The management of the burn-injured face poses unique challenges for therapy intervention. Standard compression techniques require an intimate fit and are traditionally implemented after wound closure when the patient has minimal or no dressings. Our center developed a method of self-adhesive facial wrapping that can be initiated early in care to provide custom contoured compression, decrease edema, and help maintain definition of facial features. The study aimed to characterize our experience with self-adhesive wrap in adult and pediatric patients with facial burn injuries. We conducted a retrospective chart review of patients treated with self-adhesive elastic facial wrapping at a single center between 2019 and 2023. Thirty patients were identified over this 5-year period who received self-adhesive elastic wrapping to the face. Mean age was 32.2 years, 57% of the subjects were male, median TBSA burned was 35%, and length of stay was 51 days. Self-adhesive wrap was initiated at a median of 18.5 days postadmission and was used for a median duration of 8.0 days. All patients with documented limitations in oral (n = 3) or ocular (n = 10) closure demonstrated improvements after wrap application. There was no significant association between the use of self-adhesive wrap and skin breakdown (P = .743) or graft loss (P = .726) when the wrap was applied by therapists. No complications were identified that necessitated discontinuation of the intervention. This readily available technique may be implemented early in the course of care to provide compression when other typical options are not yet appropriate or may be cost-prohibitive.

Heterotopic Ossification (HO), the development of abnormal bone in soft tissue that typically surrounds a joint can be severely debilitating. HO symptoms include intolerable pain, decreased range of motion (ROM), and change in joint end feel. Complications such as joint fusion impact quality of life, function, and total recovery. Therapists work closely with patients and may become aware of symptoms before a formal imaging diagnosis is made. The purpose of this study was to identify the difference in time from clinical assessment to imaging conformation in HO formation at our center. This was a retrospective study of patients, over a 10-year period, who developed HO to the elbow during their initial hospitalization. Data collection included basic demographic, injury and hospital data. Data specific to study objectives included diagnostic imaging and therapy assessments. ROM was categorized into mild, moderate, severe, and within normal limits (WNL). Symptoms that lead to suspicion of HO presence were categorized into pain, ROM, and end feel. Descriptive statistics were calculated. There was a total of 48 study subjects. The majority were male (n=42, 88%) flame was the most common mechanism of injury (n=43, 90%), µ TBSA 51% (range 22-95%), µ ventilator days, 77 and µ length of stay was 110 days. Emergence of symptoms were categorized into ROM (n=24), pain (n=15), and joint end feel (n=9). The mean difference of suspected HO to imaging conformation was 29.9 days (range 0- 167, ± 42.3). The mean number of days from suspected HO to start of work up was 7 days (range 0-93, ± 17.7). Average number of images prior to conformation of HO was 1.02 (range 0-4, ±1.02). Following suspicion of HO, goniometry was obtained to the elbow on average 8.9 (range 0-58, ±13.3) ROM of elbow was also collected at or near discharge and categorized into WNL (n=7), mild (n=9), moderate (n=8), and severe (n=23). Our study suggests that clinical assessment by burn rehabilitation therapists demonstrates increased sensitivity in detecting heterotopic ossification formation when compared to diagnostic imaging. Clinical assessment focusing on progressive decreasing ROM, intolerable increase in pain, as well as firm to hard humeroradial & humeroulnar end feel, may assist the transdisciplinary team to make informed decisions for the patient and their care plan. N/A

The incidence of hip flexion contracture following transtibial and transfemoral amputations is estimated to be 13% and 23%, respectively. The presence of burns and burn scars in the cutaneous field of skin associated with hip flexion complicates contracture prevention. Standard approaches for prevention or management of these contractures include positioning, ROM, exercise, intensive patient education, and in extreme cases, custom orthoses. This is a single case report of a patient with a hip flexion contracture, managed with a novel custom hinged hip extension orthosis following scar resurfacing. A 54-year-old female was struck by a semi-trailer at a crosswalk, resulting in bilateral above the knee amputations. She received a split thickness skin graft (STSG) to her L hip during acute reconstruction at an outside hospital. She presented to our institution 3 months later with a hip flexion contracture, severely limiting her mobility, and ability to fit for BLE prosthetics. Under anesthesia, goniometric measurements were taken prior to contracture release and then immediately after resurfacing A custom thermoplastic hinged hip extension orthosis was fabricated utilizing the hinge from an off-the shelf locking, hinged knee brace. The hinge was locked to prevent further hip flexion however was set to allow for increased extension. An additional strap was added to decrease hip abduction. The orthosis was worn at all times for five days. The thermoplastic components of the orthosis were re-fabricated prior to discharge. Goniometric measurements were taken at every healing milestone and weekly in the clinic. The patient tolerated the orthotic at all times and transitioned to nighttime wear upon discharge. Hip extension progressed from 60 degrees pre-operatively, to 40 degrees immediately following resurfacing to 4 degrees from neutral within one month. The patient is now in the process of being fitted for prosthetics. Utilizing a custom fabricated hinged hip extension orthosis with thermoplast components allowed for custom adjustments and progressive stretch throughout the course of care. This orthotic is a valuable alternative to the off-the-shelf devices. This custom modification allowed for immediate application following surgical correction of scars, and resulted in compelling gains in range of motion A custom fabricated hinged hip extension orthosis can progress patient ROM for functional use of prosthetics. N/A

Burn scars around the lip present difficult challenges including mouth opening, closing, management of oral secretions, cosmesis, eating, and nutrition maintenance. Management is frequently confounded due to inability to keep orthosis in proper position. Traditional microstomia prevention appliances (MPAs) require removal for daily activities (eating, drinking, brushing teeth, talking) and wearing schedule is generally shorter applications several times a day. This is a case report of a custom tooth-based intraoral orthosis to effect cutaneous stretching. A 45-year-old male suffered 34% TBSA flame burns to face, both upper extremities and chest, resulting in bilateral upper extremity amputations during his acute care phase as well as evisceration of right eye. He also developed severe perioral scar contracture, and lower lip ectropion which interfered with eating, oral secretion management, and speech. He was reliant on assistance from caretakers to place orthotics on face and/or limbs. He underwent a scar release with full thickness skin graft to lower lip ectropion, and subsequent application of a custom intra oral orthosis. Dental impressions were taken for fabrication of the appliance. The design was communicated to the lab with the use of stone models. A metal framework was designed to support the acrylic that will support the labial tissues. The patient was able to safely wear the appliance the entire day because the appliance was tooth supported, like a traditional partial denture. Lip closure and vertical mouth opening measurements were obtained and the Mouth Impairment Disability Assessment were administered prior to device implementation. Measurements were also noted at the weekly intervals. The patient gained 4 mm of active lip closure and 11 mm in mouth opening over a period of 3 weeks. He gained 2mm on the right side with lip closure and full closure on the left side during the same time. There was also improvement noted in speech and management of oral secretions. At the recent follow up, the patient reported noncompliance with the orthosis for a week. This was reflected in the measurements as loss of previous gains in mouth closure. A custom intra-oral tooth supported device facilitated improvement in mouth closure, and was easier for the patient to manage, resulting in more therapeutic effect. This novel custom tooth-based device for intra oral use uncovers a new approach to treat the intractable problem of lower lip burn scar ectropion that is easier to apply and can be worn for longer durations. This is especially important in the presence of other mobility challenges as frequently seen in large body surface are burn injuries. N/A

The management of the burn-injured face poses unique challenges for therapy intervention. Standard compression techniques, require an intimate fit and are traditionally implemented after wound closure or autologous grafting when the patient has minimal or no dressings. Garments can impart shear forces during application and may not contour well. We developed a method of self-adhesive facial wrapping to provide custom contoured compression, decrease edema, and help maintain definition of facial features. This wrapping technique can be implemented early, when garments or a facial orthosis cannot be placed. It is used in conjunction with wound care or grafting and accommodates for changes that would preclude other forms of compression. A literature search did not return results describing the use of a self-adhesive wrap on the face. The purpose of this study was to characterize our experience with self-adhesive wrap in adult and pediatric patients with facial burn injuries. This was a retrospective chart review of patients treated with self-adhesive elastic facial wrapping at our center from 2019- 2023. Data collected included burn location, TBSA, etiology, demographics, dressing interface, and treatment characteristics including number of applications, duration of use, complications, impact on facial edema, and range of motion of mouth and eyes. Descriptive statistics were calculated. Thirty subjects were identified in the 5-year period who received self-adhesive elastic wrapping to the face. Mean age was 33 years (range 0.9-82), 56.7% of the subjects were male, mean TBSA was 37.7%, and length of stay was 76.1 days. Initiation of wrap was on average at 21.5 days (range 5-76) after admission, mean duration of treatment was 14.26 days (range 1-113). Some type of insert or oral orthosis was used in conjunction with the wrap for 43%, and of the patients with limitations in oral or ocular closure, all demonstrated improvement after the wrap was applied. There was no relationship between the use of self-adhesive elastic wrap and skin breakdown (p=.743) or graft loss (p=.726). No complications were identified that necessitated discontinuation of the intervention. The use of self-adhesive elastic wrapping on facial burns helped promote mouth and eye closure, and decreased edema, without discernable complications. Facial compression can be safely initiated early in the phases of wound healing and may help decrease hypertrophic scar formation, subsequently improve function, and decrease the psychosocial impact of burn injury. The use of this readily available technique may be initiated early in the course of care, to provide early compression when other typical options are not yet appropriate or may be cost prohibitive. N/A

Application of compression bandages is standard in pain and edema management in the acute burn setting. Long stretch (LS) elastic bandage, is the bandage of choice amongst burn centers. LS bandage is known for its high elasticity which demonstrates a high resting pressure and low working pressure. LS compression, typically used for acute edema management, can also be utilized for improved pain control, and post-operatively s/p autografting of an extremity. In contrast to the LS, short stretch (SS) bandages have inverse properties. However, they offer similar benefits for edema management and are the standard in lymphedema management. Currently, no literature reports the use of SS in the acute burn setting. This case series aims to describe the use of SS and its observed effects on subjects with acute lower extremity (LE) burns and focuses on its impact on pain control and mobility in the inpatient setting. This was a retrospective case series which involved application of SS to the LE to decrease pain and improve mobility by a Certified Lymphedema Therapist (CLT). Data was collected from Jan 2022 to Sept 2024. Data collection included sensation, presence of escharotomy/fasciotomy, total number of SS applications, total duration of SS application, pre/post levels of pain, pre/post levels of mobility (JH-HLM), pre/post ability to ambulate, pre/post mobility assistance levels. Ten patients were treated with SS, 60% were male with 40% requiring LE escharotomy / fasciotomy. Sensation was intact in 90% and unknown in 1. Dependent pain was reported by 60%. Pre-SS application, 60% were unable to ambulate secondary to pain. Duration of SS treatment averaged 3.9 days (range 1-10), with a mean number of 4.1 (range 2-10) applications. Post-SS, 50 % saw an improvement in the level of assistance required and no patients worsened. Post-SS, 78% saw an improvement in their highest level of mobility. Quantitative data regarding edema was not available in the record, anecdotally no patient’s had worsening of their edema. There were no adverse events related to SS application. Our findings demonstrate SS application may result in decreased pain and improved mobility with individuals with acute LE burn injuries. No adverse events were reported. Further research is needed to determine the extent of potential benefits of SS application in the acute burn setting. The ability of SS to provide greater working pressure, in contrast to LS, which have lower working pressure, demonstrates the potential for superior pain and edema control in those with acute burn injuries. N/A

Abstract Introduction Although hand burns comprise a small TBSA percentage, they can have significant functional implications. Multiple studies show grip strength as a predictor of health and quality of life. A decrease in grip strength has been reported in multiple populations with hospital admission; however, there is limited evidence concerning how burns affect hand strength. The purpose of this study was to examine the impact of burns on grip strength, measured at hospital discharge. Methods This study is a retrospective review of data from the prospective Burn Patient Acuity Demographics, Scar Contracture and Rehabilitation Treatment Related to Patient Outcome Study (ACT). Patients had grip strength measured of both hands 3 times consecutively at discharge. Data related to grip strength of patients with burn injuries were compared to age- and sex-matched normative values. Burn characteristics, including presence of hand burns, skin grafting, and length of stay were evaluated. Results There were 307 participants in ACT; 195 (63.5%) had hand burns and met inclusion for analyses. Among those with hand burns, the majority were male (72.8%), right-hand dominant (84.1%), mean ±SD age was 42.9±17.0; LOS, 23.3±22.8 days; and TBSA, 14.5%±13.3. Among patients with hand burns, 112 (57.4%) received skin grafts to at least one hand. Expressed as the percentage of grip strength loss relative to normative data, those with a burn injury to the hand averaged -55.8±33.4%, while those with no burns to the hand averaged -25.7%±36.3%, p < .001. Patients with a skin graft to the hand averaged -65.8±27.2% grip strength, while those with hand burns, but no grafts averaged -36.1%±35.5%, p < .001. Decreased grip strength is associated with increased length of stay, r= .21, p < .001. Conclusions This study of hand strength in burn survivors at the time of hospital discharge corroborates previous reports regarding nosocomial strength loss but specific to the hand. Overall, patients hospitalized with burn injuries lose hand grip strength but more-so if a hand is burned and furthermore if a hand is skin grafted. Applicability of Research to Practice Understanding of the impact of burns on grip strength may help guide clinical decision making, allowing therapists treating those with burn injuries to anticipate deficits and subsequent functional impact. Expectation of a loss of grip strength in patients without burns to the hands should inform treatment planning during acute hospitalization to promote improved function and quality of life.

The Burn Therapist Certification (BT-C) was introduced in 2018 to acknowledge occupational therapists (OT) and physical therapists (PT) with specialized knowledge, skill, and experience in the promotion of quality burn rehabilitation. Currently, BT-Cs make up 11.7% of therapists working in burn rehabilitation (n = 39/333). The purpose of this review is to report on the contributions of BT-Cs to organizational leadership of the American Burn Association (ABA) and in the generation of new knowledge through peer-reviewed publications. Despite the small percentage of burn therapists who are certified, they have a disproportionately large involvement in leadership within the ABA and burn research in the Journal of Burn Care and Rehabilitation (JBCR). From 2018 to 2023, BT-Cs have contributed to nearly one-half (n = 26/56) of therapy authored publications in the JBCR and almost one-third (n = 65/202) of accepted abstracts at the ABA annual meeting. Certified burn therapists demonstrate substantial involvement throughout the ABA, including maintaining an 85% membership rate and, on average, serve in 53% (n = 31/59) of the therapy allotted committee positions. Therapist pursuit of certification can have a profound impact on the burn community through publication, leadership, and development of care standards. Although therapists have indicated a desire to pursue certification, barriers related to a lack of association and center support have been identified. The burn community has endorsed certification as a mark of excellence for nurses and physicians. Maximizing the value of a transdisciplinary approach to burn care is also dependent on the excellence of therapies. If the burn community desires improved engagement and contribution from therapies, it should support therapist certification.

Abstract Introduction Facial scarring can impact an individual’s self-worth and confidence. Treating facial scarring often includes fabrication and fitting of custom face masks. Facial masks are generally fabricated utilizing high or low temperature thermoplastic material. Facial masks may also include a silicone component to address scar formation. At present time, facial mask fabrication has evolved from plaster molding directly on the patient to 3-D scanning and subsequent molding. Impediments to current practice may include cost, delayed prescription, and breakage which can allow tissues to change which ultimately require extended modifications. This is a report of a single patient in which a 50/50 putty facemask with a thermoplastic overlay was utilized to address facial scarring, compliance, cost, and distance from clinic. Methods This is a case study of a 5-year-old child who suffered deep partial thickness to full thickness burn injuries to his face for whom we created a facemask with a superimposed thermoplastic overlay to maintain the position of the 50/50 putty mask. The 50/50 facemask was fabricated in a t-shape with clearance of eyes, nose and mouth. The thermoplastic overlay was fabricated to contour the exact shape of the outer face over the 50/50 putty. The Patient and Observer Scar Assessment Scale (POSAS) was administered prior to applying the custom facemask and at day 42 to evaluate efficacy. Each item on the POSAS scale is scored from 1 to 10, with 1 being normal skin and 10 representing the worst scar possible. The total score can range from 6 to 60. There is a separate overall opinion score that is rated on the same 1-10 scale. The father completed the patient portion of the scale with feedback from the child. Results The custom facemask was worn 23 hours per day for 42 days. The baseline patient score was 42 and the patient overall opinion of scarring score was 7. The observer score was 43 with an overall opinion of scarring score of 7. At day 42 both the patient score and patient overall opinion score had improved, 18 and 4 respectively. The observer score and observer overall opinion score also improved, 21 and 3 respectively. Conclusions Utilization of a 50/50 putty facemask allowed for continuous wear with less incidence of modifications due to material composition. Utilization of a 50/50 putty facial mask accommodated tissue modulation without risk of erythema in a way that thermoplastic material is unable to achieve. The facemask utilized in this single case study provided standard of care treatment while increasing ease of management for patient, decreasing cost, and allowed for same day use following initial fabrication. Applicability of Research to Practice Utilization of this type of facial mask whether exclusively or as an adjunct to a thermoplastic mask, may provide standard of care treatment and expedite scar management.

Abstract Introduction Burn therapist certification (BT-C) was introduced in 2018 to recognize therapists with specialized skill in burn rehabilitation and promote quality burn therapy. There are currently 32 BT-Cs, representing a small fraction of therapists who rehabilitate burn patients. Barriers to certification described in a Letter to the Editor by O’Neil in 2022 included an indifference to therapy research and program development. Despite efforts to call for additional support of therapy advancement and research, therapist publications continue to be sparse. This review analyzed BT-C therapists involved in publications as one indicator of a positive impact on the field. Methods A review of therapist-authored manuscripts and abstracts published in the Journal of Burn Care and Research from 2018-2022 was performed. Therapy authored publications included any manuscript or abstract with a therapist listed as a lead or contributing author. Publications with only SLP, PTA, or OTA credentials were excluded. Therapists were only considered to be certified if they had achieved BT-C at the time of publication. Results BT-C make up not more than 15% of therapists practicing in burns, yet the percentage of therapy-authored manuscripts published from 2018-2022 with a BT-C credited author is 50%. When examining supplemental editions, 31% of accepted therapy-authored submissions from 2018-2022 included a BT-C therapist. The table compares the percentage of therapy-authored manuscripts and therapy-authored submissions from BT-C versus the percentage of BT-C using the 215 identified PT and OT members from 2008 as a conservative estimate of the floor of the number of PT and OT providing routine burn care, with the current count of BT-C at 32. Conclusions Estimations of the number of PT and OT working in burn rehabilitation are difficult to determine. It is assured that therapists providing care to burn patients routinely are larger in number than those who are active members in the American Burn Association in any given year. One publication revealed 215 active PT and OT members in 2008. Despite BT-C therapists making up a small percentage of the therapy community working in burn rehabilitation, BT-C therapists contributed to half of therapy publications and almost a third of abstract submissions in each area respectively, indicating that certified burn therapists have a profound, and disproportionately large, impact on formal investigation and research. Applicability of Research to Practice Currently there is a lack of objective information that can be presented to administrators to validate support of the burn therapist certification. Supporting certification may promote quality care through involvement in research furthering best practice.

Abstract Introduction Hand edema is a common sequalae of burn injuries involving the upper extremity (UE) and larger total body surface area (TBSA) burns requiring fluid resuscitation. Hand edema can be challenging to manage depending on the severity of the injury and, if not adequately addressed, can have long-term functional implications. Multiple edema management techniques are available for therapists treating burn injuries, but little is known about their efficacy. A quality improvement project examined the efficacy of 4 strategies used at our burn center. Methods Edema management strategies evaluated included: elevation using a pre-cut foam wedge and pillow, elevation and self-adhesive wrap, elevation and cotton-elastic wrap, and elevation with a chip-bag. Figure-of-8 measurements were taken pre and post intervention. Outcomes included length of time intervention was in place, reason intervention selection, time required to apply intervention, and if intervention was intact prior to removal. Training was completed with staff to ensure consistent application of intervention. Only adult patients were included. Results A total of 23 interventions were measured. At follow up, 61% of the interventions were not intact. In each instance this was due to displacement of either the wedge or pillow. Self-adhesive wrap (3.25 cm) followed by cotton-elastic wrap (2.57 cm) in conjunction with elevation achieved the greatest reduction in edema. Elevation of the UE with a wedge and pillow are less effective in managing hand edema alone, with a mean difference of .26 centimeters (cm) decrease in edema. On average, it took therapists less time to apply cotton-elastic wrap (6.4 minutes) vs self-adhesive wrap (14.25 minutes). Conclusions In this limited sample, elevation with a pre-cut foam wedge or a pillow was least effective in reducing edema in the hand. Including a secondary edema management technique in conjunction with elevation is more effective in managing hand edema. A larger sample size may benefit increased understanding of edema management techniques within a burn center. Applicability of Research to Practice Interdisciplinary training on maintaining edema management strategies is important to promote maintenance of positioning. Further research is warranted to examine the efficacy of hand edema intervention strategies in the acute burn patient.

Abstract Introduction A variety of factors affect the fit of custom orthoses in those with burn injuries. A resting hand orthosis (RHO) is a common device within burn care, yet fabrication and fitting of this custom orthosis requires precision and expert assessment. However, burn therapists have varying degrees of education and credentials and previously we had noted preventable complications. Our center implemented a multi-tiered protocol focused on custom RHOs and found a marked decrease in complications immediately following implementation. The purpose of this QI project was to evaluate whether these improvements had been sustained over the following three-year period. Methods This was a retrospective chart review. Per protocol an RHO could be fabricated by a single certified hand therapist (CHT) or co-fabricated by two (non-CHT) therapists. Incidence of orthosis complications, defined as erythema and/or an orthotic induced partial-thickness injury to the volar second metacarpal head (index finger) was the primary outcome measure. Other data collected were average time to fabricate & modify devices and average refabrication(s) required between CHT vs non-CHT devices. Patients with missing data points was excluded. Results Eighty-five patient hands were examined from 2019-2022. Prior to implementation, total erythema occurrences were reported in 23.4% of orthoses (n=18) and total orthotic induced partial thickness injury occurred in 11.7% (n=9) of cases. Post protocol implementation erythema occurred in 5% of cases (n=5), and partial thickness injury in 0% of cases (n=0). This represents a decrease of 95% and 100%, respectively. On average CHTs fabricated RHOs in 59 minutes vs 48 minutes for non CHTs. CHTs had a complication rate of 0.0% vs 10.98% for non-CHTs. Potential complication was also limited to 0.0% for CHTS and 27% of non-CHTs. Modification rates were limited to 18.75% for CHTS vs 47.56% of non-CHTs. Conclusions Data from this QI project showed a clinically significant decrease in erythema and decrease in breakdown and number of modifications needed from utilization of either a CHT or two therapists when managing hand orthoses. Since instituting our protocol focusing on RHOs, our center has decreased complications and potential complications to improve patient outcomes. Although, most therapists receive standard education, it can be inferred that CHTs may approach orthotic fabrication through a different lens. The required studying and education required to maintain an advanced practice certification may benefit burn therapy departments. Therapists without this specialty certification can enhance skill and outcomes via co-fabrication and assessment. Applicability of Research to Practice Orthotic induced erythema may be decreased by utilizing CHTs or two non-CHTs to manage RHOs. This protocol can be expanded to include other orthoses or with other advanced certifications.

Abstract Introduction Management of shoulder burn injuries creates unique challenges as the shoulder girdle is comprised of four joints and has the largest degree of motion in the body. The complexity of arthrokinematics and cutaneokinematics requires creative positioning devices to achieve the desired effect. Shoulder positioning devices for pediatric patients are limited, and devices that allow positioning at end range can be bulky, heavy, and costly. Available hinges for upper extremity devices offer limited utility and do not withstand the tensile forces of burn scar contracture in conjuncture with and prolonged use. This is a report of a single patient for which a locking knee hinge was used to fabricate a custom static progressive shoulder flexion device. Methods This case study analyzes the impact of bilateral custom static shoulder flexion orthoses and static progressive orthoses on range of motion in a pediatric patient. Static shoulder flexion orthotics were implemented, and then transitioned to static progressive orthotics. Goniometric measurements were obtained through out hospitalization. Average variance in of range of motion at the glenohumeral joint (GH), and standard deviation of goniometric measurements comparing static and static progressive orthoses were collected. Results There was a total of 33 bilateral sets of goniometric measurements. Sixteen sets were collected utilizing static shoulder flexion orthoses. Mean flexion was 149.6⁰ and 154.6⁰ abduction of the left shoulder. Right shoulder flexion and abduction means were 149.3⁰ and 152.8⁰ degrees. There was a standard deviation (STD) of 22⁰ for the left shoulder mean goniometric measurements and STD of 23.2⁰ for the right shoulder. Seventeen sets were collected utilizing static progressive shoulder flexion orthoses. Results revealed a mean of 166.1⁰ and 166.7⁰ for flexion and abduction of the left shoulder. Right shoulder flexion and abduction averages were 169.3⁰ and 170.6⁰ respectively. There was an STD of 8.9⁰ for mean goniometric measurements of the left shoulder and STD of 4⁰ of the right shoulder. Introduction of a locking hinged shoulder flexion orthosis resulted in an increase of 80⁰ left and 90⁰ right shoulder flexion in 24 hours. The patient was able to achieve and maintain an average of 165⁰ of shoulder flexion throughout hospitalization (47 days). Conclusions Use of a locking hinged shoulder orthosis allowed for progressive increase in shoulder flexion without neurological symptoms and decreased pain and anxiety related to therapy and orthotic application. Compliance with wearing schedule was increased due to ease of application. Applicability of Research to Practice Utilization of locking hinges to create custom static progressive shoulder flexion orthoses may allow therapists to increase and maintain shoulder range of motion in pediatric patients following burn injury.

Abstract Introduction The American Burn Association (ABA) Burn Therapist Certification (BT-C) program, developed in 2018, derived from an organizational desire to promote vetted quality burn care across the interprofessional team. Leadership positions within organizations, are responsible for formulating policy, developing education, and providing oversite to ensure the success of the association. A previous study examining interdisciplinary representation within burn society leadership for the ABA and International Society of Burn Injuries, found that rehabilitation representation within governance positions was 7% and 9% within committee memberships. In a 2022 Letter to the Editor, therapists described limited center support as a barrier for obtaining BT-C. This study aims to examine BT-C member involvement within ABA society leadership. Methods Official ABA society and membership websites were accessed to identify BT-C recipients who currently hold positions within society governance and committee memberships. ABA Special Interest Group (SIG) membership was also examined. The Journal of Burn Care and Research (JBCR) website was accessed to identify BT-C recipients on the editorial board. BT-C members were compared to other therapist involvement. Results Of 32 qualified BT-C therapists, 26 continue their ABA memberships. BT-C therapists hold 3 Governance positions (Board membership and current ABA President) and maintain 36 of the available 77 committee positions (47%). Excluding the BT-C Committee from data collection, BT-C therapists make up 44% (n=23) of therapist committee positions within the ABA. BT-C therapists hold a combined 46 SIG memberships. The JBCR currently lists 2 therapists on the editorial board, both of whom are BT-C. Conclusions Despite representing a fraction of the burn therapy community, BT-C therapists continue to be leaders within the burn field by participation in ABA membership, governance, and committee memberships. Current BT-C therapists serve to establish standards in research published within the JBCR. Professional and academic societies depend on qualified leaders to set standards of burn care. Promoting BT-C within individual burn centers may stimulate leadership within the center and burn professional organizations. Applicability of Research to Practice Definitive evidence supporting the benefits of BT-C to individuals and organizations is needed to overcome current barriers to certification.

Rehabilitation therapies in the burn acute care environment continue to evolve. Immediate access to therapy is considered standard, and therapy is a key component of the transprofessional care team. Early positioning, edema management, and therapy care in the intensive care unit (ICU) environment can limit later complications; mobility in the ICU can be engaged safely using a systems-based approach in the absence of nondirectable agitation. Later in the course of acute care, early ambulation is an appropriate intervention that can improve outcomes.

Abstract Introduction Resting hand orthoses (RHO) are often used to manage hand burns but can be difficult for inexperienced clinicians to fabricate, assess, and utilize without causing complications to the patient. Previously we had shared data on how we reduced RHO related complications by utilizing burn and hand certified staff to fabricate RHOs. Methods Advanced clinicians certified in either hand, burn, or both were queried to describe the methodology they utilized to fabricate an effective RHO. From this query, a list of conditions was created. These conditions were presented to the entire group of certified clinicians and re-examined. Conditions were recorded if consensus was reached on their inclusion for a guide to fabricate a successful RHO. Results A 14-condition checklist, with 8 essential items, was developed. It is intended that this checklist can be utilized by less experienced clinicians to guide safe and effective RHO management. Conclusions The checklist is a straightforward way to assess commonly identified issues with RHO and offers a potential resource to manage effective fabrication for novice or inexperienced clinicians.

Abstract Introduction Burns crossing over a joint can result in a contracture of that joint. Axillary burns and subsequent contractures are common and may impact negatively on burn survivor rehabilitation. Positioning of burned extremities at the most lengthened position is ideal for maintenance of function and contracture prevention, 90 degrees of abduction is the most accepted position for axillary burn injuries. However, many activities of daily living require shoulder range of motion (ROM) greater than 90 degrees. The primary objective of this study was to describe and examine the incidence of paresthesia, pain, and intolerance in healthy subjects when the shoulder was placed in a position of 90 degrees or greater of shoulder abduction. Methods The subject’s nondominant upper extremity (NDE) was randomly placed in a series three of positions, including: (1) 90 degrees shoulder abduction, 30 degrees horizontal adduction with elbow extension, forearm neutral; (2) 130 degrees shoulder abduction, 30 degrees horizontal adduction, 30 degrees elbow flexion, forearm neutral; (3) 150 degrees shoulder abduction, 30 degrees horizontal adduction, 30 degrees elbow flexion, forearm neutral. Each position was maintained for a maximum of 2 hours. Subjects experiencing subjective symptoms including paresthesia lasting longer than 1 minute, pain rated greater than 3/10, and/or intolerance 2/5 was removed from the position. All subjects received at least 30 minutes of rest between positions. Results A total of 25 subjects were enrolled, mean age was 25.8 years, the majority were female (60%) and 20% had a history of NDE shoulder injury. The right arm was the dominant extremity (DE) in 88% of subjects. There were no significant differences in ROM between the DE and NDE extremity with the exception of external shoulder rotation, 94.96⁰ vs 84.8⁰ (p=.0142). Average total splint time was 136 minutes with a range of 40 – 360 minutes. Only 1 subject successfully completed all 3 splinting periods. There were 75 individual splinting events over the 3 splinting periods, and 90% of the time the splinting was stopped early. The most common reason for stopping early was paresthesia (88%) followed by pain (7%). Conclusions The positions selected represent the routine and usual care at our burn center. Patients are routinely positioned from hours to days depending on patient need. This study demonstrated that healthy subjects were unable to tolerate positioning for even two hours.

Abstract Introduction Anatomical structures of the hand are complex and delicate making hand burns particularly challenging to manage. Orthoses are a cornerstone treatment modality and unsuccessful therapeutic interventions can result in hand contracture and deformities, which can result in up to 95% impairment in upper extremity function. Therapists at our burn center have varying degrees of education and credentials, and we had noticed increased incidence of orthotic induced complications in the hand. The purpose of this QI project was to implement a formal protocol that provided guidelines around fabricating and fitting hand orthoses. Methods The protocol mandated that custom fabricated resting hand orthoses should be fabricated by a single CHT or co-fabricated by two (non-CHT) therapists. Orthoses were fabricated as indicated. Orthosis modifications and orthosis complications, defined as erythema and/or an orthotic induced partial-thickness injury to the volar second metacarpal head (index finger) were documented. For the purposes of our study, breakdown was limited to the index finger. These modifications and complication totals were compared to pre-implementation data. Any patient with missing data points was excluded. Results Seventy-seven patient hands were examined from 2016–2019. Prior to implementation of the protocol, erythema occurred with 23.4% (n=18) of orthoses and orthosis induced partial thickness injury was found in 11.7% (n=9) of cases. Post protocol implementation involved examination of 51 hands. Erythema occurred in just 2.0% of cases (n=1) and partial thickness injury in 3.9% of cases (n=2) This represents a decrease of 94.4% and 77.7%, respectively. Number of modifications was reduced by 40.9%, from 22 to 13. Conclusions Orthosis fabrication is a specialized therapy skill, requiring hands-on training and advanced anatomical knowledge. While orthotic fabrication is part of general therapy education, the depth and breadth of this education is limited by the clinical opportunities presented to each therapist. CHT’s have undergone rigorous study and testing to make them experts in orthosis management and can bolster skills in a burn therapy department. For therapists without this specialty certification, co-fabrication can also lead to improved outcomes, through real time peer review. Data from this QI project showed a statistically significant decrease in erythema and decrease in breakdown and number of modifications needed from utilization of either a CHT or two therapists when managing hand orthoses.

Abstract Introduction Early mobility in intensive care unit (ICU) patients has been demonstrated effective in improving functional status, range of motion, preventing complications, and decreasing length of stay. There is limited data regarding the early mobilization of burn ICU patients. The purpose of this study was to survey burn care providers to better understand their experience with early mobilization and explore perceived barriers and contraindications. Methods An internet-based 21-item survey was distributed to burn professionals at North American burn centers and units. Descriptive statistics were performed. Results There were a total of 63 respondents. Most respondents were physical therapists (33%), occupational therapists (33%), or nurses (25%), with >5 years of burn care experience (71%). Early mobility was characterized as both in bed and out of bed activities within 24 hours of ICU admission, up to any time during the course of mechanical ventilation or ICU stay. The majority of respondents (54%) indicated they mobilize patients on ventilators in bed and out of bed, while there was an even split on whether or not patients on vasopressor support were mobilized. Of those respondents (46%) who use the Richmond Agitation-Sedation Scale (RASS) to guide mobility, 14% mobilize patients with a RASS of -4 or -5 and 41% mobilize patients with a RASS of -3 to -2. The highest appropriate score for mobilization was +1 to +2 (76%). Hgb/Hct, line presence, ventilator mode, mental status, and vital signs were viewed as precautions to discuss with the medical team, rather than a contraindication to mobility. Respiratory rate < 6 and presence of ECMO were the areas of most concern, with the majority respondents indicating they would likely hold mobility. Most respondents indicated that they would mobilize any burn ICU patients after discussion with the medical team if necessary. The majority of respondents (72%) indicated that they did not have an early mobilization protocol for burn ICU patients. Conclusions There is a paucity of evidence available for early mobility in burn ICU patients. This survey demonstrates a lack of consensus regarding what constitutes early mobility and when patients should be mobilized. A multi-center observational trial is needed to inform the development of an evidence-based mobility protocol.