Effects of Early Exercise Rehabilitation in Severe Burns

Pathophysiological Mechanisms and Early Exercise Rehabilitation Counter Measures of Hypermetabolism and Muscle Wasting in Severe Burns.

BACKGROUND:

Postburn changes in glucose and protein metabolism are at their peak during the acute phase of severe burns. The resulting metabolic derangements lead to substantial muscle wasting, insulin resistance, which ultimately hampers full recovery and reintegration into society.

PURPOSE:

This randomized controlled trial was initiated to investigate the effects of exercise-based rehabilitation on muscle wasting, insulin resistance, and quality of life during the acute phase of severe adult burns.

METHODS:

Severly burned adults (40-80%TBSA) will be recruited from one of China's largest burn centres.

Subjects allocated to the intervention group will undergo a 6-12 week long exercise program in addition to standard care rehabilitation. As part of the exercise program, participants will carry out progressive resistance and aerobic training, initiated as soon as medical safety and patient cooperation allow. Exercise type and dosage will be chosen according to patient status in terms of grafts, mobility, and strength.

The control group will receive standard care rehabilitation only, including passive, assisted, active range of motion exercise, functional exercise, and scar treatment.

The results of this translational research will provide insight into the effects and mechanisms of exercise on both a fundamental and clinical spectrum.

Study Overview

• Status: Unknown
• Conditions: Burns
• Intervention / Treatment: Other: Standard of Care; Other: Exercise

Detailed Description

The added exercise intervention is initiated in line with the following readiness criteria, which were checked prior to each training session:

Criteria:

• Cardiorespiratory stability:
• Mean arterial pressure (MAP) 60 - 110 mmHg
• fraction of inspired oxygen (FiO2) <60%
• partial pressure of oxygen / fraction of inspired oxygen (PaO2/FiO2) >200
• Respiratory rate <40 bpm
• Positive end expiratory pressure (PEEP) <10 cmH2O
• no high inotropic doses (Dopamine >10 mcg/kg/min or Nor/adrenaline <0,1 mcg/kg/min)
• Temp. 36 - 38,5°C
• Richmond Agitation Sedation Scale (RASS) -2 - +2
• Medical Doctor clearance
• Medical research council (MRC) score lower limbs ≥3

Accordingly, the post burn starting time differs per enrolled subject.

Exercises are administered as in-bed exercises or out-of-bed exercises, depending on whether subjects are able and allowed to engage in out-of-bed mobility.

Exercise intensity for resistance training is set at 60% peak force based on a weekly peak force measurement by hand-held dynamometry, or on a 3 RM in case of out of bed exercises. Aerobic exercise intensity is set at 50-75% peak Watts determined by a weekly cycle ergometer or treadmill ramp protocol.

• Study Type: Interventional
• Enrollment (Anticipated): 90
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: David R Schieffelers; Phone Number: +32465419848; Email: david.schieffelers@uantwerp.be

Study Locations

• China
  • Hubei
    • Wuhan, Hubei, China, 430060
      • Recruiting
      • Institute of Burns, Wuhan Third Hospital & Tongren Hospital of Wuhan University
      • Contact: Xie Weiguo; Phone Number: +8618071085225; Email: wgxie@hotmail.com

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 64 years (Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• ≥40 - ≤70 %TBSA
• Burn depth: 2nd deep / 3rd degree

Exclusion Criteria:

• Electrical burn (except flash burns)
• Associated injury: fracture lower limb
• Diabetes Mellitus type 1
• Central neurological/neuromuscular disorders (interfering with assessment/exercise)
• Cognitive / psychological disorders (interfering with cooperation)
• Cardiopulmonary disease (interfering with exercise safety)
• Pregnancy
• Palliative care

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Standard of Care; Standard of care treatment: - including passive / assisted / active movements, stretching, functional exercise, scar treatment Duration: 6-12 weeks	Other: Standard of Care; Standard of care rehabilitation
Experimental: Exercise; Standard of care + added exercises Exercise type: resistance and aerobic exercise Resistance Exercise: 3x / week (manual resistance, free weights, machines) Aerobic exercise: 2x / week (cycle ergometer, treadmill) Duration: 6-12 weeks	Other: Standard of Care; Standard of care rehabilitation; Other: Exercise; Resistance and aerobic exercise in addition to standard of care rehabilitation

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in quadriceps muscle layer thickness (QMLT)	Method: B-mode ultrasound on the anterior aspect of the thigh. Technique: maximal and minimal pressure Location: measured at 1/2 and 2/3 of the distance between anterior superior iliac spine and the superior pole of the patella. Analysis: An average of 3 trials will be recorded and analyzed using dedicated software	Baseline - 12 weeks
Change in rectus femoris cross sectional area (RF-CSA)	Method: B-mode ultrasound on the anterior aspect of the thigh. Technique: minimal pressure. Location: measured at the most proximal distance where the entire muscle belly is still visible on the ultrasound image. Analysis: An average of 3 trials will be recorded and analyzed using dedicated software.	Baseline - 12 weeks

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in insulin resistance	Method: HOMA-2 calculated by fasting plasma glucose and insulin, analysed by Western Blot Chemiluminescence	Baseline and 12 weeks

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Interleukin-1	Western Blot Chemiluminescence	Baseline and 12 weeks
Change in Interleukin-6	Western Blot Chemiluminescence	Baseline and 12 weeks
Change in Tumor Necrosis Factor alpha (TNF-α)	Western Blot Chemiluminescence	Baseline and 12 weeks
Change in C-reactive protein	Western Blot Chemiluminescence	Baseline and 12 weeks
Change in Insulin like growth factor 1 (IGF-1)	Western Blot Chemiluminescence	Baseline and 12 weeks
Change in Glucagon	ELISA kits DGCG0, R&D Systems, Inc, USA	Baseline and 12 weeks
Change in Myostatin	ELISA kits DGDF80, R&D Systems, Inc, USA	Baseline and 12 weeks
Change in isometric peak force (knee extension)	Method: Hand-held dynamometry (Lafayette instrument Co. Europe, U.K.). Isometric peak fore is measured by a 'make' manoeuvre with a fixation band disallowing movement. Test position: Supine with a fixation band fixed to the hospital bed. Analysis: Best of 3 trials	Baseline and 12 weeks
Change in isometric peak force (hip flexion)	Method: Hand-held dynamometry (Lafayette instrument Co. Europe, U.K.). Isometric peak fore is measured by a 'make' manoeuvre with a fixation band disallowing movement. Test position: Supine with a fixation band fixed to the hospital bed. Analysis: Best of 3 trials	Baseline and 12 weeks
Change in isometric peak force (hip extension)	Method: Hand-held dynamometry (Lafayette instrument Co. Europe, U.K.). Isometric peak fore is measured by a 'make' manoeuvre with a fixation band disallowing movement. Test position: Supine with a fixation band fixed to the hospital bed. Analysis: Best of 3 trials	Baseline and 12 weeks
Change in hand grip strength	Method: Baseline LITE hydraulic dynamometer Analysis: Best of 3 trials	Baseline and 12 weeks
Change in Burn Specific Health Scale-Brief (BSHS-B)	Burn-specific quality of life, measured by the Burn Specific Health Scale-Brief questionnaire (Mandarin Chinese version). Total score 152 (0 worst score, 152 best score), consisting of 6 subdomains: 1) Body imagine (36 points) Simple abilities (36 points) Sexuality (24 points) Affect (32 points) Work (16 points) Interpersonal relationship (8 points)	Baseline and 12 weeks
Change in EQ-5D-5L	Overall quality of life, measured by EQ-5D-5L (Mandarin Chinese version) Total score: 25 points (0 worst score, 25 best score), consisting of 5 subdomains; Mobility (5 points); Self-care (5 points); Usual activities (5 points); pain / discomfort (5 points); Anxiety / Depression (5 points) EQ overall health assessed on a Visual Analogue Scale, Total 0-100 (0 worst, 100 best score)	Baseline and 12 weeks
Number of adverse events	Recording of complications during exercise: Graft take, Wound infections, Medical, Cardio-respiratory safety	Baseline and 12 weeks

Collaborators and Investigators

• Sponsor: Universiteit Antwerpen
• Collaborators: Research Foundation Flanders; Wuhan Third Hospital
• Investigators: Principal Investigator: Ulrike Van Daele, Faculty of Medicine and Health Sciences, University of Antwerp

Study record dates

Study Major Dates

• Study Start (Actual): November 25, 2019
• Primary Completion (Anticipated): October 1, 2021
• Study Completion (Anticipated): October 1, 2021

Study Registration Dates

• First Submitted: April 30, 2020
• First Submitted That Met QC Criteria: April 30, 2020
• First Posted (Actual): May 4, 2020

Study Record Updates

• Last Update Posted (Actual): August 12, 2020
• Last Update Submitted That Met QC Criteria: August 10, 2020
• Last Verified: August 1, 2020

More Information

Terms related to this study

• Keywords: Insulin resistance; Exercise rehabilitation; Burns; Exercise Therapy; Muscle wasting; Hypermetabolism
• Additional Relevant MeSH Terms: Wounds and Injuries; Burns
• Other Study ID Numbers: 11B8619N

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: Datasets will be made available upon request.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No