-site study in Europe showed a high return to work rate of 92% in their population, in whom the mean burn size was 8%TBSA; systematic reviews of studies in patients with burn sizes in the range 18-22%TBSA showed lower return to work rates. Regardless, the economic burden of burn injuries is substantial; in one European study the mean number of days absent from work was 59.3 per patient and the mean cost due to loss in productivity was €11,916 per patient (ref.).

No data have been published on return to work or school after burn injuries in low- and middle-income countries, although data are emerging. One important issue related to employment is our definition of 'work': in many low-resource communities, individuals have a subsistence form of living in which work may not actually involve a paid job.

Secondary conditions

Recent publications have addressed long-term medical consequences of burn injury. In a cohort of patients with burn injury in Western Australia, linked hospital and death data indicated that both minor and severe burn injuries result in increased long-term morbidity and mortality in all age groups, as well as increased risk of hospital re-admission, long-term hospitalization and prolonged hospital stay for musculoskeletal diseases. Adult patients with burn injuries and patients with trauma showed elevated rates of post-injury admissions for cardiovascular events and an increased incidence of diabetes mellitus-related admissions during the first 5 years after injury. Children with burn injury had a 1.6-times greater rate of long-term mortality than children with no injury.

Outlook

What will the future of burn care bring? We believe that burn care must change to adjust to the challenges ahead.

Epidemiology and prevention

In the area of epidemiology, it would be important to know what the exact burden and effects of burn injuries are globally. To better identify needs, treatment, prevention and knowledge translation, capturing data more accurately is imperative, which should then lead to the development of strategies that translate this knowledge into actions. We believe that global agencies such as the WHO and the International Society for Burn Injuries should be integral to initiatives. Indeed, the WHO is piloting an important check-list initiative that does not require considerable resources for data structuring. How these are translated into practice depends on the local circumstances, needs and resources.

Development of international burn registries should facilitate better understanding of burn injury aetiologies in many vulnerable populations. Cooperation between non-governmental organizations, national research networks, national health ministries and local communities to collect and analyse data about specific local aetiologies should increase awareness and knowledge, which could be subsequently applied to preventing burns. These data should include information on number of injuries, at-risk individuals and risk factors to identify vulnerable populations that could be targeted with burn prevention strategies that reflect local culture and availability of resources.

Diagnosis

Prognosis

Sepsis was prospectively predicted with 100% accuracy during the first surgery using flow cytometry analysis of adipose tissue in a recent study. Although these results are very promising, the study only included 37 patients and this technology cannot easily be translated to every burn centre. However, several other studies are also investigating prediction of sepsis and organ function after burn injury, and it seems only a matter of time until we are able to predict sepsis, multiple organ failure and death in patients. Once we can achieve accurate prediction, the challenge will be to change the trajectory. Some factors are being studied in a holistic approach to predict outcomes in the Glue Grant trial, a multicentre study examining genomic and proteomic changes after burn injury that is producing substantial data. Although the Gluegrant has completed its study, there are still studies and data resulting from this initiative that will enhance our knowledge on personalized medicine.

Acute care

Aspects of burn care also need further development, including resuscitation. Adequate resuscitation in patients with burn injury is challenging because questions abound regarding volume, composition, formulae and outcome measurement. An emerging technology is the 'burn navigator', which determines resuscitation parameters from urinary output data as a closed loop - adjusting fluid infusion volume automatically based on prior algorithms. This technology certainly has potential given that organ function such as cardiac function, and liver and kidney perfusion can be integrated, but it does require optimization. For example, urinary output is not ideal as it depends on several variables and can be misleading in determining resuscitation parameters (see above).

Another area of care that requires improvement is wound coverage. To overcome the need for uninjured donor skin in autologous STSG, artificial skin substitutes have been introduced to the market, and include TransCyte, CEA, cultured skin substitutes and various others (Table 1). However, their application is limited in patients with burn injury due to cost, labour time and availability. Nonetheless, these products have changed the way we think about tissue-engineered skin. Currently, various approaches could change the treatment paradigm for burn wound care including stem cells, stem cell 'guns' and 3D printing of autologous cells to recreate a patient's skin that would reduce the risk of scarring and the need for donor sites, moving closer to our goal of no scar, no pain.

Long-term care

The response to a burn injury is very complex, and so is the approach to its care. Although we have made some important strides in terms of survival following a burn injury, burn care needs to change over the next decades. New technologies need to be adopted in all phases of the recovery process to further improve burn outcomes, acutely and in the long term.

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Burn injury - Nature Reviews Disease Primers

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Burn injuries, particularly severe burns, are accompanied by a metabolic, immune and inflammatory response that can be challenging to manage, often leading to multiple organ failure or even death. This Primer discusses aspects of burn injury, from prevention to care of patients from both an acute and a long-term perspective.

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Useful resource for lay-understanding of burns.

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Complete Anatomy | advanced 3D anatomy platform

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A burn occurs when the skin or tissue is damaged by factors such as heat, radiation, chemicals and electricity. Symptoms of a burn include red or peeling skin, blisters, swelling, pain and white or charred skin.

Burns can be classified by their severity. First-degree burns are the mildest and most superficial, only affecting the epidermis of the skin. Second-degree burns affect the epidermis as well as some of the dermis. Third-degree burns are deeper, damaging both the epidermis and dermis. Finally, fourth-degree burns are the most severe, penetrating the epidermis, dermis and deeper tissue such as muscle and bone. There is often no pain with fourth-degree burns as the nerve endings are damaged.

In response to a burn, the body will initiate an inflammatory response to heal the wound. For example, basophils and mast cells release histamine which will cause vasodilation and increased vascular permeability. This will in turn allow increased blood flow and white blood cells to the burn site. Phagocytic white blood cells are beneficial to the wound as they "eat" bacteria, foreign particles and cell debris. There will also be an increase of other chemicals such as cytokines which help mediate the inflammatory response.

With a large or severe burn, the body's inflammatory response can sometimes be too intense and act as a detriment to recovery. For example, the body can swell due to accumulation of fluid in a condition known as edema. A serious burn can also cause the patient to enter a life-threatening state of shock in which there is a drop of blood pressure and therefore insufficient oxygen supply to the body.

More severe burns, such as third-degree and fourth-degree burns, can cause permanent changes to the affected area such as scarring. After the inflammatory phase, the burn site undergoes a proliferative phase. This involves the growth of new blood vessels and the development of new connective tissue called granulation tissue. The granulation tissue is remodeled, forming a scar on the skin.

Burns can lead to many other health issues. For example, there is a major risk of infection at the burn site. Burns can damage the skin's protective barrier allowing foreign bodies to enter the body more easily, leading to infection. It is therefore important that burns receive the proper treatment and care.

Burns can also affect your mental health in the long-term. People who have suffered from burns have reported experiencing anxiety, stress, depression and post-traumatic stress disorder (PTSD). This is especially the case for those who have experienced major burns and scarring.

It is important that burns are treated correctly. Treatment will vary depending on the cause, severity and location of the burn. In the long-term, the patient should receive sufficient follow-up care, especially in terms of mental health.

To learn more about the layers of the skin which can be damaged by burns, you can check out our Skin Detailed Model in Complete Anatomy.

If you don't have a Complete Anatomy account, be sure to try it for yourself with a FREE 3-day trial.

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Understanding a Burn Injury | Complete Anatomy

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3D4Medical is an award-winning 3D technology company that specializes in medical, educational and health & fitness software for student/patient education and professional reference.

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Serves as a valuable tool for comprehending lymphoedema, its origins, and its unique characteristics compared to other oedema forms.

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What is lymphedema?

Lymphedema is an abnormal collection of lymphatic fluid in the tissues just beneath the skin. This swelling commonly occurs in the arm or leg, but it may also occur in other body areas including the breast, chest, head and neck, and genitals. Lymphedema develops when a body region, where lymphatic vessels and lymph nodes are missing or impaired, becomes overloaded with lymphatic fluid.

Lymphatic fluid is normally transported in our body by an extensive network of vessels and nodes. When these vessels are damaged or malformed, there is a risk that lymphatic fluid will not be adequately transported and may result in fluid backing up in body tissues. When fluid congests in the tissue, swelling occurs. This swelling is called lymphedema.

If the condition is left untreated, it leads to progressive tissue swelling over time. Lymphatic fluid congestion also reduces healthy blood flow to the tissue, interferes with wound healing, and enables bacteria to grow, which increases the risk for tissue infections.

Lymphedema should not be confused with other types of edema resulting from venous insufficiency, cardiac conditions, kidney failure, or other inflammatory processes. These swelling conditions are systemic, while lymphedema occurs only in the specific regions of the body.

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What is Lymphedema? - National Lymphedema Network

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Lymphedema is an abnormal collection of lymphatic fluid in the tissues just beneath the skin. This swelling commonly occurs in the arm or leg, but it may also occur in other body areas including the breast, chest, head and neck, and genitals.

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Complete Decongestive Therapy - Gold Standard Rx

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Complete Decongestive Therapy - Gold Standard Rx

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Gold standard Rx of lymphoedema.

Two phases, 1) the therapist reduces the swelling and improves skincare, 2) maintenance of above by the patient while incorporating it into their daily lives.

Phase 1

Manual lymph drainage or MLD

Multi-layer, short-stretch bandaging.

Drainage exercises.

Meticulous skin and nail care.

Compression garments,

Patient education in self-care.

Phase 2

Self-Manual Lymph Drainage (S-MLD).

Lymphatic exercises e.g, a) at home, b) in the pool.

Meticulous skin and nail care.

Compression therapy e.g, a) self-bandaging, (b) compression garments, c) garments with velcro, d) pneumatic pumps.

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The Gold Standard Treatment for Lymphoedema – The O’Reilly Centre

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What is the “Gold Standard Treatment” for lymphoedema?

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Pit stop educational resource on lymphoedema.

Covers

- Background and Context

- Diagnostics

- Treatment

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Lymphoedema is an abnormal accumulation of protein-rich fluid (oedema ) in the interstitium most often in the arm(s) and/or leg(s), and occasionally in other parts of the body. This causes chronic inflammation and reactive fibrosis of the affected tissues. Lymphoedema can develop when lymphatic vessels are missing or impaired (primary), or when lymph vessels are damaged or lymph nodes removed with cancer surgery (secondary).

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Health with Muriel - Swelling and Lymphoedema by Tipp FM Radio

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Muriel Cuddy // Lymphoedema - Radio Podcast 

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Muriel Cuddy // Lymphoedema - Radio Podcast 

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Information on

Treatment modalities.

Lymphatics and the system.

Function of the lymphatics.

Case studies.

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Health with Muriel - Swelling and lymphoedema by Tipp FM Radio

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Muriel Cuddy from Mareto 80/20 jined Fran in studio to talk about Lymh phatic drainage, lymph nodes, lymphoedema and sweeling.

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Great resource with detailed podcasts.

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Play Oxford Lymphoedema Practice and discover followers on SoundCloud | Stream tracks, albums, playlists on desktop and mobile.

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Tips and tricks on MLD.

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MLD is a massage technique developed by Dr Emil Vodder to stimulate and drain the body's lymphatic system and reduce swelling. Siobhan is a Certified Lymphedema Therapist (CLT) since 1996. She uses these specialised MLD techniques and sequences to stimulate lymphatic nodes and vessels and move lymph fluid along to the deeper system for processing. In breast cancer rehab for example, MLD is used in combination with manual therapy, decongestive exercises and compression sleeves to drain the treatment area.
Long term lymphoedema care.
When patients need long term care, Siobhan with refer the patient to lymphoedema services and MLD therapists in their area. MLD therapists in Ireland are listed by location on http://www.mldireland.com
Conditions we treat with MLD include:

Cancer treatment.

Post-surgical swelling.

Lipoedema in the legs.

Pregnancy related swelling.

In sports.

Sinusitis sufferers.

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MLD is a massage technique developed by Dr Emil Vodder to stimulate and drain the body's lymphatic system and reduce swelling. Siobhan is a Certified Lymphedema Therapist (CLT) since 1996. She uses these specialised MLD techniques and sequences to stimulate lymphatic nodes and vessels and move lymph fluid along to the deeper system for processing.

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Skin Care Tips for Lymphoedema - Resource 

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Skin Care Tips for Lymphoedema - Resource 

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Reduce your risk of skin breaks by using insect repellent, sun screen and wearing protective clothing, such as a high collared shirt, long pants, boots, gardening gloves and oven gloves

Try products that state they have a low pH.

If we select products and practices that are compatible with the body’s own highly evolved mechanisms, we can boost our skin’s ability to defend itself from fungal and bacterial infections, including cellulitis.

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Lymphedema Self-Care Practices Tips for Soft Supple Skin – The O’Reilly Centre

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By Siobhan O’Reilly Bracken, MISCP MPA MSc CLT updated 28/09/20

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Lymphedema management: Manual lymph drainage for upper extremities

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Lymphedema - causes, symptoms, diagnosis, treatment, pathology

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Absolute

Acute infections.

Cardiac oedema.

Acute DVT.

Renal failure.

Relative

Malignant disease.

Abdominal MLD

Pregnancy.

Diverticulitis, Crohn's Disease, Ulcerative Colitis.

Aortic aneurysm.

Intra-abdominal scar.

Recent surgery.

History of pelvic DVT.

Unexplained abdominal pain.

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Around 15,000 people in Ireland are living with lymphoedema.

Primary lymphoedema may affect around 1 in 6,000 people.

Secondary lymphoedema affects

- 2 in 10 people with breast cancer.

- 5 in 10 people with vulval cancer.

- 3 in 10 people with penile cancer.

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A comprehensive online resource.

Key highlights are:

- Understanding lymphoedema and the types of lymphoedema.

- Symptoms and diagnosis.

- Treatment options.

- Prevention and risk reduction.

- Additional resources for patients and family members to download.

Overall this document gives the patient a sense of empowerment, provides professional resources that are accessible and gives guidance to carers.

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Lymphoedema develops when the lymphatic system does not work properly. The lymphatic system is a network of channels and glands throughout the body. It helps fight infection and remove excess fluid.

It's important to diagnose and treat lymphoedema as soon as possible. If it's not treated, it can get worse.

Symptoms of lymphoedema

The main symptom of lymphoedema is swelling in all or part of a limb (arm or leg). It can affect another part of the body too.

You may find it hard to fit into clothes. Your jewellery and watches can feel tight.

At first, the swelling may come and go. It may get worse during the day and improve overnight. Without treatment, it usually becomes more severe and does not go away.

Other symptoms in an affected body part can include:

an aching, heavy feeling

difficulty with movement

skin infections

hard, tight skin

folds in the skin

wart-like growths on the skin

fluid leaking through the skin

Causes of lymphoedema

The cause of lymphoedema is usually a problem with the lymphatic system.

The lymphatic system is a network of vessels and glands spread throughout the body. The lymphatic system helps fight infection and drain fluid from tissues in your body.

There are 2 main types of lymphoedema:

primary lymphoedema

secondary lymphoedema

The cause of primary lymphoedema is an alteration (mutation) in the genes that affect the lymphatic system. It can develop at any age. But it usually starts during infancy, adolescence, or early adulthood.

The cause of secondary lymphoedema is damage to the lymphatic system. Cancer treatment, infection or injury can damage to the lymphatic system. An inflammation (swelling) or lack of movement in a limb can also lead to lymphoedema.

Read more about the causes of lymphoedema

Who's affected by lymphoedema

Around 15,000 people in Ireland are living with lymphoedema.

Primary lymphoedema is rare. It may affect around 1 in 6,000 people. Secondary lymphoedema is more common.

Secondary lymphoedema affects around:

2 in 10 people with breast cancer

5 in 10 people with vulval cancer

3 in 10 people with penile cancer

People who have treatment for melanoma in the lymph nodes in the groin can also get lymphoedema.

Your treatment team will tell you if your cancer or cancer treatment could cause lymphoedema.

The treatment planned will try to avoid damage to your lymph nodes. Lymph nodes are pea-sized lumps of tissue that contain white blood cells. They help remove bacteria, viruses and other causes of infection from your body.

Read more about lymphoedema and cancer - cancer.ie

Diagnosing lymphoedema

See your GP if you have the symptoms of lymphoedema, such as swelling in your arms and legs. They may refer you to a specialist.

Doctors can diagnose lymphoedema from your symptoms and medical history. They'll examine the affected body part and measure it to see if it's enlarged.

You may need more tests to assess and track your condition.

Read more about diagnosing lymphoedema

Treating lymphoedema

There's no cure for lymphoedema. But it's possible to control the main symptoms. There are techniques to reduce fluid build-up and improve the flow of fluid through the lymphatic system.

Treatment includes:

wearing compression garments

taking care of your skin

moving and exercising often

having a healthy diet and lifestyle

using specialised massage techniques

If you keep up your treatment plan, your symptoms should become less noticeable.

Read more about treating lymphoedema

Complications of lymphoedema

Lymphoedema can have a big psychological impact.

Cellulitis is another common complication of lymphoedema. It can be serious if not treated quickly.

Cellulitis

If you have lymphoedema, there is excess fluid in your tissues. This increases your risk of infection.

Cellulitis is a bacterial infection of the dermis (deep layer of skin). Cellulitis can sometimes cause lymphoedema.

Symptoms of cellulitis can include:

redness and a feeling of heat in the skin

pain and increased swelling in the affected area

a high temperature

chills

The treatment for cellulitis is usually oral antibiotics (taken by mouth).

Severe cases may need intravenous antibiotics (given into a vein). You need to have this treatment in a hospital.

Psychological impact

Living with a condition that affects your appearance can cause a great deal of distress. This can lead to periods of depression.

You may have depression if you've been feeling down for the past few months and no longer find pleasure in things you usually enjoy.

If this is the case, talk to your GP or a member of your lymphoedema treatment team. Effective treatments are available for depression.

Talking to other people with lymphoedema can be reassuring. It can help to decrease feelings of isolation, stress and anxiety.

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Lymphoedema is a long-term condition that causes swelling in the body's tissues. It can affect any part of the body but usually develops in the arms or legs.

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Complex Regional Pain Syndrome Webinar - Video

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Complex Regional Pain Syndrome Webinar - Video

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Detailed resource that talks through a lot of patient case studies and scenarios

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WEBINAR | Pediatric Complex Regional Pain Syndrome (CRPS)

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Guidelines on the Management of Chronic Pain in Children - WHO - Resource

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Guidelines on the Management of Chronic Pain in Children - WHO - Resource

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Comprehensive, evidence-based recommendations for treating chronic pain.

Recognises chronic pain as a complex interplay of biological, psychological, and social factors, necessitating a holistic treatment strategy.

Encourages the use of physiotherapy.

Recommends CBT.

Suggests cautious use of medications.

Emphasises involving both the child and family in the treatment process to ensure that care plans are tailored to the child's developmental stage and family dynamics.

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Guidelines on the management of chronic pain in children

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Guidelines on the management of chronic pain in children, developing and implementing national and local policies for pain management and protocols in children, implementing national and local regulations for pain management in children, pain management and protocols

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The Royal College of Emergency Medicine Best Practice Guideline for the Management of Pain in Children (2017) - Resource

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The Royal College of Emergency Medicine Best Practice Guideline for the Management of Pain in Children (2017) - Resource

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Recognition and alleviation of pain should be a priority when treating ill and injured children. This process should start at the triage, be monitored during their time in the ED and finish with ensuring adequate analgesia at, and if appropriate, beyond discharge.

In treating pain, pay attention to the other factors distressing the child such as fear of the unfamiliar environment and people, parental distress, people in uniforms, needle avoidance, fear of injury severity etc.

Also has recommendations for the timely administration of analgesia.

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Best Practices in Pain Assessment and Management for Children - Resource

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Best Practices in Pain Assessment and Management for Children - Resource

# data[].attributes.body
Pain is often under-evaluated, especially in the youngest children and those who are cognitively impaired.

Developmentally appropriate pain assessment tools.

Supports a multidisciplinary approach, including pharmacological, psychological, and physical therapies.

Stresses the need for educating healthcare providers, families, and children about pain management strategies.

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Best practices in pain assessment and management for children

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Abstract. Pain assessment and management are essential components of paediatric care. Developmentally appropriate pain assessment is an important first ste

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Complex Pain on Children and Young People - Assessment. British Journal of Anaesthesia Education - Resource

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Complex Pain on Children and Young People - Assessment. British Journal of Anaesthesia Education - Resource

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Pain as a biopsychosocial phenomenon may be summarised as ‘threat–attention–response’.

Pain has an impact on sleep, mood, school attendance, and social interactions.

Encourages identifying underlying conditions and evaluating sensory and motor function changes.

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Complex pain in children and young people: part I—assessment

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Key pointsPain as a biopsychosocial phenomenon may be summarized as ‘threat–attention–response’.Complex pain requires a multidimensional assessment of func

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There is significant interplay between anxiety and pain perception in children.

Incorporating the HSE's anxiety self-help strategies into a comprehensive pain management plan can be instrumental in addressing the multifaceted nature of complex paediatric pain.

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Anxiety is a feeling of worry or fear that everyone experiences at times.

You can feel anxious or worried when you are concerned about something you are experiencing or that is about to happen. For example, a test, speaking in public, a job interview or a social occasion.

Feelings of anxiety are your body's natural reaction to some stressful or dangerous situations. They focus your attention and can help you react. A healthy amount of anxiety is OK and can keep you safe.

But anxiety can sometimes build up over time and be difficult to manage.

Our tips to help with anxiety can help you manage and reduce feelings of anxiety.

Signs of anxiety

Anxiety affects different people in different ways.

Anxiety can affect how you think, feel and behave, including:

being on edge, restless or irritable

feeling a sense of dread

difficulty concentrating or making decisions

repeatedly checking things or seeking assurance from others

avoiding situations or putting off doing things you are worried about

an increase or decrease in your appetite or craving junk food

loss of interest in sex

Physical signs of anxiety can include:

dizziness

sweating

shortness of breath

trembling

headaches

tummy aches or diarrhoea

tiredness

sleep problems

nightmares

teeth-grinding or jaw clenching

a strong, fast or irregular heartbeat

pins and needles

a dry mouth

muscle tension or neck and shoulder pain

a flare-up of another health problem, for example, dermatitis or asthma

Signs of anxiety can be mistaken for a physical illness. Talk to your GP if you are concerned about any of these signs.

If your anxiety has been going on for a while or getting worse, you may need to talk to someone else.

Causes of anxiety

What causes one person's anxiety may not create the same response in someone else. Anxiety can be brought on by different situations or experiences.

Anxiety can be an understandable response to a stressful event in your life, for example:

Sometimes it can be difficult to know what is making you anxious. This can be upsetting or stressful. If you learn to recognise what is making you anxious, it can help you deal with the uncertainty.

Anxiety can also be part of stress.

Tips to help with anxiety

There are many things you can try to help you learn how to manage feelings of anxiety.

Every day, for at least 2 weeks, make a note of how you are feeling at different times of the day.

Rate your anxiety on a scale of 1 to 10 and note:

where you were

who you were with

what you were doing

what you were thinking

This will help you see what situations are most likely to make you anxious. Think of anything you might be able to do to make these situations easier.

Make a list of the things you are anxious about. If you think there are things you can do to help with them, write a plan.

Include in your plan:

what you can do about it

how you can do it

when you will do it

If there are things you can do, do them as soon as possible or set a time for when you can. Start with the small or easiest ones first. Gradually build up to facing your bigger problems or fears.

If the anxiety returns, remind yourself that you have either taken action or have a plan in place.

If you don't stick to your plan, don't be too disappointed. Focus on small achievements.

Manage your screen time

Screen time is the time you spend looking at a device such as a phone, tablet, computer, games console or TV.

Screen time can take up time that could be spent outdoors, socialising or being physically active. It can also expose you to stress, bullying or negativity through social media.

To help manage your screen time:

make screen free zones in your home, for example, the bedroom

turn off or limit notifications on your phone

avoid using screen time when you're bored or stressed

avoid screen time during meals or when you are with family or friends

swap screen time for healthier alternatives

manage your social media apps and feeds

If your worry is overwhelming, set aside an amount of 'worry time' to go through your worries each day.

Try 15 to 30 minutes each day to start with. When the time is up, focus your thoughts on other things until tomorrow.

Challenge unhelpful thoughts

Negative thought patterns can make anxiety worse. They can lead to unhelpful feelings and actions.

Do not accept a negative thought as a fact, challenge it.

Ask yourself:

what is the evidence for and against your negative thought?

are there other ways you can look at this situation?

if you were to be positive about the situation, how would you view it?

Try to change a negative thought for a more helpful one. Sometimes you will be able to, but it is OK if you cannot
Change your thinking and improve your mental health

Talk about your feelings

If you feel anxious, it can help to talk to a friend or family member about how you feel.

Telling someone about how you are feeling can help to make things clearer for you. It can help you understand why you are feeling anxious and to get help with how to manage it.
How to talk to someone about what's troubling you

Breathing exercises

Breathing exercises can help your mind and body get control of a difficult situation. They only take a few minutes to do and can help you manage strong emotions and reduce stress.
Relaxation tips and breathing exercises

Mindfulness

Mindfulness teaches you to become aware of the present moment. This helps you enjoy things more.

You can learn to not react or become overwhelmed by what's going on around you by doing mindfulness. Instead, you notice your thoughts, feelings and sensations.

Mindfulness can be an easy activity you can fit into your day.
How to practice mindfulness

Anxiety can make you feel more tired than usual. It can also make it more difficult to get or stay asleep.

Sleep is important for mental health. It helps you to think clearly and gives you the energy to deal with problems.

Most people need 5 to 9 hours sleep a night. More than 7 hours is recommended for adults. The ideal amount is 8 hours, but everyone's different.
Tips for better sleep

Healthy eating

What you eat can make a difference to your mental health. A diet rich in foods such as fruit, vegetables, whole grains, nuts and seeds can boost your energy and mental health.

Healthier food choices can improve your mental and physical health.
8 healthy eating tips to improve mental health

Physical activity

Physical activity can help you sleep, relax and feel better. It can help reduce stress and burn off anxious energy. It can also be a good way to meet people and get more involved in your community.

Any activity is useful, as long as it is suited to your ability and you do enough of it. Find something that you enjoy doing. This will help keep you motivated to do it every day.
Physical activity and your mental health

Alcohol and anxiety

Alcohol affects your mental health and can make anxiety worse in the long-term. Some people call the effects of alcohol the next day ' the fear'. This is when you feel you have done yourself some lasting damage after a night of drinking.

Using alcohol to cope with difficult feelings can create long-term problems, including addiction.

Cutting back on alcohol can make you feel better physically and mentally.
Tips for drinking less

Self-help resources for anxiety

Clear Fear app

A free app that helps you manage the symptoms of anxiety.

Get Clear Fear from the App Store

Get Clear Fear from Google Play

Mindshift CBT app

A free app that helps you reduce worry, stress and panic. It is based on cognitive behavioural therapy (CBT).

Get Mindshift from the App Store

Get Mindshift from Google Play

Headspace app

An app that teaches meditation and mindfulness skills.

Get Headspace from the App Store

Get Headspace from Google Play

Minding your Wellbeing Programme videos

Five videos that help you learn more about mindfulness, gratitude, self-care and resilience.

Watch the Minding Your Wellbeing Programme videos

Stress Control course

For many people, stress can include or be linked to feelings of anxiety or low mood.

Our 'Stress Control' course can help you learn stress management skills.
StressControl.ie
When to talk to someone else

If you have tried our tips and the self help resources but you think you need extra support, it may help to talk to someone.
Mental health supports and services
Text About It

Text About It is a free, 24/7 service, providing everything from a calming chat to immediate support for your mental health and emotional wellbeing.

Free-text HELLO to 50808 for an anonymous chat with a trained volunteer, any time.
textaboutit.ie
Samaritans

Samaritans services are available anytime, for confidential and non-judgemental support.

Freephone Samaritans on 116 123
jo@samaritans.ie
samaritans.ie

Worried about someone else

If you notice someone is struggling with their mental health, this can be worrying. You may not know what to do.
How to help someone experiencing mental health issues
Talk to a GP or mental health professional if:

you are finding it hard to cope

anxiety is having a negative affect on your day-to-day life

your anxiety has been going on for a while or getting worse

Ask for an urgent appointment if you are in crisis.
Generalised anxiety disorder Social anxiety (social phobia)
If you feel you are going to harm yourself or someone else, get help as soon as possible from:

If you go to an ED, it can help to bring someone with you.

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Anxiety is a feeling of worry or fear that everyone experiences at times. Find tips to help you manage and reduce feelings of anxiety.

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Electronic pain diary.

Smartphone-based pain assessment.

Designed for use in paediatric cancer by SickKids.

While initially being designed for cancer-related pain, it is also a valuable tool for managing various types of complex paediatric pain.

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International Association for the Study of Pain (IASP)

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The Pain Squad App - International Association for the Study of Pain (IASP)

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We know that pain is one of the most common and distressing symptoms for children with cancer. This pain results from many different aspects of cancer and its treatment, including […]

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Designed to help children and young people manage anxiety using Cognitive Behavioural Therapy (CBT) techniques.

It offers tools such as breathing exercises, relaxation techniques, and thought-challenging activities to reduce anxiety symptoms.

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An initiative by the Canadian science-media partnership that is a valuable resource for addressing paediatric pain.

It aims to promote awareness, reducr the stigma around paediatric pain, and fosters effective pain management practices, ultimately improving the quality of life for children experiencing pain.

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Explore our various pain management resources. You can search by type of resource (e.g., blog posts, videos, images) and by category (e.g., needle pain, pain assessment, cancer pain).

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Useful resource for those that are visual learners.

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A wide range of educational material for PGP.

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Range of exercises with instructions for women who have PGP provided by the National Maternity Hospital.

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Share your videos with friends, family, and the world

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National Maternity Hospital Videos on moving in bed.

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Share your videos with friends, family, and the world

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Previous history of low back pain.

Previous trauma to the pelvis.

Heavy work.

Smoking.

Pluripara.

Young age.

Belief of a weak back.

Increased weight during pregnancy.

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Great resource for PGP.

Exercises with guidance.

Tips and tricks to ease pain.

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Find out what pelvic girdle pain (PGP) is, what the symptoms and causes are and when to get help.

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Great resource for all things women's health.

Educational videos on PGP.

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Physiotherapists are involved in caring for mums to be and new mums through a range of different services.

Mums to be
We provide 'preparation for parenthood' classes with the parent education midwife, social work and mental health support midwives. Currently these classes are zoom based supported by educational videos of the class information. You will be informed about these classes at your booking visit.

The physiotherapy classes within this programme are:

Class One
Pregnancy exercise and advice

Class Five
Coping skills and positions for labour
Baby handling and development
Postnatal exercise and advice

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Physiotherapists are involved in caring for mums to be and new mums through a range of different services. Mums to be We provide 'preparation for parenthood' classes with the parent education midwife, social work and mental health support midwives. Currently these classes are zoom based supported by educational videos of the class information.

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Resources on

Pregnancy care.

Postnatal care.

Newborn care.

Women's health.

Times, days of classes.

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The physiotherapy team at The Coombe Hospital provides a range of services to pregnant and postnatal women, newborns and women attending gynaecology services in the hospital. The department is located on the ground floor of the hospital. We offer appointments Monday to Friday from 8am – 4pm and you can contact us at 01 408 5319 or at physio@coombe.ie.

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Supine position.

Prolonged static standing (decreased cardiac output).

Increased basal metabolic rate (heat production) above non-pregnant levels (increased maternal core temp above 1.5* C (early pregnancy).

Avoid activities with high risk of falls.

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Vaginal bleeding.

Dizzy/faint.

Chest pain.

Headache.

Calf pain / swelling.

Uterine contractions or decreased
foetal movement.

Vaginal fluid leak.

If any of these occur, it is recommended that the patient stops exercising immediately.

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Dr. Sinéad Dufour | Understanding Pelvic Girdle Pain by Let's Talk Pelvic Health

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In episode 2 of Let’s Talk Pelvic Health, we chat with Dr. Sinéad Dufour, a pelvic physiotherapist, clinical professor and researcher in the areas of pelvic health and pain science. She teaches us all about pelvic girdle pain, what causes it and how best to manage it.  This is a must-listen for anyone struggling with this condition, as it provides hope and reassurance that you can get better.  Sinead works in Ontario, Canada and offers virtual care. 

To make an appt, https://thewomb.janeapp.com/locations/the-womb-burlington/book.

To explore courses offered through her virtual teaching platform, visit https://reframerehab.com/pages/course-calendar

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Load transfer test: Active straight leg raise Share(2)

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Pain Provocation - Patrick-FABER Test (2)

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Pain Provocation - Patrick-FABER Test (2)

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Laslett et al (2005)

Sensitivity = Approx. 60%

Specificity = Approx. 50%

This means that the FABER test alone is not entirely recommended, however -> using the FABER in combination with other SIJ provocation tests (P4 test, Gaenslens test, long dorsal ligament palpation) enhances diagnostic accuracy.

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Pain Provocation - Patrick-FABER Test (1)

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Pain Provocation - Patrick-FABER Test (1)

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Pain Provocation Tests; Patrick -Faber Test

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Sensitivity = 87%

Specificity = 94%

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Active Straight Leg Raise Test | Sacroiliac & Pelvic Girdle Pain

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Useful in assessing the psychological aspect of PGP.

Catastrophising can have a significant negative impact on recovery and disability levels.

Developed by Sullivan et al, 1995

- 13 items divided into 3 subscales - Rumination, Magnification, Helplessness.

- Scored 0 (not at all) to 4 (all the time).

Useful in combination with ODI and/or PPQ.

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Pelvic Pain Questionnaire - Stuge et al (2012)

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Pelvic Pain Questionnaire - Stuge et al (2012)

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Unlike generic tools (ODI), the PPQ is tailored for PPG.

Captures PPG's multidimensional nature.

Has 2 main sections

1) Activity related questions

2) Symptom related questions

-> Addresses both functional limitations and pain perception = holistic view.

High inter-rater and intra-rater reliability.

ideal for monitoring changes over time.

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Originally for Low Back Pain, but can be adapted to PGP.

Assesses the impact of pain on daily activities and quality of life, offering a quantifiable measure to track changes over time.

10 sections, each with 6 statements that are scored 0-5.

Higher scores indicate greater disability.

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Symptoms include diminished endurance for standing, sitting, and walking.

Pain or discomfort in any or all of the following places

- over your pelvis, especially at the pubic bone at the front.

- along your groin area.

- below your tummy.

- in your hips.

- across one or both sides of your lower back or buttocks (bottom).

Reports of difficulty transferring load from the LL and the trunk.

Difficulty parting your legs (getting out of a car).

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There is a growing body of evidence highlighting the benefits of exercise for anyone with/beyond cancer.

Patients should familiarise themselves with cancer exercise guidelines - avoid inactivity -> SOMETHING IS BETTER THAN NOTHING.

Targeted exercise prescription - must consider the long-term Rx SEs and how they interfere with the ability to exercise.

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Hb level < 8.0 g/dL

Avoid high intensity activities that require significant O2 transport.

Absolute neutrophil count < 0.5 x 10^9 /L

Avoid activities that may increase risk of bacterial infection (swimming).

Platelet count < 50 x 10^9 /L

Avoid activities that increase risk of bleeding (contact sports).

Fever >38* C

? systemic infection - avoid high intensity activities.

Ataxia, dizziness, or peripheral neuropathy

Avoid balance and coordination activities.

Severe cachexia (loss of >45% premorbid weight)

Loss of muscle mass limits exercise to mild intensity.

Dyspnoea

Exercise tolerance.

Bone pain

Avoid high-impact activities.

Severe nausea

Exercise tolerance.

Extreme fatigue

Exercise tolerance.

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HR is not as useful as an outcome measure as it is affected by chemotherapeutics -> therefore making it less reliable.

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6-20 scale to replicate the patient's HR (x10).

Participants are asked to rate their exertion on the scale during the activity, taking into consideration feelings of physical stress and fatigue, disregarding any factor such as leg pain or breathlessness but focusing on the whole feeling of exertion.

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Borg rating of perceived exertion (RPE) is an outcome measure scale used in knowing exercise intensity prescription. It is use in monitoring progress and mode of exercise in cardiac patients as well as in other patient population undergoing rehabilitation and endurance training.

Borg RPE scale was developed by Gunnar Borg for rating exertion and breathlessness during physical activity; that is, how hard the activity is as shown by high heart and respiration rate, profuse perspiration and muscle exertion.

Versions And Scoring

Borg original version is a scale of 6-20; it has a high correlation to heart rate and multiplying each number by 10 gives the training heart rate as at the time of scoring. It was later reconstructed to category (C) ratio (R) scale, termed Borg CR10 Scale or modified Borg Dyspnoea Scale which is mostly used in diagnosis of breathlessness and dyspnea, chest pain and musculo-skeletal pain. The CR-10 scale is best used in a specific area of the body sensation such as muscle pain or from pulmonary responses.

9 = 'very light' exercise which equals walking slowly for few minutes at own pace of a healthy individual..

13 = 'somewhat hard' but the individual is still able to continue the activity.

17 = 'very hard'. A healthy person can continue but must push themselves beyond their comfort of being very fatigued.

19 = extremely strenuous exercise.for most people, the hardest they have ever experienced.

Intended Population

It is intended for all patient under rehabilitation. and for monitoring exercise prescription in athletes.It may not be suitable for children's use as the scoring is difficult to interpret in this age group.

Method of Use

The scale is a very simple numerical list. Participants are asked to rate their exertion on the scale during the activity, taking into consideration feelings of physical stress and fatigue, disregarding any factor such as leg pain or breathlessness but focusing on the whole feeling of exertion. This number chosen connotes the intensity of activity allowing the participant to speed up or slow down movements/activity. The scale takes few seconds to complete, can be self or researcher administered in single occasion or multiple times.

Reliability

Testing of the subject twice was used in ascertaining reliability in a study and Borg RPE was found to be reliable in rating exertion The verbal anchor using VAS of the scale when tested in different clinical group and setting was found to have no significant difference in meaning in the groups except for the group that has a brain injury.

Originally RPE was validated against heart rate. With time, RPE has since been researched extensively in a variety of different conditions and population groups.

Borg RPE scores were positively associated with heart rate in adults during exercise sessions using the Wii Fit Plus.

Skinner et al, found no significant differences in any of the physiological and perceptual variables in work intensity when the work load was presented in a random order and compared with those obtained during the progressive exercise test.

A recent study reported that the Borg RPE scale may be used in individuals with Parkinson's disease in which formal exercise testing may not be available.

Responsiveness

A work done in a laboratory setting comparing physiological measurements and actual lifting tasks in the workplace found a relationship between perceived physical exertion and individual physical capacity; in both cardiovascular and muscular work. However, a research by by Village et al. shows a weak relationship between perceived physical exertion and workload

References

1. Rating of perceived exertion. Available from: https://en.wikipedia.org/wiki/Rating_of_perceived_exertion(accessed 24 May 2019)

2. Skinner JS, Hutsler R, Bergsteinová V, Buskirk ER. The validity and reliability of a rating scale of perceived exertion. Medicine and science in sports. 1973;5(2): 94-6.

3. Vivo Phys-Evan Mathews. RPE - Rating of Perceived Exertion. Available from: http://www.youtube.com/watch?v=HgEHl0-IB14[last accessed 30/4/2019]

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Borg rating of perceived exertion (RPE) is an outcome measure scale used in knowing exercise intensity prescription. It is use in monitoring progress and mode of exercise in cardiac patients as well as in other patient population undergoing rehabilitation and endurance training.

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American College of Sports Medicine Roundtable on Exercise... Medicine & Science in Sports & Exercise

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 Specific Considerations for Exercise in Oncology

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 Specific Considerations for Exercise in Oncology

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Intensity

BORG Scale - RPE

HR is not too useful as certain treatments (chemotherapy) affect resting HR.

Lines & Attachments

Care needed not to disrupt same when exercising.

Prostate CA

Potential risk of fracture.

Breast CA

Ensure arm/shoulder issues are resolved before commencing any UL programme.

Monitor for changes in symptoms or swelling.

Women with lymphoedema should wear a compression bandage.

Colon CA

Ostomy - caution RE contact sports or weight lifting.

Avoid excessive intra-abdominal pressures.

Haematopoietic stem cell transplant

Multiple myeloma patients should be treated if they have osteoporosis.

Gynaecological

Swelling/inflammation of the LL or groin - ensure symptoms have resolved before starting LL exercise training.

Monitor for changes.

Metastatic CA

Bone health.

Symptomatic vs Asymptomatic.

Pain levels.

Patient education.

Schmittz et al, 2010

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American College of Sports Medicine Roundtable on Exercise... : Medicine & Science in Sports & Exercise

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a, MD, PhD Carole M. Schneider, PhD, FACSM Vivian E. von Gruenigen, MD Anna L. Schwartz, PhD, FAAN Early detection and improved treatments for cancer have resulted in roughly 12 million survivors alive in the United States today. This growing population faces unique challenges from their disease and treatments, including risk for recurrent cancer, other chronic diseases, and persistent adverse effects on physical functioning and quality of life. Historically, clinicians advised cancer patients to rest and to avoid activity; however, emerging research on exercise has challenged this recommendation. To this end, a roundtable was convened by American College of Sports Medicine to distill the literature on the safety and efficacy of exercise training during and after adjuvant cancer therapy and to provide guidelines. The roundtable concluded that exercise training is safe during and after cancer treatments and results in improvements in physical functioning, quality of life, and cancer-related fatigue in several cancer survivor groups. Implications for disease outcomes and survival are still unknown. Nevertheless, the benefits to physical functioning and quality of life are sufficient for the recommendation that cancer survivors follow the 2008 Physical Activity Guidelines for Americans, with specific exercise programming adaptations based on disease and treatment-related adverse effects. The advice to “avoid inactivity,” even in cancer patients with existing disease or undergoing difficult treatments, is likely helpful.…

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Exercise principles remain the same, despite the different patient population. There are some specific considerations that must be made.

- individualisation - based on baseline cardioresp fitness and/or muscular strength.

- progressive overload - training stress is increased across the intervention.

- recovery - appropriate rest between sessions to optimise physiological adaptation.

- specificity - designed to induce improvements in the primary outcome.

FITT-VP Principle

Frequency

Intensity

Type

Time

Volume

Progression

Sasso et al, 2015