2017-18 HSC Section 3 Green Book

b u r n s 4 3 ( 2 0 1 7 ) e 7 – e 1 7

Table 1 – Rehabilitation protocol. Rehabilitation exercise Orofacial contractures/oral dysphagia Active range of movement exercises

Intensity of practice

Frequency of practice (sessions per day)

10 reps

5 2 3

Cheek retractor mouth splint

1 h

Orastretch

5 30 s hold

Pharyngeal dysphagia Masako manoeuvre (base of tongue strengthening) Effortful swallow (pharyngeal strengthening)

10 reps 10 reps

5 5

stretches [29] , use of the Orastretch 1 [5_TD$DIFF] ( www.craniorehab.com ) device, in addition to a mouth splint regime using the Free Access II Cheek Retractor 1 ( www.morita.com ) as detailed in Table 1 . These were combined with dysphagia rehabilitative exercises including base of tongue (Masako Manoeuvre) [30] and pharyngeal strengthening (Effortful Swallow) [31] exer- cises, selected to address common pharyngeal stage impair- ments observed in this population. Consistent with the principles of neuroplasticity, each exercise was conducted in a repetitious (10 repetitions) and intensive (5 time daily) manner [26,28] ( Table 1 ). Although there is currently no evidence for the exact number of repetitions which must be completed to achieve change, the frequency and repetition rate of tasks was selected to ensure it was sufficient to improve strength [32] , and matched the active exercise component of the orofacial contracture regime to simplify performance of the protocol for patients. Therapy was initiated once the patient was able to volitionally able to engage in treatment. The patient continued treatment through their admission and wound healing. If the patient received debridement and skin grafting to the face, all orofacial treatment components were ceased at the time of surgery. The active range of movement exercises were re- commenced at five days post grafting while mouth splinting and use of the Orastretch 1 was re-commenced between day 5 and 7 post-operatively, following consultation with the managing Burns Surgeon. Initially, all therapy tasks were demonstrated, assisted and supervised by the treating clinician, until the patient was deemed competent with independent practice with or without family/carer assistance. The patient was also provided with brochures detailing the treatment regime in pictorial and written format. Once independent with the treatment programme, the clinician reviewed adherence on a daily basis whilst an inpatient and weekly as an outpatient through to treatment completion. Monitoring of treatment adherence involved observing the patient carry out the treatment regime in addition to taking linear measurements of mouth opening. Feedback was provided to the patient accordingly and progress documented in the patient’s clinical file. Patients were weaned from orofacial contracture treat- ment once their orofacial burn wounds had healed, any indication of circumoral scar tissue had stabilised and functional goals had been achieved to the best of the patient’s ability with no deterioration over 3 months post scar stabilisation. Scar tissue was defined as the presence of tissue surrounding the vermillion evidently restricting maximal mouth opening range of movement. Scar tissue stabilisation was defined as the lack of further loss of mouth range of movement as measured by vertical and horizontal linear

mouth opening. Patients ceased dysphagia rehabilitation treatment once they demonstrated complete dysphagia resolution and effectual ability to swallow all food and fluid consistencies without evidence of any physiological swallow- ing deficits or the aid of any compensatory strategies on FEES. Dysphagia resolution was defined as the capacity to achieve normal scores on the impairment based outcome measure tools detailed below. Multiple outcome measures were used to document rehabili- tation progress in relation to orofacial contractures, oral function, as well as the clinical and physiological functions of the swallow. Tools and the time-points for collection are outlined in Table 2 . Duration of therapy to: (a) resolution of dysphagia and (b) scar stabilisation, was recorded (in days) for both patients. A second clinician scored all FEES videos to ensure inter- rater reliability: a high degree of inter-rater reliability ( > 80% exact agreement) was obtained. Case 1 was a 54 year old man with 53% total body surface area (TBSA) deep dermal and full thickness flame burns affecting his face, chest, back, upper and lower limbs with an associated inhalation component. He was initiallymanaged at a burn unit interstate and intubated for a period of 20 days, however due to ongoing issues with secretion clearance and surgical procedures he was re-intubated for a further 29 days prior to insertion of tracheostomy. Following a period of tracheos- tomy weaning complicated by recurrent chest infections, the patient was successfully decannulated on Day 101. He was subsequently transferred to our facility at Day 104. Case 1 underwent multiple surgical procedures at both facilities including debridement and grafting of all burnt areas includ- ing face and neck, free flap to the dorsum of his right hand with multiple subsequent revisions, contracture releases to the neck, hand, right eye and mouth, as well as gastrostomy insertion. 2.2. Outcome measurement 3. Results 3.1. Case 1: Medical history

3.2.

Case 1: Outcomes data

At the time of initial swallow assessment at our facility, Case 1 presented with severely compromised VROM (15 mm) and HROM (47 mm) compared to published normative data [20]

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