Decreased neuroplasticity in minor burn injury survivors compared to non-injured adults: A pilot study in burn injury survivors aged 45 years and older

ObjectiveNeuroplasticity is the capacity of the brain to change or adapt with experience: brain changes occur with use, disuse, and injury. Repetitive transcranial magnetic stimulation (rTMS) can be used to induce neuroplasticity in the human brain. Here, we examined rTMS-induced neuroplasticity in the primary motor cortex in burns survivors and controls without injury, and whether neuroplasticity is associated with functional recovery in burns survivors.MethodsSixteen burn injury survivors (total body surface area of burn injury <15%) and 13 non-injured control participants were tested. Repetitive TMS (specifically, spaced continuous theta-burst stimulation[cTBS]) was applied to induce neuroplasticity 6 and 12 weeks after injury in burn survivors and in two sessions separated by 6 weeks in controls. Motor evoked potentials (MEPs) elicited by single-pulse TMS were measured before and after rTMS to measure neuroplasticity. Burns survivors completed a functional assessment 12 weeks after injury.ResultsNon-injured controls showed decreased MEP amplitude 15?30 min after spaced cTBS in both experimental sessions. Burn survivors showed a smaller change in MEP amplitude after spaced cTBS compared to controls 6 weeks after burn injury but no difference compared to controls 12 weeks after burn injury. In burn survivors, there was a significant positive association between general health outcome (Short-Form Health Survey) and the change in MEP amplitude after spaced cTBS 12 weeks after injury (r=.73, p = .01).ConclusionsThe current findings suggest that burn survivors have a reduced capacity for neuroplasticity early in the recovery period (6 weeks after injury), which normalizes later in the recovery period (12 weeks after injury). Furthermore, the results provide preliminary evidence to suggest that burn survivors with normalized neuroplasticity 12 weeks after injury recover faster after burn injury.     

Resilience and psychological distress among burn survivors

IntroductionBurn is one of the highly occurring injuries worldwide. In case of an acid attack, survivors are considered an embarrassing element for the family. In other words, survivors’ dignity is judged by the scars on their faces and bodies. Burn survivors experience physical pain of wounds, along with unseen psychological agony. Here, resilience is the most captivating phenomenon that can lead the survivor to normalcy in life after experiencing such traumas. The current study is aimed to explore the role of resilience in the psychological distress of burn survivors.Method160 burn survivors were selected with an age bracket of 18–78 years from indoor hospital settings. To explore resilience, Urdu translated version of the Connor-Davidson Resilience Scale (CD-RISC) by Naz (2011) was used and for symptoms of psychological distress, Urdu version of Depression Anxiety Stress Scale- 21 (DASS-21) by Aslam and Kamal (2017). was also used. The data were analyzed via SPSS 23.ResultsFindings revealed that there is a significant negative relationship between resilience and psychological distress among burn survivors. Moreover, resilience predicted psychological distress. A significant difference was found between types of burn on depression and anxiety. Furthermore, the relationship between resilience to stress and depression is moderated by age of the burn survivor at the time of the incidence. A significant negative relationship between age with psychological distress among burn survivors was observed. The treatment period was associated positively with resilience and negatively with stress among burn survivors. Results also revealed no significant gender difference. However, a significant difference was found between types of burn on depression and anxiety.ConclusionThe findings of current study would be helpful for the medical professionals, mental healthcare providers, and policymakers who can help to develop and implement rehabilitation programs and mental health demands for the said population and can initiate and plan resilience promoting programs that would help promote adaptive coping to deal with trauma.     

Post burn pruritus--a review of current treatment options

Post burn pruritus is a well recognised symptom in almost all burn patients. Yet, there is insufficient awareness about the etiopathogenesis and a lack of a systematic approach in the assessment and treatment of this distressing symptom. The current standard therapies include antihistamines, which are effective as sole therapy in only 20% patients, and emollients. There is a lacunae of clear consensus on the care of patients not responding to antihistamines. We review the literature on the etiology and pathogenesis of post burn pruritus, which has both central and peripheral pathways. The published studies on the currently available therapeutic options to treat itch in burns are discussed. On the basis of current evidence in literature, gabapentin used in the treatment of neuropathic pain, has demonstrated great promise, and is suggested as the next option for this subset of patients, not relieved with antihistamines.     

No difference observed in short-interval intracortical inhibition in older burn-injury survivors compared to non-injured older adults: A pilot study

ObjectiveThe study aimed to investigate short-interval intracortical inhibition (SICI) in burns survivors and non-injured controls, and establish whether paired-pulse transcranial magnetic stimulation (TMS) is a sensitive tool to investigate SICI after burn-injury.MethodsBurn survivors underwent experimental assessments at 6- and 12-weeks after injury, and control participants underwent two equivalent sessions 6 weeks apart. Single-pulse transcranial magnetic stimulation (TMS) was used to record motor-evoked potentials (MEPs) from a hand muscle and paired-pulse TMS was used to measure SICI. Functional measures were obtained for comparison at 12-weeks after injury.ResultsThere was no significant difference in SICI between burns survivors and non-injured controls at either 6- or 12-weeks after burn injury. There was no evidence of correlations between SICI and functional outcome measures in burns survivors.ConclusionsThese results show that paired-pulse TMS is a useful method for investigating cortical inhibition following burn injury, and that SICI circuits in the primary motor cortex are not affected by minor burn injury. This study presents details for definitive future studies of primary motor cortex function after minor burn injury.     

Boosting focally-induced brain plasticity by dopamine

Dopamine (DA) simultaneously produces both excitation and inhibition in the human cortex. In order to shed light on the functional significance of these seemingly opposing effects, we administered the DA precursor levodopa (L-dopa) to healthy subjects in conjunction with 2 neuroplasticity-inducing motor cortex stimulation protocols. Transcranial direct current stimulation (tDCS) induces cortical excitability enhancement by anodal and depression by cathodal brain polarization, which is not restricted to specific subgroups of synapses. In contrast, paired associative stimulation (PAS) induces focal excitability enhancements of somatosensory and motor cortical neuronal synaptic connections. Here, we show that administering L-dopa turns the unspecific excitability enhancement caused by anodal tDCS into inhibition and prolongs the cathodal tDCS-induced excitability diminution. Conversely, it stabilizes the PAS-induced synapse-specific excitability increase. Most importantly, it prolongs all of these aftereffects by a factor of about 20. Hereby, DA focuses synapse-specific excitability-enhancing neuroplasticity in human cortical networks.     

Cultural adaptation of the 5-D itch scale and its reliability for Brazilian burn survivors

This was a methodological study whose objective was to culturally adapt the 5-D itch scale for Brazilian Portuguese and verify its practicability, acceptability and reliability for burn survivors. This study followed the five internationally recommended steps for the adaptation process: translation, synthesis, back translation, assessment by an expert committee and pretesting process; besides, an evaluation of its practicability, acceptability and reliability was conducted. The pretest was carried out with thirty burn survivors – hospitalized or on outpatient follow-up – from two public hospitals in the state of São Paulo. Most burn survivors were male (18; 60%), aged at mean of 39.2 (SD = 11.1), with deep partial burn injuries (16; 59.3%), percentage of total burn surface area of 12.3 (SD = 9.8); and most accidents occurred at domestic environment (18; 60%). The Brazilian version had semantic and idiomatic, conceptual and cultural equivalences, with a satisfactory content validity index for each item (CVI-I). Mean application time was 3.5 minutes, acceptability was good, and there was evidence of reliability for the total score (0.793). The Brazilian version of the 5-D itch scale showed equivalence and evidence of reliability for assessing pruritus and its impact in burn survivors.     

Use of gabapentin and pregabalin for pruritus and neuropathic pain associated with major burn injury: A retrospective chart review

Introduction

Pruritis after burn is one of the most common chronic complaints in burn survivors. Pruritus is often indistinguishable from neuropathic pain. There is a paucity of studies reporting the use of gabapentin and pregabalin to treat both pruritus and neuropathic pain. The purpose of this current study is to explore and document the effect of gabapentin and pregabalin in children and adolescent burn survivors.

The utility of a burn specific measure of pain anxiety to prospectively predict pain and function: a comparative analysis

Patients treated for burn injuries commonly experience high levels of acute pain and anxiety during hospitalization, particularly as it relates to their dressing changes and other medical procedures. A new instrument, the burn specific pain anxiety scale (BSPAS), was designed to characterize patient's anxiety in this setting, but its predictive validity in relation to other measures of anxiety has yet to be demonstrated. In this study, 27 patients with acute burn injuries completed three measures of anxiety upon admission to a major medical burn trauma center. Scores on the anxiety measures were compared with regard to their ability to predict subsequent ratings of procedural and background pain levels, pain medication usage, and physical and emotional functioning upon discharge. In support of criterion-related validity, the BSPAS was the best predictor of procedural pain levels as rated later the same day relative to the other global anxiety measures; moreover, the BSPAS did not predict later-day background pain levels as hypothesized. Both the BSPAS and the global anxiety measures were found to significantly predict total number of pain medications over a 24-h period. Finally, the BSPAS was the only significant predictor of decreased physical role functioning at discharge whereas the other more global measures of anxiety were better predictors of emotional functioning. These results provide preliminary evidence that the BSPAS is a unique and valid indicator of pain-related anxiety surrounding burn care in hospitalized patients and may be useful in identifying those patients at risk for decreased functional capacity at the time of discharge.     

Validation and the future of stimulation therapy of the primary motor cortex

The use of electrical motor cortex stimulation (EMCS) for post-stroke pain was established in Japan and has spread globally. EMCS has been used for the treatment of neuropathic pain, Parkinson's syndrome, and recovery of motor paresis. Since 2000, repetitive transcranial magnetic stimulation (rTMS) has been developed for the treatment of various neurological disorders. rTMS is a non-invasive method with almost no adverse effects. In the USA, rTMS of the left dorsolateral prefrontal cortex was approved for the treatment of major depression in 2008. rTMS of the primary motor cortex (M1) has been studied worldwide for the treatment of neuropathic pain, Parkinson's disease, motor paresis after stroke, and other neurological problems. New methods and devices for rTMS therapy are under development, and rTMS of the M1 is likely to be established as an effective therapy for some neurological disorders. The present review discusses EMCS and rTMS of the M1 concisely.     

The effectiveness of a pain and anxiety protocol to treat the acute pediatric burn patient

This retrospective review of 286 acute pediatric burn survivors treated in 2001 evaluated the effectiveness of a pharmacotherapeutic protocol for pain, anxiety, and itching. Background pain, procedural pain, exercise pain, anxiety, incidence of acute stress disorder (ASD), and itch were measured with standardized instruments. When this review was compared to similar reviews done in 1993-1994 and 1998, a steady trend toward using more potent pain medications in this patient population is evident. While the use of acetaminophen alone decreased from 50.6% of patients in 1993-1994 and 26.3% in 1998 to 7.3% in 2001, the use of opiates increased from 44.8% in 1993-1994 and 66.9% in 1998 to 81.3% of patients in 2001. Likewise, the use of benzodiazepines for anxiety has increased from 59.8% in 1998 to 77.5% of patients in 2001. During that same period the incidence of ASD decreased from 12.1% in 1993-1994 to 8.7% of patients in 2001. For effective pain and anxiety management, the average administered dose of lorazepam and morphine also increased, providing impetus to revise the pharmacotherapeutic pain protocol. Having a standard pain protocol furnishes a framework for periodic review and facilitates updating of pain and anxiety treatment practices.     

Catecholaminergic consolidation of motor cortical neuroplasticity in humans

Amphetamine, a catecholaminergic re-uptake-blocker, is able to improve neuroplastic mechanisms in humans. However, so far not much is known about the underlying physiological mechanisms. Here, we study the impact of amphetamine on NMDA receptor-dependent long-lasting excitability modifications in the human motor cortex elicited by weak transcranial direct current stimulation (tDCS). Amphetamine significantly enhanced and prolonged increases in anodal, tDCS-induced, long-lasting excitability. Under amphetamine premedication, anodal tDCS resulted in an enhancement of excitability which lasted until the morning after tDCS, compared to approximately 1 h in the placebo condition. Prolongation of the excitability enhancement was most pronounced for long-term effects; the duration of short-term excitability enhancement was only slightly increased. Since the additional application of the NMDA receptor antagonist dextromethorphane blocked any enhancement of tDCS-driven excitability under amphetamine, we conclude that amphetamine consolidates the tDCS-induced neuroplastic effects, but does not initiate them. The fact that propanolol, a beta-adrenergic antagonist, diminished the duration of the tDCS-generated after-effects suggests that adrenergic receptors play a certain role in the consolidation of NMDA receptor-dependent motor cortical excitability modifications in humans. This result may enable researchers to optimize neuroplastic processes in the human brain on the rational basis of purpose-designed pharmacological interventions.     

Invasive and non-invasive brain stimulation for treatment of neuropathic pain in patients with spinal cord injury: A review

Context

Past evidence has shown that invasive and non-invasive brain stimulation may be effective for relieving central pain.

Objective

To perform a topical review of the literature on brain neurostimulation techniques in patients with chronic neuropathic pain due to traumatic spinal cord injury (SCI) and to assess the current evidence for their therapeutic efficacy.

Methods

A MEDLINE search was performed using following terms: “Spinal cord injury”, “Neuropathic pain”, “Brain stimulation”, “Deep brain stimulation” (DBS), “Motor cortex stimulation” (MCS), “Transcranial magnetic stimulation” (TMS), “Transcranial direct current stimulation” (tDCS), “Cranial electrotherapy stimulation” (CES).

Results

Invasive neurostimulation therapies, in particular DBS and epidural MCS, have shown promise as treatments for neuropathic and phantom limb pain. However, the long-term efficacy of DBS is low, while MCS has a relatively higher potential with lesser complications that DBS. Among the non-invasive techniques, there is accumulating evidence that repetitive TMS can produce analgesic effects in healthy subjects undergoing laboratory-induced pain and in chronic pain conditions of various etiologies, at least partially and transiently. Another very safe technique of non-invasive brain stimulation – tDCS – applied over the sensory-motor cortex has been reported to decrease pain sensation and increase pain threshold in healthy subjects. CES has also proved to be effective in managing some types of pain, including neuropathic pain in subjects with SCI.

Conclusion

A number of studies have begun to use non-invasive neuromodulatory techniques therapeutically to relieve neuropathic pain and phantom phenomena in patients with SCI. However, further studies are warranted to corroborate the early findings and confirm different targets and stimulation paradigms. The utility of these protocols in combination with pharmacological approaches should also be explored.     

Inhaled methoxyflurane for pain and anxiety relief during burn wound care procedures: an Australian case series

Pain is a common and significant feature of burn injury. The use of intravenous opioids forms the mainstay of procedural burn pain management, but in an outpatient setting, the demand for novel agents that do not require parenteral access, are easy to administer and have a rapid onset are urgently needed. One such agent is the inhaled anaesthetic agent, methoxyflurane (MF). The aim of this study was to conduct a pilot investigation into the clinical effectiveness of MF inhaler on pain and anxiety scores in patients undergoing burn wound care procedures in an outpatient setting. A prospective case series involved recruiting patients undergoing a burn wound care procedure in an ambulatory burn care setting. Pain and anxiety were assessed using numerical rating scales. Overall, median numerical pain rating score was significantly higher post‐dressing [pre‐dressing: 2; interquartile range (IQR): 1–3 versus post‐dressing: 3; IQR 1·5–4; P = 0·01], whereas median numerical anxiety score significantly reduced following the dressing (pre‐dressing: 5; IQR 4–7 versus post‐dressing: 2; IQR 1–2; P < 0·001). Our study suggests that there is a role for MF in the pain management armamentarium in those undergoing burn care procedures in the ambulatory care setting. However, there is an urgent need for larger case series and randomised controlled trials to determine its overall clinical effectiveness.     

Health utilities in burn injury survivors: A systematic review

BackgroundAn estimated 11 million burn injuries with medical attention occur every year worldwide. Although potentially deadly, burn injuries are now considered a chronic disease with multiple lifetime physical and psychological sequelae. However, it remains unclear how these events affect patients’ utility scores. We aimed to conduct a systematic review to summarize the utility scores of burn injury survivors.MethodsWe conducted on March 18^th, 2020 a systematic review of the published literature using a search strategy designed in collaboration with a research librarian. Our search strategy aimed to identify studies that provided burn injury survivors’ utility scores via a standardized indirect instrument.ResultsWe identified 15 studies that reported burn injury survivors’ utility scores. Most studies used the EQ-5D instruments to assess patients’ utility scores. Results varied substantially between studies, ranging from a low of 0.06 to a high of 0.972. Our review identified two key trends. First, utility scores seem to be negatively correlated with the severity of the burn injury. Second, utility scores in adults tend to increase in function of the time since injury.ConclusionUnfortunately, due to differences in study design and settings, patient populations and instruments used to assess patients’ utility scores, we were unable to combine all study results into a single value. In spite of this limit, results we identified support previous trends identified by others regarding the relationship between utility scores and the burn injury severity and/or the time since injury.     

Acute burn injuries associated with long-term mortality: a systematic review and meta-analysis

BackgroundEmerging evidence suggests that the pathophysiological impact of acute burn injuries may have chronic health consequences. We conducted a systematic review and meta-analysis to investigate the association between burn injuries and long-term mortality in patients surviving to initial discharge from hospital.MethodsMedline and Embase databases were searched on 22 October 2021. Studies were eligible for inclusion if they compared long-term mortality amongst burn survivors to non-injured controls from the general population. When the same output metrics related to mortality were reported, meta-analyses were undertaken using a random effects model. Risk of bias was assessed using the Joanna Briggs Institute (JBI) critical appraisal tool.ResultsFollowing an extensive literature search, six studies (seven articles) were identified for inclusion. They were predominantly based in high-income countries, with each comparing burns’ survivors to matched non-injured controls from the general population. The four studies included in the meta-analysis had a combined unadjusted odds ratio of 2.65 (1.84 – 3.81; 95 % confidence interval) and adjusted mortality rate ratio of 1.59 (1.31 – 1.93; 95 % confidence interval). Thus, burn survivors demonstrated greater mortality rates when compared to their non-injured counterparts. Similar findings were illustrated in the remaining studies not included in the meta-analysis, with the exception of one study which found no significant difference between the two groups.ConclusionsOur review suggests that acute burn injuries may be associated with greater long-term mortality rates (unadjusted and adjusted). The underlying mechanism is unclear and further work is required to establish the role of certain factors such as biological ageing processes, to improve outcomes for burn patients.     

Patient-controlled analgesia: a double-blind study in burn patients

A double-blind controlled study was performed to assess the efficacy and safety of patient-controlled analgesia in burn patients. This method was compared with conventional analgesic therapy consisting of intermittent intravenous morphine injections. Twenty-four adult patients hospitalised for burn injuries participated in the study. The McGill Pain Questionnaire, visual analogue scales and verbal-numeric scales were administered at regular intervals to measure various components of the patients' pain experience, degree of pain relief, anxiety levels, adverse side effects and overall treatment efficacy. Although statistical significance was found in only one measure, the results suggested better pain control in patients who were administered morphine by patient-controlled analgesia as compared with intermittent injections. Analysis of the side effects showed no difference between the groups. The amount of morphine administered over the trial period was also similar for the two groups but considerable interpatient variability was seen. Although further research is needed to determine the conditions for optimal use of patient-controlled analgesia, it is concluded that it is a safe, effective and improved method for controlling pain in selected burn patients.     

Properties of an ideal burn dressing: A survey of burn survivors and front-line burn healthcare providers

Objectives

The objective of this study is to identify what burn survivors and front-line staff indicate would improve satisfaction with burn dressings, and the ranking of importance of different burn dressing characteristics. These findings will guide the development of future dressings to meet these needs.

Traitement neurochirurgical de la douleur chronique

Neurosurgical treatment of pain used two kind of techniques: 1) Lesional techniques interrupt the transmission of nociceptive neural input by lesionning the nociceptive pathways (drezotomy, cordotomy, tractotomy…). They are indicated to treat morphine-resistant cancer pain and few cases of selected neuropathic pain. 2) Neuromodulation techniques try to decrease pain by reinforcing inhibitory and/or to limit activatory mechanisms. Chronic electrical stimulation of the nervous system (peripheral nerve stimulation, spinal cord stimulation, motor cortex stimulation…) is used to treat chronic neuropathic pain. Intrathecal infusion of analgesics (morphine, ziconotide…), using implantable pumps, allows to increase their efficacy and to reduce their side effects. These techniques can improve, sometimes dramatically, selected patients with severe and chronic pain, refractory to all other treatments. The quality of the analgesic outcome depends on the relevance of the indications.     

Aromatherapy for the relief of symptoms in burn patients: A systematic review of randomized controlled trials

Background

Aromatherapy is often used to manage several conditions, including pain, psychological distress, and burn-related symptoms. The objective of this review was to assess the current evidence regarding the efficacy of aromatherapy as a treatment for burn wounds.

Implantable technology for pain management

Neuropathic pain is a well-recognized chronic pain condition. This can have a significant impact in patients' quality of life. Neuromodulation is defined by the International Neuromodulation Society as ‘the therapeutic alteration of activity in the central or peripheral nervous system either electrically or pharmacologically’. Electrical stimulation can be performed at the motor cortex, deep brain, spinal cord, dorsal root ganglion, peripheral nerve and peripheral nerve field. Pharmacological modulation is achieved by directly infusing drugs to the central nervous system. Although neuromodulation has become increasing popular, it is still currently believed to be underused in treating neuropathic pain. This modality has provided us with a non-pharmacological approach to manage patients with neuropathic pain. Patients should have been assessed by a multidisciplinary team before undergoing neuromodulation. This review highlights the present and future management of patients with chronic intractable pain using neuromodulation.