Clinical Leadership

Clinical Leadership

Soothing the Suffering From Burn Injuries


	Virtual reality helps burn patients imagine they are in an icy, soothing environment.

UW researchers have found a parallel between diabetic neuropathy, a loss of sensation because of poor blood flow, and hypersensitive burn scar tissue. They hope the connection will help burn patients who experience chronic pain.

Dr. Nicole Gibran, associate professor of surgery and the director of the UW Burn Center at Harborview Medical Center, is leading an NIH-funded study on the implications of diabetic neuropathy for burn wound repair. Burn wounds often scar with distinct, excessive tissue growths associated with an increase in blood vessels and nerves. These are called hypertrophic scars.

"Burn patients face excruciating pain, particularly during wound care and cleaning," said Gibran. "Darker skinned people and children are more likely to develop hypertrophic scars. It's unclear why."

Gibran's group hypothesizes that hypertrophic burn scars are the opposite of diabetic neuropathy, which is a nerve dysfunction due to poor blood circulation in the hands and feet. Perhaps, Gibran suggested, the slow wound healing associated with diabetic neuropathy is the result of a decrease in nerves.

"There are no animal models for hypertrophic scars," explained Gibran. "Because there are models for diabetic wound healing, I've adopted that as a means to study the roles of nerves in wound healing. Ultimately, we would like to be able to find the underlying cause of these scars."

Gibran's research is one example of the UW Burn Center's emphasis on advancing knowledge about scar healing and pain management. The UW Burn Center at Harborview Medical Center serves the five-state WWAMI region and treats between 400 and 500 patients each year. Just fewer than half of those patients face a lifetime of chronic pain from scar tissue formation.

Gibran is also an attending surgeon at Harborview Medical Center. She described the Burn Center as a leader in research and patient care. It is staffed with providers who are focused on the quality of care and rehabilitation of patients.

Gibran succeeded Dr. David Heimbach, professor surgery and director of the center since 1977. The Burn Center opened in 1974 as a specialized care unit. Dr, Loren Engrav, professor of surgery and former chief of the UW Division of Plastic Surgery, joined the team in 1977. Since Children's Hospital & Regional Medical Center in Seattle closed its acute care burn center, all severely burned children in the region have been referred to Harborview. Pediatric rehabilitation services remain at Children's.

In October 2002, the National Institute on Disability and Rehabilitation Research, under the auspices of the Department of Education, funded the UW Burn Center as one of the nation's four Burn Injury Rehabilitation Centers of Excellence for the 14th consecutive year. Engrav and dr. David Patterson, professor of rehabilitation medicine, serve as principal investigators on the grant. Patterson, a psychologist, uses hypnotherapy to help burn patients concentrate on something other than their pain. Burn Center researchers are also collaborating with the UW College of Engineering in the Human Interface Technology (HIT) Lab to use virtual reality to help ease pain. During a painful procedure, patients attend to a virtual task, such as rinsing an object down an imaginary sink, an activity that keeps their mind off the procedure.

At present, early burn wound excision and skin grafting are usually a burn patient's best option for optimal recovery and rehabilitation. However, hypertrophic scar formation still complicates recovery from burn injuries.

Because nerves produce mediators that promote inflammation at the wound site, an increase in nerves, besides causing pain, may also contribute to the inflammatory response. Proteins, such as cytokines and growth factors, that are released at the site of the injury can act as mediators. These proteins participate in a cross talk between cells.

"One of my research interests is to try to understand how the proteins that the nerves produce may influence inflammation," said Gibran. "Taking an anti-inflammatory drug does not reliably get rid of the itching. My interest in that would be far more than just solving the itching. People go crazy from the itching. We'd like to prevent the scar from forming in the first place."

Development Note

A few years ago, Zane Behnke was in a serious car crash. At Harborview Medical Center, he was successfully treated for severe burns. During his rehabilitation, Behnke and his family experienced the innovative care and compassion of the Burn Center staff. Out of gratitude, the Behnkes made a generous contribution to the center. Harborview's reputation for burn care, treatment, and research also prompted Ethicon, Inc., to establish the UW Regional Burn Center Endowment this year.