Pain, Depression, and Physical Functioning Following Burn Injury

Advances in emergency services and acute burn care in recent decades have led to extraordinary improvements in survival rates following burn injury. Nearly 95% of the approximately 40,000 persons who are hospitalized for burn injuries annually in United States will survive (American Burn Association, 2007) Much greater variability is found when outcomes beyond surviv ability are considered. For example, depression is well recognized as a significant problem following burn injury (Fauerbach et al 2007; Patterson et al., 1993). For most burn survivors, average scores on depression indices fall within the mild to moderate range (Choniere, Melzack, Rondeau, Girard, & Paquin, 1989; Thombs, Haines, Bresnick, Magyar-Russell, Fauerbach, & Spence, 2007; Wiechman et al., 2001). However, moderate to severe symptoms of depression have been found in 18% to 45% of burn survivors years after their physical injuries have healed (Pallua, Kunsebeck, & Noah, 2003; Thombs et al., 2007; Wiechman et al., 2001). Pain is another serious problem for burn survivors, particularly during the early phases of burn care when open wounds are being subjected to debridement and movement therapies (Summer, Puntillo, Miaskowski, Green, & Levine, 2007). In addition, pain remain a concern for years after burn injury wounds have closed Choniere and colleagues (1989) found ongoing pain concerns 35% of a sample of burn survivors who were at least 1 year after injury. Similarly, Dauber, Osgood, Breslau, Vernon, and Carr (2002) found that 52% of burn survivors who were an average of 10 years after injury reported the presence of pain. Of those with pain, 45% reported that pain interfered with their daily lives (Dauber et al., 2002). Malenfant and colleagues (1996) found pain in over 36% of their sample and demonstrated that pain prevalence, did not vary greatly between 1 and 4 years after injury. Although noting that the average severity of pain was mild (3.4 on a 0–10 visual analogue scale) among burn survivors, Malenfant and colleagues (1996) point out that pain severity varied widely both within and between patients. For example, 19% of their sample reported average pain as severe. Pain and depression obviously represent suffering for burn patients; thus, these conditions deserve attention in research and clinical settings. In addition, both pain and depression have been associated with other negative outcomes among burn patients. For example, two studies have demonstrated that elevated pain during -hospitalization for burn injuries is associated with poorer adjustment and reduced physical functioning up to 2 years after discharge from the hospital (Patterson, Tininenko, & Ptacek, 2006; Ptacek, Patterson, Montgomery, & Heimbach, 1995). Depression has been associated with reduced physical function (Thombs et al., 2007) and change in physical health over time (Thombs, Bresnick, Magyar-Russell, Lawrence, McCann, & Fauerbach, 2007) among burn patients. Although past studies have clearly shown that pain and depression have prospective associations with physical functioning, much less is known about how these conditions might interact as predictors of functioning among survivors of burn injuries. Cognitive–behavioral theories of pain, depression, and functioning have emphasized that certain cognitive processes associated with pain and depression may make the co-occurrence of these conditions especially deleterious to functioning. For example, persons with pain and depression show enhanced memory for negative self-referent pain and illness information as compared with persons with pain who are not depressed (Pincus, Pearce, McClelland, & Isenberg, 1995). Vlaeyen and Morley (2004) have noted that co-occurring pain and depression may activate cognitive processes or “stop-rules” that guide a person toward completing or terminating a task. For example, following stop rules, a person may terminate a functional activity as soon as he or she no longer enjoys the task, perhaps due to pain perceptions. Understanding associations between pain, depression, and physical functioning is critical because burn survivors have considerable difficulties in returning to personal, social, and community roles after their injuries have healed (Costa et al., 2003; Esselman et al., 2001). In summary, medical advances have ensured that the number of persons living with burn injuries will continue to increase, making it critical to learn more about how physical functioning is affected by common complications such as pain and depression. This study examined associations between pain and depression shortly after discharge from burn care and physical functioning at 1 and 2 years after discharge from burn care. We hypothesized that both pain and depression would independently be associated with physical functioning at 1 and 2 years after burn care. In addition, we hypothesized that the interaction of pain and depression would account for additional variation in postburn physical functioning. Specifically, we hypothesized that associations between pain and physical functioning would be strongest among burn survivors with higher levels of depression.