2017-18 HSC Section 3 Green Book

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More recently Rumbach et al. [23] described in more detail their multidisciplinary approach adopted to assist the reha- bilitation in a 23 year old man who sustained 60.5% TBSA burns. He exhibited both oral and pharyngeal dysphagia characterised by impairments in: lip closure, mastication, swallow initiation, hyolaryngeal excursion and pharyngeal/ laryngeal sensation. Multidisciplinary rehabilitation strategies utilised to treat the oral dysphagia included: active and passive oral range of movement exercises (conducted twice daily), mouth splinting regime (minimum of 10 min, twice daily) and scar massage. Multidisciplinary management of pharyngeal dysphagia involved: use of a speaking valve to facilitate secretion management and restore laryngeal sensation, controlled and effortful swallow to improve bolus control and transit, airway protection manoeuvres in addition to laryngeal range of movement exercises to improve hyolar- yngeal excursion, and dietary modification to reduce aspira- tion risk. Pharyngeal swallowing tasks were completed daily, at a frequency of 10 repetitions per exercise. The study reported that the patient achieved a normal oral diet without restriction at Day 91. Functional oral range of movement was established by Day 133 and maintained at 6 months post injury, however treatment was ongoing. As evidenced by these three case studies, there is some early evidence to support positive responses to behavioural treatment, incorporating both swallowing and oral contrac- ture elements, for patients following severe thermal burn. However there is little evidence to guide the specific nature and intensity of this treatment. In 2009, Richard et al. [24] published a summit paper summarising discussions between key international profes- sionals in clinical burn care rehabilitation. The focus of discussions was the various aspects of physical rehabilitation and the key rehabilitation principles for scar management following burn. The importance of exercise, splinting, mas- sage and pressure therapy was identified. These principles, when recently applied specifically to the management of orofacial contractures, have demonstrated effective remedia- tion of both vertical and horizontal mouth opening im- pairment caused by circumoral contracture [6,17,19–21,23] . As such, any comprehensive dysphagia rehabilitation pro- gramme post head and neck burn needs to incorporate these principles to target the orofacial structural changes post burn that can impact swallowing. Furthermore, a comprehensive dysphagia rehabilitation protocol must also address any weakness and potential sensory-motor changes. Swallowing rehabilitation in general typically involves the application of exercise regimes and specific manoeuvres which target the range, strength and coordination of muscles necessary for safe and efficient swallowing [25,26] . This approach assumes the potential for the neural substrates involved in swallowing to be modified in response to the specific application of therapeutic strategies. In other words, effecting change on a physiological and pathophysiological level in response to training that is specific, repetitive, intensive and timely amongst other factors [27,28] . As evidenced from the three single case studies which have described active rehabilitation techniques for managing dysphagia following thermal burn [6,19,23] , there currently is no consensus regarding which techniques should be used to

achieve positive change in swallow physiology in this population. Although it is recognised that dysphagia and orofacial contractures may be significant negative consequences following severe burn to the head and neck, there remains minimal evidence to direct and inform rehabilitation. The current case series describes a pilot trial of a multifaceted treatment programme, combining key elements of scar contracture management [24] and driven by principles of neuroplasticity to optimise swallowing [27,28] that was specifically designed for patients with severe burn to the head and neck. The objective of this work is to begin to develop the set of key rehabilitation principles/elements which should be adopted for dysphagia rehabilitation in this specialised population. All patients admitted to Concord Repatriation General Hospi- tal for management of significant orofacial burn and subse- quent severe oropharyngeal dysphagia were considered for inclusion within the study. Patients were excluded from the cohort if their prognosis was deemed poor and they were unlikely to survive hospital admission, had experienced previous burn to the orofacial region, had previous surgery to the lips (e.g. excision of squamous cell carcinoma), were unable to be monitored through to treatment completion (e.g. they were an overseas visitor), or demonstrated total non- compliance with completing non-surgical rehabilitation. During the 12 month study period (July 2014–June 2015) a total of 711 patients were admitted to the NSWStatewide Burn Injury Service at Concord Repatriation General Hospital, however only 6 exhibited full thickness head and neck burns. Of these, 1 passed away, 1 was an overseas visitor and 2 did not demonstrate severe dysphagia. The remaining 2 patients met all study inclusion criteria and both consented to participate. The rehabilitation protocol contained elements specifically targeting oromotor contractures as well as key pharyngeal stage swallowing deficits. Research has demonstrated that for the effective management of scar tissue in the prevention of contractures resulting in reductions in range of movement, that stretching should be administered in an opposing direction of the contractile force and be of functional relevance [24] . Ideally, stretching and exercise treatment should commence early and utilise a combination of strategies including active range of movement, active-assisted range of movement and splinting in order to achieve maximal range and functional goals [24] . Optimal frequency and duration of these treatments specific to the burns population are not well documented in the literature, however based on generally accepted principles of exercise physiology maximal tissue stretch can be obtained through high repetition and frequent practice. Orofacial contracture management was therefore based on the programme previously published [20,21] . Specifically this consisted of a combined exercise and stretching regime involving active range of movement mouth 2. Methods 2.1. Orofacial and dysphagia rehabilitation protocol

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