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Service Delivery Innovation Profile

Group Music and Exercise Classes Improve Range of Motion in Select Joints in Very Young Burn Patients


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Snapshot

Summary

Before the disruption of full operations due to damage sustained in Hurricane Ike, Shriners Hospital for Children/University of Texas Medical Branch in Galveston held a fun, age-appropriate group music and exercise program for pediatric burn victims between the ages of 2 and 6 years old. One-hour sessions, offered three times a week as an adjunct to existing occupational and physical therapies, incorporated a succession of activities designed to promote active range of motion and physical activity. A 12-week comparison study of range of motion in knees and elbows found that the program improved range of motion in the assessed joints. Anecdotal reports from clinicians and parents indicate improvement in children's physical function. Most recently, the program is proposing to conduct a randomized clinical trial comparing the Group Music and Exercise Program to the current Standard of Care. In addition to measurements of range of motion, investigators will also measure the effects of this program on lean mass and psychosocial health.

Evidence Rating (What is this?)

Moderate: The evidence consists of nonrandomized comparisons of active and passive range of motion in 15 patients who participated in the program with that of 9 similar patients receiving standard care; anecdotal reports from patients and families are also provided.
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Developing Organizations

Shriners Hospital for Children; University of Texas Medical Branch
Galveston, TXend do

Date First Implemented

2004
Januarybegin pp

Patient Population

Age > Child (6-12 years); Vulnerable Populations > Children; Age > Preschooler (2-5 years)end pp

Problem Addressed

Very young burn victims face severe physiologic challenges, including loss of muscle mass and bone density, which can lead to weakness and functional disability. Physical rehabilitation for these patients typically focuses on passive range of motion, in which a physical or occupational therapist moves the patient's limbs and does not involve supplemental exercise. Exercise that encourages active range of motion and age-appropriate activity can help; yet, programs consisting of such therapies often do not target children younger than 7 years old.
  • Physiologic implications: Severe burns prompt a prolonged hypermetabolic reaction that causes long-term damage to muscles and bones (including significant loss of muscle mass and bone density), which often leads to weakness, osteoporosis, and functional disability.1
  • Unrealized potential of active range-of-motion exercises for very young patients: Most pediatric burn victims receive physical rehabilitation focused on passive range of motion. In some institutions, older children also receive supplemental exercise therapy that focuses on active range of motion, progressive resistance weight training, and aerobic exercise. This type of therapy has been shown to improve functional and physiologic outcomes, including improvements in strength, lean body mass, pulmonary function, and distance walked.2,3,4 However, because some aspects of existing resistance and endurance exercise programs are not developmentally appropriate for very young children, burn victims aged 7 years old and younger have historically not received this type of exercise regimen, despite the potential benefits.1

What They Did

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Description of the Innovative Activity

Before the disruption of full operations due to damage sustained in Hurricane Ike, Shriners Hospital for Children/University of Texas Medical Branch in Galveston held a fun, age-appropriate group music and exercise program for pediatric burn victims between the ages of 2 and 6 years old. One-hour sessions, offered three times a week as an adjunct to occupational and physical therapies, incorporated a succession of activities designed to promote active range of motion and physical activity. Key elements included the following:
  • Population served: Hospital clinicians, including physicians, nurses, and physical/occupational therapists, referred patients to the program; eligible patients were between the ages of 2 and 6 years old with burns on at least 40 percent of their body. Patients with preexisting or injury-related brain or neurologic damage were not eligible. The program primarily served "residential outpatients" at the hospital (see the Context of the Innovation section for more information).
  • Program logistics: Eligible patients could join the class at any time. Classes typically had between two and seven participants, with four participants as the ideal class size. The 1-hour program was offered at 9 a.m. on Mondays, Wednesdays, and Fridays. A parent or caregiver also participated in each session.
  • Structured program components: Each 1-hour session consisted of activities designed to progressively build up endurance, with peak intensity reached during the third activity (followed by a cooldown period). All activities targeted specific functional movements to promote healing. Use of musical instruments encouraged goal-directed movement, with live and recorded music providing auditory cues for the tone and tempo of activities. Sessions, which included both a cognitive (e.g., following directions) and social component (e.g., cooperative play), built on young children's natural interest in repetition and willingness/ability to imitate movement. Session leaders encouraged parents to use similar games and activities outside of the class to help their children return to normal functionality.
    • Warmup song: The children selected shakers and noisemakers from a box (with adaptive devices to enhance grasping when necessary) and sat in chairs arranged in a circle. The music therapist played a "hello" song on the guitar, directing children to "shake up high," "shake down low," kick their legs, "march" in their chairs, and tap on their stomachs (which requires bending of the elbow). The music therapist manipulated the tempo of the song to match the desired movements (e.g., "march slowly" or "march quickly") and slowed the song down as necessary to allow children to perform more difficult movements, such as reaching up high. Participating in this song enabled the children to loosen up in preparation for greater movement in subsequent activities, which is especially important because burns cause the skin to become tight.
    • First activity: The first activity typically worked on sit-to-stand movements, using significant repetition to build strength. For example, the class would frequently play musical chairs (without the progressive exclusion of participants).
    • Second activity: The second activity built intensity through a game such as follow-the-leader, which typically incorporated marching, knee-bending, and playing a small instrument.
    • Third activity: The third activity, which was designed to reach maximum intensity, typically made use of upbeat, recorded music to encourage greater speed. For example, the class might march in a parade around the hospital floors, engage in relay races, or navigate obstacle courses down the hallway.
    • Fourth activity: The fourth activity served as a "cooldown" exercise, with the group returning to the playroom to hear calming classical music and participate in activities such as throwing soft beach balls, popping bubbles created by bubble machines, or playing limited-intensity chase games.
    • Goodbye song: The music therapist concluded the session by turning out the lights, pulling out floor cushions for seating, and playing a soft "goodbye" song.

Context of the Innovation

Before the disruption of full operations due to damage sustained in Hurricane Ike, Shriners Hospital for Children/University of Texas Medical Branch in Galveston was a 30-bed institution specializing in the care of pediatric burn patients. The hospital also treated "residential outpatients"—that is, children who require extensive daily rehabilitative care but not 24-hour nursing. (These children lived in nearby or onsite hospital-owned apartments.) The hospital had been providing a supplemental exercise program in conjunction with traditional rehabilitation therapies for severely burned children over the age of 7 years old. Based on the positive outcomes from this program (including improvements in lean body mass, bone density, and pulmonary function), the hospital's chief of staff recommended that all patients, regardless of age, participate in active range of motion therapy as part of their recovery. Because some aspects of the existing program (e.g., treadmill training, strength training using weights) were not appropriate for very young children, the hospital's music therapist (who had been working collaboratively with occupational and physical therapists on individual patient rehabilitation plans) designed an appropriate exercise program that integrated music for these younger patients.

Did It Work?

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Results

A 12-week study comparing severely burned patients who participated in the program with similar patients receiving standard care assessed range of motion in elbow and knee joints and found that the program improved active and passive range of motion in the assessed joints. Anecdotal reports from clinicians and parents indicated improvement in children's physical function.
  • Active range of motion improvements:
    • In all four joints assessed: Over 12 weeks, program participants exhibited a statistically significant improvement in active range of motion in both elbows (a mean improvement of 33.4 degrees in the right elbow and 32.8 degrees in the left elbow) and both knees (a mean improvement of 32.9 degrees in the right knee and 39.5 degrees in the left knee).
    • Favorable comparison with standard of care group in two of four joints: Patients receiving standard care experienced smaller improvements than the intervention group in the right elbow and both knees and lost active range of motion in the left elbow. When comparing the intervention group with the standard of care group, the researchers found that differences between the two groups in active range of motion improvements were statistically significant for the left elbow and right knee only.
  • Passive range of motion improvements:
    • In three of four joints assessed: Over the 12-week study period, program participants experienced improvements in passive range of motion in both elbows (a mean improvement of 14.6 degrees in the right elbow and 10.6 degrees in the left elbow), although the difference in the left elbow was not statistically significant. Improvements over time were statistically significant for both knees (a mean improvement of 20 degrees in the right knee and 24 degrees in the left knee).
    • In comparison with standard of care group not statistically significant: Compared with intervention patients, patients receiving standard care experienced smaller improvements in both knees and lost passive range of motion in both elbows. However, the difference in passive range of motion between groups was not statistically significant for any joint assessed.
  • Anecdotal improvements: Anecdotal reports from involved clinicians and parents indicated that participants improved with regard to strength, endurance, coordination, and developmentally appropriate behavioral independence.

Evidence Rating (What is this?)

Moderate: The evidence consists of nonrandomized comparisons of active and passive range of motion in 15 patients who participated in the program with that of 9 similar patients receiving standard care; anecdotal reports from patients and families are also provided.

How They Did It

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Planning and Development Process

Key elements of the planning and development process included the following:
  • Conducting literature search: The music therapist conducted a literature search on music and exercise therapy programs for very young children but failed to identify any published studies or existing programs.
  • Obtaining senior management approval: The music therapist received approval from the hospital's chief of staff to develop an in-house program and to purchase needed equipment.
  • Developing activities: The music therapist developed the program by adapting activities included in exercise programs for healthy children between the ages of 2 and 6 years. Adaptations were made in consultation with occupational/physical therapists and exercise physiologists, with the goal of creating movements that improve active range of motion in severely burned patients.

Resources Used and Skills Needed

  • Staffing: The program required no new staff, as the music therapist incorporated program development and implementation into her daily responsibilities. The music therapist had 10 years of experience in treating children with burns, so she was knowledgeable about the physical components of burn recovery.
  • Costs: Equipment costs were approximately $2,000 to cover small musical instruments, a CD player, CDs, bubble machines, balls, and other toys.
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Funding Sources

National Institutes of Health; University of Texas Medical Branch; Shriners Hospital for Children; Firefighter's Association
The program was funded internally by Shriners Hospital for Children/University of Texas Medical Branch; the comparison study was cofunded by the hospital and the National Institutes of Health.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Hold morning sessions: Younger children are most alert and, therefore, best able to participate, in the morning.
  • Provide appropriate structure: Programs for very young children must be highly structured to accommodate limited attention spans. In addition, structure is comforting to young patients who have experienced a traumatic event.
  • Use live music when possible: The tempo of live music can be manipulated to encourage desired movements.
  • Confer with experienced therapists as necessary: Individuals interested in developing a similar program should confer with physical therapists and other burn rehabilitation experts if they lack experience in recovery from burns.

Sustaining This Innovation

  • Facilitate program admission: Allow rolling admission so that patients can join the group at any time.
  • Be sensitive and patient: Working with children who have been traumatized can be challenging. For example, some children may have to watch for several weeks before they will participate. Typically, however, children will join in once they are ready.

More Information

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Contact the Innovator

Oscar E. Suman, PhD
Associate Director of Research
Director of the Children's Wellness and Exercise Program
Shriners Hospital for Children-Galveston
Professor
Leon Hess Professorship for Burn Injuries Research
University of Texas Medical Branch
815 Market Street
Galeveston, TX 77550
(409) 770-6557
Email: oesuman@utmb.edu

David N. Herndon, MD
Chief of Staff and Director of Research
Shriners Hospital for Children-Galveston
Professor of Surgery
Jesse H. Jones Distinguished Chair in Burn Surgery
University of Texas Medical Branch
815 Market St.
Galveston, TX 77550-2725
(409) 770-6919
E-mail: dherndon@utmb.edu

Innovator Disclosures

Dr. Suman and Dr. Herndon reported having no financial interests or business/professional affiliations relevant to the work described in this profile other than the funders in the Funding Sources section.

References/Related Articles

Neugebauer CT, Serghiou M, Herndon DN, et al. Effects of a 12-week rehabilitation program with music & exercise groups on range of motion in young children with severe burns. J Burn Care Res. 2008;29:939-48. [PubMed] 

Celis MM, Suman OE, Huang TT, et al. Effect of a supervised exercise and physiotherapy program on surgical interventions in children with thermal injury. J Burn Care Rehabil. 2003;24:57-61. [PubMed]

Suman OE, Mlcak RP, Herndon DN. Effect of exercise training on pulmonary function in children with thermal injury. J Burn Care Rehabil. 2002;23:288-93. [PubMed]

Cucuzzo NA, Ferrando A, Herndon DN. The effects of exercise programming vs traditional outpatient therapy in the rehabilitation of severely burned children. J Burn Care Rehabil. 2001;22:214-20. [PubMed]

Suman OE, Spies RJ, Celis MM, et al. Effects of a 12-week resistance exercise program on skeletal muscle strength in children with burn injuries. J Appl Physiol. 2001;91:1168-75. [PubMed]

Footnotes

1 Neugebauer CT, Serghiou M, Herndon DN, et al. Effects of a 12-week rehabilitation program with music & exercise groups on range of motion in young children with severe burns. J Burn Care Res. 2008;29:939-48. [PubMed]
2 Cucuzzo NA, Ferrando A, Herndon DN. The effects of exercise programming vs traditional outpatient therapy in the rehabilitation of severely burned children. J Burn Care Rehabil. 2001;22:214-20. [PubMed]
3 Suman OE, Spies RJ, Celis MM, et al. Effects of a 12-week resistance exercise program on skeletal muscle strength in children with burn injuries. J Appl Physiol. 2001;91:1168-75. [PubMed]
4 Suman OE, Mlcak RP, Herndon DN. Effect of exercise training on pulmonary function in children with thermal injury. J Burn Care Rehabil. 2002;23:288-93. [PubMed]
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Original publication: April 28, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: March 26, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: February 14, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.