Abstract
Contracture is a common complication of burn injury and can cause significant barriers to functional recovery and rehabilitation. There are limited studies of quantitative range of motion after burn injury. The purpose of this study is to examine quantitative contracture outcomes by anatomical location, burn size, and length of stay in adults. Data were obtained from the Burn Model System National Database from 1994 to 2003. All adult patients with a joint contracture at acute discharge were included and 16 joint motions were examined. Contractures were reported as both mean absolute loss of normal range of motion in degrees and percent loss of normal range of motion. Analysis of variance was used to assess for a linear trend for contracture severity by burn size and length of stay. Data from 659 patients yielded 6,228 instances of contracture. Mean absolute loss of normal range of motion ranged from 20° to 65° representing an 18 to 45% loss of normal movement across the studied joint motions. In the majority of joint motions, contracture severity significantly increased with larger burn size and longer length of stay; however, wrist and many lower extremity joint movements did not demonstrate this trend. The data illustrate the quantitative assessment of range of motion deficits in adults with burn injury at discharge and the relation to burn size and length of stay.
Scar contracture following burn injury can lead to severe functional impairments and disability for burn survivors(1). Prevention and treatment of soft tissue contracture are key goals of early burn care in the weeks and months following injury(2–4). One challenge for implementing studies for burn contracture is the relative lack of baseline range of motion (ROM) outcome data that reflect the anticipated severity of contractures for a given joint motion and burn severity5. Prior research using the Burn Model System (BMS) database has helped us to define burn contracture outcomes using qualitative categorical severity ratings(6–9); however, quantitative outcomes across multiple joint motions from a multicenter database have not been examined previously. Because the standard measurement method in clinical practice is using degrees of ROM, employing a quantitative approach makes results more concrete and directly comparable to individual practice methods. It also provides more granular data that may be more informative to the clinician readership of physical and occupational therapists, physiatrists, and surgeons. Additionally, such data would aid future studies investigating contracture interventions.
The BMS National Database is a multicenter database funded by the National Institute on Disability, Independent Living, and Rehabilitation Research. The BMS National Database contains prospective longitudinal data across a wide range of variables. During the period of 1994–2003, the database included contracture-associated ROM outcomes at multiple joints at the time of discharge.
The aim of this study is to review quantitative ROM outcomes at multiple joint motions, by burn size, and by acute hospital length of stay (LOS) in adult burn survivors. Burn size was selected as a defining injury characteristic known at admission, whereas LOS reflects initial burn injury as well as complicating factors such as age, comorbidities, and inhalational injury(10–12). The goal of the study is to provide a point of reference for ROM outcomes at discharge.
METHODS
Study Population and Database
Data were obtained from the BMS National Database from 1994 to 2003 for burn patients aged 18 years and older. The BMS National Database included data on survivors who were fluent in either English or Spanish and met the American Burn Association criteria for a severely burned person, namely, those with one or more of the following:
deep second- and third-degree burns greater than 10% TBSA in patients under 10 or over 50 years of age;
deep second- and third-degree burns greater than 20% TBSA in all other age groups;
deep second- and third-degree burns with serious threat of functional or cosmetic threat that involves face, hands, feet, genitalia, perineum, or major joints in all age groups;
third-degree burns greater than 5% TBSA;
deep electrical burns including lightning injury;
burn injury with inhalation injury; and
circumferential burns of the extremity or chest.
Details about the inclusion or exclusion criteria of the BMS National Database can be found at http://burndata.washington.edu/standard-operating-procedures, and the complete detailed inclusion and exclusion criteria have been described previously(13).
Data Variables
Patient demographic data included age, gender, and ethnicity. Clinical data included burn size by percent total body surface area (TBSA), etiology of injury, number of surgeries, length of acute hospital stay, and presence and length of inpatient rehabilitation hospital stay. The primary outcome variable for this study was ROM recorded at the time of acute hospital discharge.
Table 1 provides the database definitions of normal ROM for each joint. The defined normal ROM and the specific methodology for ROM measurements at each joint are detailed in the BMS National Database Data Dictionary(14). Per the database protocol, ROM data were only entered in cases where contracture was present and the patient did not have full, active ROM at the specified time point. With regards to rehabilitation terminology consensus statements, joint motions in this study refer to the direction of impaired ROM(15). A single patient could contribute multiple contracture data points if multiple locations of joint contracture were present. ROM measurements from 16 areas of impaired motion from the shoulder, elbow, wrist, hand, hip, knee, and ankle joints were included in the study (Table 1). In the database, joint ROM was reported as active ROM in degrees, starting from neutral position if possible. For example, elbow flexion was defined as 0° to +140°. Therefore, a measurement of +140° would indicate full active flexion and reports less than +140° indicate a lack of full joint flexion. The maximum normal arc for elbow flexion is 140°. ROM data were excluded if the data were invalid, for example, a ROM value outside the range of the defined ROM (elbow flexion of less than 0 or greater than +140°) or if ROM data reflected normal ROM (no contracture present).
Table 1.
Definitions of normal joint motions
| Joint | Muscle action | Defined ROM, degrees | Maximum normal arc, degrees |
|---|---|---|---|
| Shoulder | Abduction | −50 to 180 | 230 |
| External rotation | −90 to 90 | 180 | |
| Flexion | −50 to 180 | 230 | |
| Elbow | Extension | −140 to 0 | 140 |
| Flexion | 0 to 140 | 140 | |
| Wrist | Extension | −60 to 60 | 120 |
| Flexion | −60 to 60 | 120 | |
| Thumb | MP flexion | −40 to 60 | 100 |
| IP flexion | −30 to 80 | 110 | |
| Finger | MP flexion | −20 to 90 | 110 |
| PIP flexion | −30 to 100 | 130 | |
| DIP flexion | −30 to 70 | 100 | |
| Hip | Flexion | −30 to 100 | 130 |
| Knee | Flexion | 0 to 150 | 150 |
| Ankle | Dorsiflexion | −40 to 20 | 60 |
| Plantarflexion | −20 to 40 | 60 |
DIP, distal interphalangeal; IP, interphalangeal; MP, metacarpalphalangeal; PIP, proximal interphalangeal.
Given joint-to-joint variability in normal movement, one cannot necessarily compare ROM measurements across joints (a measurement of +60° would indicate full range for wrist extension but a loss of 120° for shoulder abduction). Therefore, for this study, data were converted to two alternate forms to enable comparisons. The first is absolute loss, defined as the degrees absent from normal, full motion for a specific joint. The second is percent loss, defined as the absolute loss divided by the maximum normal arc. For example, a measurement of +100° for elbow flexion would represent an absolute loss of ROM of 40° (the difference between the recorded value of +100° of flexion and the defined maximum flexion ROM of +140°) and a percent loss of ROM of 29% of the joint’s maximum normal arc of 140° (40° absolute loss/140° = 29% percent loss).
Analysis
Summary demographic and injury-related data were calculated for the population as a whole as well as by TBSA burn severity categories (<20%, 20–40%, and >40%). ROM outcomes (number of contractures, absolute loss, and percent loss) were calculated for all joint motions. In addition, ROM outcomes were examined by TBSA burn severity and acute hospital LOS (≤30 days, >30, <60 days, and ≥60 days) categories.
TBSA groupings were used to examine the impact of a larger burden of injury and associated increased morbidity. Previous research has shown that the volume of soft tissue injury both proximal to and distal from a given joint affects joint movement(16). Therefore, patients with larger overall TBSA burn injuries may face increased challenges in maintaining joint movements.
LOS was anticipated to be related to TBSA, but also with the potential to evaluate the impact of other factors such as pre-existing comorbidities, age, inhalational injury, and hospital-associated complications on the severity of contracture(10–12, 17). In addition, because contracture data were examined at acute hospital discharge, this stratification allowed for examination of a specific time point postinjury.
Analysis of variance was performed to assess associations between measures of injury severity (TBSA and LOS) and ROM outcomes. For these analyses, the dependent variable was the absolute loss of ROM by joint movement, and the independent variable was TBSA or LOS category. A contrast representing the linear trend of ROM loss from low to moderate to high severity categories in terms of TBSA and LOS was formulated and tested. A P-value of less than .05 was considered statistically significant.
RESULTS
The demographic and clinical characteristics of the study population are reported in Table 2. Overall, data from 659 patients yielded 6,228 instances of contracture, with a mean of 9.4 contractures per patient. The majority of patients were white (65.2%), male (79.5%), and with fire or flame injuries (67.1%).
Table 2.
Patient demographics and injury characteristics
| All | TBSA groups | |||
|---|---|---|---|---|
| <20% | 20–40% | >40% | ||
| N | N (%) | N (%) | N (%) | |
| Patients, number | 659 | 320 (48.6%) | 232 (35.3%) | 107 (16.2%) |
| Contractures, number | 6228 | 2406 (38.6%) | 2203 (35.4%) | 1619 (26.0%) |
| Mean ± SD | Mean ± SD | Mean ± SD | Mean ± SD | |
| Age, yr | 41.4 ± 14.7 | 42.7 ± 15.6 | 42.0 ± 14.6 | 36.1 ± 10.4 |
| TBSA burn injury, percent | 24.0 ± 17.8 | 10.0 ± 5.5 | 28.8 ± 6.5 | 55.6 ± 11.1 |
| TBSA grafted, percent | 12.8 ± 12.9 | 5.5 ± 4.2 | 14.3 ± 9.3 | 30.6 ± 17.1 |
| OR trips, number | 2.3 ± 2.2 | 1.4 ± 1.3 | 2.5 ± 2.0 | 4.8 ± 2.7 |
| Acute hospitalization LOS, days | 31.9 ± 24.7 | 19.8 ± 14.2 | 36.0 ± 23.3 | 58.9 ± 28.1 |
| Rehabilitation LOS of patients admitted to rehabilitation, days | 26.2 ± 17.1 | 24.3 ± 22.8 | 21.9 ± 12.1 | 31.1 ± 18.7 |
| N (%) | N (%) | N (%) | N (%) | |
| Admissions to rehabilitation | 97 (14.7%) | 12 (3.8%) | 43 (18.5%) | 42 (39.3%) |
| Gender | ||||
| Male | 524 (79.5%) | 243 (75.9%) | 195 (84.1%) | 86 (80.4%) |
| Female | 135 (20.5%) | 77 (24.1%) | 37 (16.0%) | 21 (19.6%) |
| Ethnicity | ||||
| White non-Hispanic | 428 (65.2%) | 184 (57.5%) | 168 (72.4%) | 76 (71.0%) |
| Black non-Hispanic | 125 (19.1%) | 77 (24.1%) | 37 (16.0%) | 11 (10.3%) |
| Hispanic | 73 (11.1%) | 37 (11.6%) | 20 (8.6%) | 16 (15.0%) |
| Native American | 12 (1.8%) | 7 (2.2%) | 3 (1.3%) | 2 (1.9%) |
| Other | 18 (2.7%) | 12 (3.8%) | 4 (1.7%) | 2 (1.9%) |
| Etiology of burn | ||||
| Fire/flame | 440 (67.1%) | 162 (50.8%) | 180 (78.3%) | 98 (91.6%) |
| Scald | 48 (7.3%) | 35 (11.0%) | 10 (4.3%) | 3 (2.8%) |
| Grease | 41 (6.3%) | 35 (11.0%) | 6 (2.6%) | 0 (0%) |
| Electricity | 36 (5.5%) | 24 (7.5%) | 11 (4.8%) | 1 (0.9%) |
| Flash | 35 (5.3%) | 15 (4.7%) | 17 (7.4%) | 3 (2.8%) |
| Hot object | 23 (3.5%) | 22 (6.9%) | 1 (0.4%) | 0 (0%) |
| Chemical | 14 (2.1%) | 12 (3.8%) | 1 (0.4%) | 1 (0.9%) |
| Tar | 10 (1.5%) | 8 (2.5%) | 2 (0.9%) | 0 (0%) |
| Other | 9 (1.4%) | 6 (1.9%) | 2 (0.9%) | 1 (0.9%) |
OR, operating room; SD, standard deviation
Contracture outcomes for the entire study population are summarized in Table 3. Mean absolute losses ranged from 20° to 65° across the 16 joint motions. Shoulder contractures represented the largest absolute ROM losses (shoulder abduction: 65°; shoulder flexion: 61°); the elbow, wrist, thumb, and ankle joint motions demonstrated the smallest absolute ROM losses. Percent ROM losses ranged from 18 to 45% across the sixteen joint motions. Elbow, wrist, and thumb movements demonstrated low percent losses and ankle movements exhibited the greatest percent losses with 34 and 45% loss in dorsiflexion and plantarflexion, respectively.
Table 3.
Contracture severity by joint movement
| Joint motion | Contractures, number | Patients, number | Absolute loss ROM, mean degrees ± SD | Absolute loss ROM, range | Percent loss ROM |
|---|---|---|---|---|---|
| Shoulder abduction | 270 | 246 | 65 ± 34 | 5–160 | 28% |
| Shoulder ER | 82 | 82 | 39 ± 22 | 3–103 | 22% |
| Shoulder flexion | 435 | 286 | 61 ± 34 | 5–180 | 26% |
| Elbow extension | 222 | 161 | 25 ± 16 | 3–75 | 18% |
| Elbow flexion | 270 | 205 | 33 ± 27 | 2–140 | 24% |
| Wrist extension | 289 | 211 | 22 ± 13 | 2–75 | 19% |
| Wrist flexion | 263 | 195 | 23 ± 14 | 1–100 | 19% |
| Thumb MP flexion | 232 | 155 | 22 ± 12 | 5–65 | 22% |
| Thumb IP flexion | 205 | 138 | 41 ± 18 | 5–91 | 37% |
| Finger MP flexion | 1,108 | 215 | 35 ± 20 | 2–105 | 31% |
| Finger PIP flexion | 1,122 | 224 | 33 ± 21 | 2–127 | 26% |
| Finger DIP flexion | 1,020 | 201 | 33 ± 17 | 1–85 | 33% |
| Hip flexion | 93 | 52 | 28 ± 21 | 5–100 | 22% |
| Knee flexion | 267 | 156 | 51 ± 24 | 5–150 | 34% |
| Ankle dorsiflexion | 198 | 126 | 20 ± 11 | 4–60 | 34% |
| Ankle plantarflexion | 152 | 125 | 27 ± 14 | 3–50 | 45% |
DIP, distal interphalangeal; ER, external rotation; IP, interphalangeal; MP, metacarpalphalangeal; PIP, proximal interphalangeal; SD, standard deviation.
Table 4 demonstrates contracture outcomes by burn severity. In general, burden of injury as measured by TBSA was associated with increased contracture severity. The following joint motions exhibited worse ROM impairments with higher TBSA burn category: shoulder abduction (P < .001), shoulder external rotation (P = .026), shoulder flexion (P < .001), elbow extension (P = .006), elbow flexion (P = .004), thumb metacarpophalangeal (MCP) flexion (P = .014), thumb interphalangeal (IP) flexion (P = .020), finger MCP flexion (P = .028), and finger distal interphalangeal (DIP) flexion (P = .004). There was no significant relationship between TBSA severity and contracture outcome for the following joint motions: wrist extension, wrist flexion, finger proximal interphalangeal (PIP) flexion, hip flexion, knee flexion, ankle dorsiflexion, or ankle plantarflexion.
Table 4.
The impact of burn size on contracture severity by joint motion.
| TBSA < 20% | TBSA 20 to 40% | TBSA > 40% | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Joint motion | N | Absolute loss ROM, mean degrees | Percent loss ROM, mean | N | Absolute loss ROM, mean degrees | Percent loss ROM, mean | N | Absolute loss ROM, mean degrees | Percent loss ROM, mean | P-value for linear trend |
| Shoulder abduction | 78 | 52 | 23% | 110 | 64 | 28% | 82 | 80 | 35% | <.001 |
| Shoulder ER | 18 | 34 | 19% | 33 | 33 | 19% | 31 | 48 | 27% | .026 |
| Shoulder flexion | 124 | 53 | 23% | 181 | 58 | 25% | 130 | 73 | 32% | <.001 |
| Elbow extension | 50 | 22 | 16% | 89 | 23 | 16% | 83 | 30 | 21% | .006 |
| Elbow flexion | 92 | 30 | 21% | 95 | 30 | 21% | 83 | 41 | 29% | .004 |
| Wrist extension | 107 | 21 | 17% | 107 | 24 | 20% | 75 | 23 | 19% | .24 |
| Wrist flexion | 91 | 22 | 18% | 108 | 24 | 20% | 64 | 24 | 20% | .38 |
| Thumb MP flexion | 98 | 21 | 21% | 79 | 21 | 21% | 55 | 26 | 26% | .014 |
| Thumb IP flexion | 89 | 38 | 35% | 73 | 41 | 37% | 43 | 46 | 42% | .020 |
| Finger MP flexion | 469 | 34 | 30% | 370 | 34 | 31% | 269 | 37 | 33% | .028 |
| Finger PIP flexion | 480 | 33 | 25% | 380 | 34 | 26% | 262 | 34 | 26% | .49 |
| Finger DIP flexion | 445 | 34 | 34% | 338 | 29 | 29% | 237 | 38 | 38% | .004 |
| Hip flexion | 31 | 30 | 23% | 22 | 21 | 16% | 40 | 32 | 24% | .70 |
| Knee flexion | 96 | 52 | 34% | 93 | 52 | 34% | 78 | 51 | 34% | .90 |
| Ankle dorsiflexion | 71 | 19 | 32% | 69 | 20 | 34% | 58 | 22 | 37% | .14 |
| Ankle plantarflexion | 67 | 27 | 45% | 56 | 29 | 48% | 29 | 23 | 39% | .25 |
DIP, distal interphalangeal; ER, external rotation; IP, interphalangeal; MP, metacarpalphalangeal; N, number of joint contractures; PIP, proximal interphalangeal; SD, standard deviation.
Table 5 demonstrates contracture outcomes by LOS category. Similar to TBSA, longer LOS was frequently associated with greater ROM losses for a given join motion. The following joint motions exhibited worse ROM impairments with longer LOS: shoulder abduction (P < .001), shoulder external rotation (P = .039), shoulder flexion (P < .001), elbow extension (P = .008), thumb MCP flexion (P = .001), thumb IP flexion (P = .018), finger MCP flexion (P = .001), finger PIP flexion (P = .003), and finger DIP flexion (P < .001). Ankle plantarflexion demonstrated the opposite correlation, with longer LOS associated with decreased ROM losses (P = .001). There was no significant relationship between LOS category and contracture outcome for the following joint motions: elbow flexion, wrist extension, wrist flexion, hip flexion, knee flexion, or ankle dorsiflexion.
Table 5.
The impact of length of stay on contracture severity by joint motion.
| LOS < 30 days | LOS 30–60 days | LOS > 60 days | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Joint motion | N | Absolute loss ROM, mean degrees | Percent loss ROM, mean | N | Absolute loss ROM, mean degrees | Percent loss ROM, mean | N | Absolute loss ROM, mean degrees | Percent loss ROM, mean | P-value for linear trend |
| Shoulder abduction | 100 | 52 | 23% | 106 | 65 | 28% | 64 | 85 | 37% | <.001 |
| Shoulder ER | 22 | 35 | 20% | 31 | 34 | 19% | 29 | 48 | 27% | .039 |
| Shoulder flexion | 170 | 50 | 22% | 159 | 62 | 27% | 106 | 77 | 33% | <.001 |
| Elbow extension | 72 | 22 | 16% | 83 | 24 | 17% | 67 | 30 | 21% | .008 |
| Elbow flexion | 114 | 30 | 22% | 93 | 33 | 24% | 63 | 38 | 27% | .07 |
| Wrist extension | 145 | 21 | 18% | 88 | 23 | 19% | 56 | 25 | 20% | .09 |
| Wrist flexion | 136 | 22 | 19% | 89 | 25 | 21% | 38 | 20 | 17% | .46 |
| Thumb MP flexion | 121 | 21 | 21% | 71 | 22 | 22% | 40 | 28 | 28% | .001 |
| Thumb IP flexion | 108 | 38 | 35% | 60 | 42 | 38% | 37 | 46 | 42% | .018 |
| Finger MP flexion | 551 | 33 | 30% | 326 | 36 | 32% | 231 | 38 | 34% | .001 |
| Finger PIP flexion | 556 | 33 | 25% | 342 | 31 | 24% | 224 | 38 | 29% | .003 |
| Finger DIP flexion | 522 | 32 | 32% | 296 | 32 | 32% | 202 | 38 | 38% | <.001 |
| Hip flexion | 38 | 28 | 21% | 13 | 20 | 16% | 42 | 31 | 24% | .44 |
| Knee flexion | 132 | 50 | 34% | 70 | 48 | 32% | 65 | 57 | 38% | .06 |
| Ankle dorsiflexion | 87 | 20 | 34% | 52 | 19 | 32% | 59 | 22 | 37% | .36 |
| Ankle plantarflexion | 81 | 29 | 48% | 41 | 29 | 48% | 30 | 19 | 31% | <.001 |
DIP, distal interphalangeal; ER, external rotation; IP, interphalangeal; MP, metacarpalphalangeal; N, number of joint contractures; PIP, proximal interphalangeal; SD, standard deviation.
Three joint motions demonstrated different associations with TBSA and LOS groupings. Elbow flexion was associated with TBSA, but not LOS; finger PIP flexion and ankle plantarflexion were associated with LOS, but not TBSA.
DISCUSSION
This is the first study to illustrate quantitative ROM outcomes for burn survivors with contracture at acute hospital discharge and stratify those outcomes by injury severity. Contracture severity varied by joint movement reflecting specific patterns of contracture development across burn injury populations.
For most joint movements, the severity of ROM loss was associated with burn size and duration of hospitalization. In general, it is expected that patients with larger injuries and extended hospital courses have more severe contractures(9); markers of burn severity are associated with other adverse outcomes such as pneumonia and multiple organ failure.(18) It is interesting to note that some joint motions did not exhibit significant associations with burn severity; wrist and lower extremity contractures were not associated with TBSA or LOS. And in contrast to other joint motions, longer LOS significantly correlated with a lower severity of plantarflexion contractures. The explanation for this unexpected correlation is not clear and may relate to the potentially multifactorial influences on LOS—additional research should be performed to confirm whether this finding is reproducible. The authors considered examining whether the presence of burn or graft at the site of contracture affected outcomes; however, the data set provides locations of burn by limb but does not specify particular locations or burn sizes on the limb limiting this analysis. Future research is needed to better understand the factors associated with specific contracture patterns—in particular, those of high severity and less correlation to expected factors such as burn size.
Three prior studies have used the BMS database to examine contracture outcomes in adult survivors at acute discharge(7–9). These studies used a qualitative approach to defining contracture severity with mild, moderate, and severe contractures defined by dividing the normal arc of joint motions into thirds and found the majority of contractures to be mild or moderate. In addition to qualitative outcome results, these prior studies identified predictors of contracture such as gender, ethnicity, and medical complications. Although this paper uses the same data set as the aforementioned articles, the quantitative outcome data in this study allow for a more granular comparison to specific joint ROM outcomes. The numerical contracture outcome data provide a better context for evaluation of differences among practice methods, are more definitive for clinicians, and can be used to inform the design of future studies.
As an illustration of this potential use, these data can be considered in the context of prior studies using quantified ROM outcomes. Godleski et al evaluated shoulder ROM following an axillary contracture program in the burn intensive care unit(19). At acute discharge, mean shoulder abduction ROM losses were 48° (left arm) and 62° (right arm). Considered as a potential point of reference, the current analysis found that patients in the TBSA 20–40% range discharged with mean absolute losses of 64°. Although there are limits to this comparison without controlling for other factors, it provides a baseline to consider the anticipated contracture severity for this patient group.
Ultimately, the importance of loss of ROM is not just a matter of absent degrees of movement, but rather the subsequent negative impact on functional recovery and independence of burn survivors. There is an ongoing need to better understand the consequences of contracture severity on activities and quality of life. The area is inherently challenging due to the wide variety of joint movements in the body, the broad scope of human activities, and potentially compounding effects of multiple joint involvement. A recent review by Korp et al explores the difficulties of understanding what constitutes “functional” ROM—for example, knowing the movement necessary to complete a task effectively(20). Beyond considering functional implications, this study provides contracture outcome data in both absolute and percentage terms to allow two different approaches to considering joint motion losses in burn survivors. Finally, readers should consider the normal ROM values defined by the dataset, given the amount of ROM loss was relative to this value and that there are a range of accepted normal values used in clinical practice.
There are relative strengths to the collected data: it reflects outcomes from four centers spanning 9 years and encompasses data from over 600 burn survivors. The anticipated variations in admission patterns and treatment protocols add generalizability to the data at the expense of specificity of the results to a particular population or approach. In a post hoc analysis, the severity of contracture outcomes for each joint was found to have significant differences across centers. Given the differences in the populations and unclear variability in practice patterns, it is difficult to interpret the differences in raw data between centers. Moreover, this highlights a significant need for further research to explore the impact of practice patterns on contracture outcomes.
There are a number of relative limitations as well: the database does not provide enough context to anticipate the potential risk for contracture for a given patient due to a lack of granular data on the amount and depth of burn or surgical intervention for any specific anatomical location. Ongoing research focused on predictive models of contracture development may augment future research in these areas(21). Additional limitations center around the choice of discharge from acute care as a time point, which could be corelated to contracture severity or treatment as well as nonclinical issues such as delays in transition of care, and the emphasis of the database on more severe cases of burn injury. Finally, the data reflect care practices from the time period of 1994–2003. In the interim period, there have been few large evidence-based updates in contracture management(22), as well as systematic reviews illustrating challenges in identifying effective interventions for contractures(23, 24).
CONCLUSION
This study presents a quantitative assessment of ROM deficits in adults with burn injury at discharge in a multicenter database. In the majority of cases, contracture severity correlated with burn size and duration of hospitalization, though notable exceptions were present. These results may serve as a detailed point of reference for mean contracture severity for similar populations of burn survivors at the time of transition from acute care.
FUNDING
The contents of this manuscript were developed under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research, NIDILRR grant number 90DP0035. NIDILRR is a center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS).
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