Ambulation Following
Lower Extremity Skin Grafts
By:
Aubrey Rimer
Doctoral Candidate
University of New Mexico School of Medicine
Division of Physical Therapy
Class of 2015
Advisor:
Tiffany Pelletier PT, DPT
Approved(by(the(Division(of(Physical(Therapy,(School(of(Medicine,(
University(of(New(Mexico(in(partial(fulfillment(of(the(requirements(for(
the(degree(of(Doctor(of(Physical(Therapy.(
Table of Contents
ABSTRACT ______________________________________________________________________
3
SECTION 1: BACKGROUND AND PURPOSE ___________________________________________ 4
SECTION 2: CASE DESCRIPTION _________________________________________________ 5 - 13
INTRODUCTION
5
EXAMINATION
6
PATIENT HISTORY
6
SYSTEMS REVIEW
7
TESTS AND MEASURES
8
EVALUATION
9
DIAGNOSIS
9
ASSESSMENT
9
PROBLEM LIST
10
PLAN OF CARE
10
PROGNOSIS & GOALS
10
INTERVENTIONS
11
OUTCOMES
12
SECTION 3: EVIDENCE BASED ANALYSIS _________________________________________ 13 - 14
METHODOLOGIES OF SEARCH
13
DISCUSSION
14
CONCLUSION
15
REFERENCES ____________________________________________________________________ 16
TABLES & FIGURES __________________________________________________________________
TABLE 1: TESTS AND MEASURES
8
TABLE 2: DIAGNOSIS, ICD-9 CODES, AND PHYSICAL THERAPY DIAGNOSIS
9
TABLE 3: PHYSICAL THERAPY PROBLEM LIST
10
TABLE 4: LITERATURE RESULTS
18
TABLE 5: LITERATURE INCLUSION / EXCLUSION CRITERIA
20
FIGURE 1: ARTICLES INCLUDED AND EXCLUDED FOR ANALYSIS
17
APPENDIX A: EVIDENCE APPRAISAL _____________________________________________ 21 - 63
(
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(
2!
ABSTRACT
BACKGROUND / PURPOSE: The standard protocol for ambulating patients following split-thickness skin grafts
to the lower extremity is an initial several days of immobilization. Research over the past decades supports
a trend towards earlier ambulation, however burn clinics nation wide have been hesitant to implement such
protocols.1 The purpose of this literature review was to answer to the following PICO question: In adults
with lower extremity split thickness skin grafts secondary to full-thickness burns, is early ambulation better
than late ambulation in regards to preserving functional mobility while ensuring graft healing?
CASE DESCRIPTION: The patient was a 22-year-old male with no significant past medical history, admitted for
partial and full thickness flame burns to the posterior aspect of the left lower extremity covering
approximately 4% of his total body surface area.
METHODS: An electronic search of the literature was performed with a critical appraisal of eight articles.
Chosen studies compared early ambulation, defined as ≤ 3 days of bed rest, to late ambulation, defined as
≥ 4 days of bed rest, on graft healing.2
OUTCOMES: There was a consensus in the literature supporting immediate ambulation of patients with
isolated lower extremity burns. No studies of any patient population showed that early ambulation
compromises graft take.
CONCLUSION: Immediate ambulation is a safe intervention for patients who were previously ambulatory, are
medically and psychologically stable, with wounds <300cm2 that are not on the plantar surface of the foot.
Ambulation is safe to begin once the patient recovers from anesthetic (4 to 48 hours post-op) with
compression wrapping and splinting of any joints the graft crosses.
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3!
SECTION 1: BACKGROUND AND PURPOSE
This case study involved a 22-year-old male admitted to the burn clinic for partial and full thickness flame
burns to the posterior aspect of the left lower extremity covering approximately four percent of his total body
surface area. The patient had no significant prior medical history, was generally healthy, and worked
delivering medical equipment.
Two million burn accidents occur each year in the US, with 500,000 patients receiving medical treatment,
40,000 requiring hospitalizations, and 4,000 resulting in death.3 Fire and flame account for 46% of all
burns, and roughly 70% of burn victims are male.3 In addition to burns, other causes of full thickness
integumentary impairments requiring skin grafting include lesions, venous stasis ulcers, diabetic ulcers, and
lacerations. The most common surgical interventions for these injuries are skin grafts or flaps.4 Flaps are a
unit of skin, underlying tissue, and blood supply transferred from a donor site to a recipient site. They are
more complex, were not an indicated intervention for this case study, and are not included within the scope
of this research.
Skin grafts consist of the epidermis and varying amounts of dermis depending on whether they are splitthickness or full thickness grafts. Grafts are not vascularized and require neovascularization for survival.
This process takes between four to six days.5 During this period of revascularization there is concern over
increasing the risk of graft failure by either floating the graft off of the wound bed with edema or hematoma,
or with shearing forces. Consequently, it has been the common practice to restrict skin graft patients to
post-operative bed rest for an average of five days.1,5
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4!
Studies that investigate ambulation protocols following skin grafting dating back to the 1970s have
supported early ambulation; however burn clinics nation wide have been hesitant to implement such
protocols, due to continued fear of graft failure from hematoma, shearing, or lack of graft adherence, as
well as the only recent development of practice guidelines.1,2,6 The purpose of this investigation into the
literature was to answer to the following PICO question: In adults with lower extremity split thickness skin
grafts secondary to full-thickness burns, is early ambulation better than late ambulation in regards to
preserving functional mobility while ensuring graft healing?
SECTION 2: CASE DESCRIPTION
INTRODUCTION
The case study involved a 22-year-old male with no significant past medical history, admitted to the hospital
burn clinic for partial and full thickness flame burns to the posterior aspect of the left lower extremity
covering approximately 4% of his total body surface area. The patient sustained the burn when he
attempted to move a pallet into a bonfire, caught his leg on the pallet, tripped, and the burning pallet fell
onto the posterior side of his left lower leg.
The patient sought early medical attention from his primary care physician, receiving initial wound care. At
a follow-up appointment with his primary care physician the wound was evaluated and it was determined
further medical attention was required due to the depth of the burns. That same day the patient was
evaluated by a physician at the hospital and scheduled for debridement and homograft surgery in five days.
The day after homograft placement he was evaluated by physical therapy. Three days later the patient was
taken to the operating room for debridement and autografting. Three days after autografting, on
postoperative day three, the bandages were removed and an initial observation of the graft was performed
along with an order to begin physical therapy. That same day the patient was discharged from the hospital
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5!
home with family support and follow-up scheduled in the outpatient burn clinic. His total hospital length of
stay was 7 days.
EXAMINATION: HISTORY, SYSTEMS REVIEW, AND TESTS & MEASUREMENTS
HISTORY
Initial Physician Visit: Mid-October followed by homograft surgery 5 days later.
PT EVALUATION: 1 day status post homograft surgery
CHIEF COMPLAINT: Partial and full thickness flame burns to posterior aspect of left lower leg (540
square centimeters, roughly 4% total body surface area), status post excision and homograft
placement. He spent the night on bedrest in the PACU (post-anesthesia care unit) awaiting an
open recovery room.
HISTORY OF PRESENT ILLNESS: The patient was a 22-year-old male who reported attending a bonfire
approximately two weeks ago at which he moved a large pallet into the fire, tripped, and the pallet
fell onto the posterior aspect of his left leg. He was wearing jeans at the time and was unsure how
long the pallet remained on his leg. He sought early medical attention from his primary care
provider; receiving local wound care with Silvadene and petroleum gauze dressings. The patient
was later reassessed by his primary care provider who felt that the wounds were significant enough
to require referral to the hospital, where the patient was assessed and scheduled for homografting
The patient complained of constant burning pain in the left lower extremity, which was relieved by
pain medication, and increased by movement, rubbing of clothing, and showering.
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6!
His current complaint was only of some tightness of the left knee. Split-thickness skin graft
placement was scheduled for the following day with a tentative discharge in 4 days, with a total
hospital length of stay of 7 days.
PATIENT MEDICAL HISTORY: no significant past medical history
SURGICAL HISTORY: tonsils and adenoids removed as a child
MEDICATIONS: none
OCCUPATION: Pt was employed delivering durable medical equipment.
LIVING ENVIRONMENT: Pt lived in a condo with his mother and father. There were 7 stairs up to enter
the front door of the condo, no stairs inside. Mother was available 24/7 to provide assistance as
needed.
PRIOR LEVEL OF FUNCTION: Pt was independent with all mobility, ADLs, and driving.
FAMILY HISTORY: Denied family history of bleeding disorders or reactions to anesthesia. Both
parents were living.
SOCIAL HISTORY: Denied tobacco and illicit drugs, occasional alcohol use
PATIENT VALUES / GOALS: Pt hoped to return to work as soon as possible. He was unconcerned
about potential scarring, stating, “I’ll look tough”.
SYSTEMS REVIEW:
VITAL SIGNS: Blood Pressure 126/73, Pulse Rate 72, Temperature 36.8, Respirations 18 bpm,
O2Sat 96% on room air, Height 180 centimeters, Weight 97 kilograms, BMI of 30.
GENERAL: Young male with no apparent distress upon examination
HEENT: Head: Normocephalic, atraumatic. Eyes: Pupils were equal, round and reactive to light.
Extraocular muscles were intact. Sclerae were anicteric. Nose: without epistaxis. Throat: no
thyromegaly. Trachea was midline. Range of motion was full.
CARDIOVASCULAR: Regular rate and rhythm. No murmurs, rubs or gallops.
PULMONARY: Clear to auscultation bilaterally. No wheezes, rales or rhonchi.
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7!
GASTROINTESTINAL: Abdomen was soft, nontender, nondistended, positive bowel sounds. No
organomegaly or splenomegaly noted.
SKIN: No rashes or other lesions noted. Approximately 4% total body surface area burn to his
posterior leg, including both full thickness and partial thickness areas. Full thickness is
approximately 200 square centimeters at time of evaluation.
NEUROLOGIC: Strength and sensation were grossly intact. Alert and appropriate for his age.
PSYCHIATRIC: No obvious signs of anxiety or depression.
TESTS AND MEASURES:
Table 1: Tests and Measures
Tests and
MD Eval
Measures
Orientation
Alert & Orientated
x4
Intact command
following,
safety/judgment,
problem solving
Pain
Left posterior
lower leg: burning
Increases with
movement and
showering,
decreases with
pain meds
Wound /
Burns: 4% total
Graft
body surface area
Assessment
Full thickness:
200 cm2
ROM
Strength
Sensation
Proprioception
!
PT Eval
s/p allograft
Alert & Orientated x4
Intact command
following,
safety/judgment,
problem solving
PT Eval
s/p autograft POD 3
Alert & Orientated x4
Intact command
following,
safety/judgment,
problem solving
PA Outpt Burn
Clinic
Alert &
Oriented x4
Left knee: tightness
Left thigh donor site:
stinging
Some itching to
left calf, no
pain
Excision and homograft
(10/28)
Unable to visually
assess. Per medical
team graft does not
cross ankle/knee joints
and is 540 cm2 in size
Debridement and
STSG (10/30)
Assessed at dressing
take down. Meshed,
no signs of infection,
no drainage, intact
wound margins, clear
in color, small
hematoma present.
Grossly WFL
Graft: Intact,
well healed, no
open wounds,
no signs of
infection Donor
Site: well
healed, slight
pink
discoloration
WFL, no
problems with
ambulation
Grossly WFL
Grossly intact
Grossly intact
Grossly 4-5/5
Intact fine touch and
localization of touch
Intact bilateral toes
Grossly 4-5/5
Not tested
Not tested
8!
Tests and
Measures
Coordination
Balance:
Sitting
Standing
Bed Mobility
Transfers:
Sit to Stand /
Stand to Sit
Ambulation
Distance
Level of
assistance
Assistive
Device
Gait
Stairs
MD Eval
PT Eval
s/p allograft
Intact bilaterally
Sitting: Good
Standing: Fair (Contact
guard assist with initial
standing, improved to
supervision)
Modified Independent
PT Eval
s/p autograft POD 3
Not tested
Sitting: Good
Standing: Good
Contact Guard /
Supervision
100 ft
Standby Assistance
No assistive device
Gait: initially slow with
decreased step length
on R, normalized with
cuing and practice
Independent /
Independent
150 feet x2
Standby Assistance
No assistive device
Gait: slight decrease
of left ankle ROM
secondary to
dressings. Initial
slight decrease of
knee ROM, which
normalized with
cueing and
stretching.
Not tested
Not tested
PA Outpt Burn
Clinic
Independent
Independent /
Independent
EVALUATION:
DIAGNOSIS:
Table 2: Diagnosis, ICD-9 Codes, and physical therapy diagnosis
Diagnosis
ICD-9 Codes
Physical Therapy Diagnosis
Practice Pattern 7D: Impaired Integumentary
Partial and full thickness flame
945.3
Integrity Associated With Full-Thickness Skin
burns to the left lower extremity
Involvement and Scar Formation
NARRATIVE ASSESSMENT
The patient was a 22-year-old male status post an initial excision and homograft placement, followed
by split-thickness autograft placement secondary to partial and full thickness flame burns to the
posterior aspect of the left lower extremity. Burns covered approximately 4% of total body surface area.
!
9!
The patient was otherwise healthy with no significant prior medical history. The patient presented with
left lower extremity graft, minimally limited left ankle range of motion during ambulation, decreased
endurance, and an increased risk of hypertrophic scarring and possible contracture of left ankle and
knee due to age and location and depth of burns. The patient was previously independent with all
mobility and activities of daily living, worked delivering durable medical equipment, and lived with his
parents in a condo with seven steps to enter. Skilled physical therapy was recommended to minimize
risk of scar contracture formation and maximize functional outcomes.
CLINICAL JUDGMENTS AND PROBLEM LIST
Table 3: Physical therapy problem list
Wounds
Range of Motion
Pain
Physical Activity
Gait
Work
Recreation
Impairments
1. Split thickness autograft covering 4% total body surface area (540 cm2) on
left posterior leg
2. Donor site on left anterior thigh
3. Minimally limited left ankle ROM
4. Stinging at donor site, itching at graft site
Functional Limitations
5. Limited dependent positioning of left lower extremity (sitting, standing,
ambulating)
6. Decreased gait speed
7. Decreased left toe clearance during ambulation
Participation Restrictions
8. Unable to work delivering durable medical equipment
9. Unable to play flag football
PLAN OF CARE
Physical therapy sessions 2-3x per week until goals were met or patient was discharged from hospital.
Physical therapy anticipated interventions included transfer training, gait training, therapeutic exercises,
therapeutic activities, balance training, self-care education, caregiver training, safety education, pain
management, and joint protection.
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10!
SHORT TERM GOALS (2 weeks):
1. Patient will demonstrate ROM within normal limits by goniometric measurement of left knee
and ankle.
2. Patient will Ambulate a minimum of 300 feet over variable surfaces with equal gait pattern
independently and without assistive device.
3. Patient will ascend/descend 7 stairs reciprocally with safe technique and 1 rail.
4. Patient will independently don/doff ace compression wrapping from left toes to thigh in figure-8
pattern.
5. Patient will demonstrate/verbalize precautions and positioning to maximize graft healing.
LONG TERM GOALS (1 month):
6. Patient will return to work delivering durable medical equipment.
7. Patient will verbalize and demonstrate long term skin care including sun protection, protection
against shearing forces and correct use of compression garments.
PROGNOSIS:
The rehab prognosis for this patient to meet the above goals was excellent. The patient’s graft was well
adhered, he had minimal pain, was in good health with no comorbidities, and had a supportive mother
who was available 24/7 to assist as needed. Both the patient and his mother recalled positioning, ROM,
wound care, compression wrapping, and long-term skin care instructions. He was scheduled a followup appointment in the Outpatient Burn Clinic in two weeks.
INTERVENTIONS
The patient was seen twice by physical therapy during his acute care hospital stay: once for an initial
evaluation following allograft surgery, and once for a re-evaluation following autograft surgery (See Table 1:
Tests and Measures, for details).
The patient was originally evaluated by physical therapy following allograft placement. During this visit the
left leg was figure-of-8 wrapped to the knee, history was taken, and the patient’s bed mobility, transfers,
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11!
and ambulation were assessed. He was not seen by physical therapy again until new orders were placed
following his autograft surgery on post-operative day three. After reviewing the evidence, this patient met
the criteria for immediate ambulation following recovery from anesthesia, and would have been a good
candidate for such an intervention. This would have allowed for more physical therapy sessions during his
acute care stay.
However, the patient was not seen by physical therapy until post-op day three when the surgical dressings
were removed by the Physician Assistant for the initial viewing of his graft. Assessment of the graft showed
no signs of infection, no drainage, intact wound margins, the graft was clear in color, and there was a small
hematoma present. The graft did not cross the ankle or knee joints. Due to the high quality of graft
adherence, discharge orders were placed by the surgeon for that same afternoon. Nursing completed
wound cleaning, bandage placement, and returned the patient to his room.
The patient was then seen by PT for re-evaluation of mobility, education on compression wrapping,
positioning, graft care, the PT plan of care, family training, and instruction in a home exercise program
including range of motion for the ankle and knee. The left lower extremity was wrapped from toes to thigh,
just below the donor site, with elastic bandages in figure-of-8 pattern. The donor site was left bare for the
remainder of its healing, however the patient was instructed on how to compression wrap from toes to
above the waist for donor site comfort as needed. Both the patient and his mother were instructed on the
compression wrapping technique and when to use it. The patient was educated on positioning of the limb to
limit dependent positioning, and to promote elevation to reduce the risk of edema. Protection against
shearing forces was addressed. The patient’s bed mobility, transfers, and ambulation were assessed (see
Table 1: Tests and Measures, for details). Gait training and ankle and knee range of motion exercises were
performed to improve symmetry of stride length, increase toe push-off and heel strike on the left, increase
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12!
endurance, and prevent contracture due to scar formation to normalize gait pattern and return to prior level
of function. The patient was discharged home with a scheduled follow-up appointment in Outpatient Burn
Clinic in two weeks.
OUTCOMES
The patient was seen for two physical therapy visits before being discharged from the hospital. On the day
of discharge he was independent with bed mobility, transfers, and ambulation of 150 feet. Goals met
included the ability to don and doff compression wrapping independently, and verbalize positioning, longterm skin care, and protection against shearing. The patient was making progress towards the remaining
goals. Stairs were not assessed at time of discharge. The patient was scheduled for follow-up with physical
therapy in the Outpatient Burn Clinic.
SECTION 3: EVIDENCE BASED ANALYSIS
METHODOLOGIES OF SEARCH:
An electronic search was conducted using Pubmed, CINAHL, Cochrane, and Web of Knowledge
databases for research concerning ambulation protocols following lower extremity skin grafting secondary
to full thickness burns. Search terms included ‘ambulation’, ‘mobilization’, and ‘lower extremity skin graft’.
Search methods are detailed in Figure 1. The search was limited to articles written within the last twenty
years, in English, with adult human subjects. Articles were excluded if they were case studies, involved flap
procedures, included wound vac or unna boot interventions, or contained complex trauma patients. The
search identified an initial 136 articles, after exclusions, eight appropriate articles were appraised using
forms adopted from the Guide to Evidence-Based Physical Therapy Practice7 (See Appendix A).
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13!
DISCUSSION
The objective of this literature review was to answer the following PICO question: In adults with lower
extremity split thickness skin grafts secondary to full-thickness burns, is early ambulation better than later
ambulation in regards to preserving functional mobility while ensuring graft healing? The articles reviewed
compared early ambulation protocols to the traditional late ambulation protocols and their effects on graft
healing. A consensus was revealed in the literature supporting immediate ambulation following lower
extremity split-thickness skin grafting, noting that early ambulation neither improves or jeopardizes graft
take if external compression is applied1,2,4,5,6,8,9).
Despite evidence advocating for early ambulation following split skin graft surgeries, studies reviewing
plastic surgery departments nationwide suggests it is not routinely practiced1. The burn center followed a
traditional ambulation protocol for the majority of its patients. Many of these patients are complex, with
multiple comorbidities, systemic diseases, and were the types of patients excluded from studies on graft
healing. Wallenberg included subjects with questionable peripheral arterial circulation as well as diabetics,
and concluded that graft failure was related to systemic diseases rather than ambulation protocols9. More
research into this patient population is needed to determine if they too may benefit from early ambulation
after grafting.
There has been a general healthcare trend towards early ambulation of patients, primarily to prevent
secondary complications from bed rest including deconditioning, pulmonary embolism, joint stiffness, and
prolonged hospital stays. Secondary outcome measures in several studies included length of stay,
deconditioning, ambulation distance, and pain. The majority of studies measuring length of stay found a
significant reduction among early ambulatory groups1,2,8, one found no significant difference5.
Deconditioning and pain were found to be reduced by early ambulation5,8.
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14!
All the studies reviewed included the use of compression wrapping prior to the dependent positioning of the
lower extremity. The precise application and guidelines for compression wrapping are not well defined.
Some studies defined their use of compression wrapping as two-layers of elastic bandages applied in a
figure-of-eight pattern; however the details of this application are unclear and vary by clinical site. Further
research into compression wrapping parameters is needed.
Several of the studies allow for bathroom privileges during bed rest for the late ambulation groups2,5,8.
Distance to the restroom, whether the grafts were compression wrapped, time spent with the graft in
dependent positioning, and whether the subjects ambulated independently, with assistance, or with an
assistive device is unknown. The guidelines for patients on bed rest with bathroom privileges is an area of
needed clarification.
This case study was a young adult with no comorbidities, in overall good health, with a limited lower
extremity skin graft. He had orders of bed rest with bathroom privileges, however he was observed
ambulating approximately 200 feet in the hall without the advised external compression wrapping on postoperative day three. Despite this dependent positioning and lack of compression at times, his graft
successfully healed. During his hospital stay he expressed a desire to ambulate more frequently and
sooner than he was permitted. A review of the literature supports further promotion of early ambulation
protocols by physical therapists in burn clinics.
CONCLUSION / BOTTOM LINE
The purpose of this study was to answer the following PICO question: In adults with lower extremity split
thickness skin grafts secondary to full-thickness burns, is early ambulation better than late ambulation in
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15!
regards to preserving functional mobility while ensuring graft healing? There is a consensus in the literature
that there is no difference in graft healing between patients managed with early mobilization versus postoperative bed rest. Immediate ambulation is a safe intervention for patients who were previously
ambulatory, are medically and psychologically stable, with wounds <300cm2 that are not located on the
plantar surface of the foot2. Ambulation is safe to begin once the patient recovers from anesthetic (4 to 48
hours post-op) with compression wrapping and splinting of any joints the graft crosses.
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16!
REFERENCES
1. Burnsworth B, Krob MJ, Langer-Schnepp M. Immediate ambulation of patients with lower-extremity
grafts. J Burn Care Rehabil. 1992; 13: 89-92.
2. Nedelec B, Serghiou MA, Niszczak J, McMahon M, Healey T. Practice guidelines for early ambulation
of burn survivors after lower extremity grafts. J Burn Care Res. 2012; 33: 319-329. DOI:
10.1097/BCR.0b013e31823359d9
3. Chirieleison S. Rehabilitation following a burn injury. 06/27/2014. Powerpoint Presentation.
4. Southwell-Keely J, Vandervord J. Mobilisation versus bed rest after skin grafting pretibial lacerations: A
meta-analysis. Plast Surg Int. 2012; 207452. doi: 10.1155/2012/207452.
5. Lorello DJ, Peck M, Albrecht M, Richey KJ, Pressman MA. Results of a prospective randomized
controlled trial of early ambulation for patients with lower extremity autografts. J Burn Care &
Research. 2014; 35, 5: 431-436.
6. Smith TO. When should patients begin ambulating following lower limb split skin graft surgery? A
systematic review. Physiotherapy. 2006; 92: 135-145.
7. Jewell DV. Guide to Evidence-Based Physical Therapist Practice, 2nd Ed. Jones and Bartlett Learning,
LLC; 2011.
8. Luczak B, Ha J, Gurfinkel R. Effect of early and late mobilisation on split skin graft outcome. Australas
J of Dermatol. 2012; 53: 19-21.
9. Wallenberg L. Effect of early mobilization after skin grafting to lower limbs. Scand J Plast Reconstr
Hand Surg. 1999; 33: 411-413.
10. Harvey I, Smith S, Patterson I. The use of quilted full thickness skin grafts in the lower limb: reliable
results with early mobilization. J of Plastic, Reconstructive & Aesthetic Surgery. 2007; 62; 969-972.
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!
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!
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!
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!
!
!
!
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!
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18!
!
Luczak et al (2012)
Australia
Lorello et al (2014)
USA
Harvey et al (2007)
Australia
Burnsworth et al
(1992)
USA
Study & Origin
Retrospective
Review
Prospective
Randomized
Controlled
Trial
Case Series
Retrospective
Case Series
Design
Table 4. Section 3: Literature Results
#
1
10
5
8
!
Oxford
Level of
Evidence
4
4
1b
2b
Purpose of Study
Compare early
ambulation protocol at
Mercy Burn Clinic to
109 other burn centers
Determine if using
quilted full thickness
skin grafts on the lower
limbs allows for early
ambulation without graft
loss due to shearing or
friction.
Demonstrate that pts
beginning ambulation
within 24 hours of LE
grafting will have no
increased risk of graft
failure than those
immobilized until POD
5.
Review guidelines for
the mobilization of post
Subjects
n= 58
Burns
Average
TBSA
grafted:
4.1%
n=60
92 grafts for
lesions
(BCC, SCC,
Melanoma)
below the
knee
Mean age
82.8 years
n= 32
Burns
n=48
Outcome
Measures
Results
Helped
Answer
PICO
Question
Yes
Ambulation
day (>30 ft)
Average graft take 96.4%
EAG vs survey:
Ambulate >30’ 1.7 vs 7.2
days (p<0.001).
D/C 6.9 vs 9.4 days
(p<0.01).
LOS: 10.2 vs 12.6 days
(p<0.012)
No
LOS
Post-op day
discharge
Graft take
5 pt (7 grafts) did not attend
2 week follow up.
At 2nd week:
100% take = 89.4%,
70-99% take = 5.9%,
50% take = 1.2%,
40% take = 1.2%,
0% take = 2.4%
Yes
Yes
No difference in graft loss.
Significant differences in
deconditioning: 0 vs 6
EAG reported less graft site
pain (1.3/10 vs 3.14/10)
EAG walked longer on POD
5: 23.4 vs 12.03 minutes.
Significant difference in
percentage of graft loss:
EAG 1.0% vs SAG: 7.7%
Post-op
ambulation day
Graft take
Pain at graft
and donor
sites
Post-op d/c
LOS
Graft take
Infection
19!
!
Evaluate evidence for
early ambulation of LE
burns s/p grafting
split skin graft patients.
3a
Nedelec et al
(2012)
Canada
Practice
Guideline
2
1b
Determine when to
begin ambulation in
patients with LE STSG
6
Systematic
Review
Smith, TO (2006)
UK
1a
4
1c
Determine whether
strict bed rest is
required after splitthickness skin graft
surgery to the lower
extremities.
Assess early
mobilization vs bed rest
on skin grafting
Prospective
Randomized
Study
Review MetaAnalysis
Wallenberg L
(1999)
Sweden
Southwell-Keely et
al
(2011)
Australia
9
!
17 articles
total
n=644
Post-op
ambulation day
Graft take,
LOS
Deconditioning
Hematoma
Hypergranulati
on
LOS
n=725
n=145
Graft take by
POD 14
Graft take
Graft healing,
Systemic
corticosteroids,
post-op
mobility
n=50
All types of
skin defects
(p=0.008),
Post-op LOS: 3.92 vs 7.96
days (p=0.0001),
Total LOS: 7.72 vs 13.57
days.
Yes
Yes
Yes
No difference in graft
healing between groups.
Corticosteroids negatively
effect graft healing.
Yes
No significant difference in
graft loss: 88% vs 91%
(p=0.45), infection (p=0.22),
hematoma (p~1), or
hypergranulation (p=0.24).
Support for EA only with
compression, & immobilized
joints if crossed by graft
Studies began ambulation
immediately to >1 week
postop. Ambulation does not
significantly affect graft take.
Grafts healed in 80% of the
EAG and 88% in the SAG.
3 arterial leg ulcers did not
heal.
2 graft site infections did not
heal.
All trauma wounds healed.
20!
!
#
Burnsworth et al
(1992)
Study
!
Table 5: Literature Inclusion / Exclusion Criteria
1
Inclusion Criteria
Patients from Mercy Hospital Burn Center of Pittsburgh and patients
from 109 national burn centers who had burns limited to their lower
extremities and required skin grafting, with no medical illnesses that
would affect wound healing.
Any excisional defect on the lower limb requiring grafting where a
suitable full thickness donor site was available.
Lorello et al (2014)
Australia
10 Harvey et al (2007)
5
≥18 years old, LE burn, ambulating a minimum of 2x/day with PT prior
to autograft placement
8
English-language, human subject, clinical trial
6
4
LOS:!length!of!stay!
N:!number!of!subjects!
POD:!!postOop!day!
Patients from the Plastic and Reconstructive Surgery Department at
Royal Perth Hospital over a 6-month period.
All studies providing original data on patients with LE wounds that
required grafting
Luczak et al (2012)
Australia
Nedelec et al
(2012)
Canada
Smith, TO (2006)
RCT or prospective cohort studies with split skin grafting to leg
lacerations, early mobilization vs bed rest interventions, and outcome
of graft healing.
All types of skin defects including patients with questionable peripheral
arterial circulation and diabetics.
2
Southwell-Keely et al
(2011)
Australia
Wallenberg L (1999)
Sweden
9
ABBREVIATIONS
D/C:!discharge!
EAG:!early!ambulation!group!
LE:!lower!extremity!
!
Exclusion Criteria
Medical illnesses that would affect wound healing (e.g.
vascular insufficiency).
Excess adiposity where grafting to deep fascia would be
too technically difficult or leave unacceptable cosmetic
results.
< 18 years old, diabetes mellitus (or increased levels of
HgB A1C during hospitalization), peripheral vascular
disease, lower extremity pitting edema ≥2+, cellulitis
before surgery, nonambulatory before surgery.
Multi-trauma patients, other factors resulting in limited
mobility, burns >10% TBSA.
Non-English or French, non-reviews, non-full length
articles
Cadaver studies, case reports, abstracts, letters,
comments, editorials, review articles, unpublished, and
non-English.
Non-English studies, lower level studies
Those in wheelchairs and the demented.
SAG:!standard!ambulation!group!
STSG:!SplitOthickness!skin!graft!
21!
!
Intervention – Evidence Appraisal Worksheet
Citation:
Burnsworth B, Krob MJ, Langer-Schnepp M. Immediate ambulation of patients with lower-extremity grafts.
J Burn Care Rehabil. 1992; 13: 89-92.
Level of Evidence (Oxford scale): 4
Is the purpose and background information sufficient?
Appraisal Criterion
Study Purpose
Reader’s Comments
Stated clearly?
Usually stated briefly in abstract and in greater detail in
introduction. May be phrased as a question or
hypothesis.
A clear statement helps you determine if topic is
important, relevant and of interest to you. Consider how
the study can be applied to PT and/or your own situation.
What is the purpose of this study?
Yes. To assess the effects of Mercy Hospital’s early
ambulation protocol, we compared it to patients with
burns treated in other burn centers.
Literature
Relevant background presented?
A review of the literature should provide background for
the study by synthesizing relevant information such as
previous research and gaps in current knowledge, along
with the clinical importance of the topic.
Traditional practices for lower extremity skin grafting
include bed rest for several days despite literature
advocating a less restrictive postoperative course. This
article is to look into how accepted early ambulation
practices are in burn centers nationally.
Describe the justification of the need for this study
Does the research design have strong internal validity?
Appraisal Criterion
!
!
Discuss possible threats to internal validity in
the research design. Include:
! Assignment
! Attrition
! History
! Instrumentation
! Maturation
! Testing
! Compensatory Equalization of
treatments
Reader’s Comments
The two groups were from different facilities.
Unknown whether 12 patients who did not require PT
because they ambulated >30’ immediately post-op were
included in the study.
Age, sex, and cause of injury between groups was
similar.
No compensation was provided to patients.
Student’s t test was used.
22!
!
!
!
Compensatory rivalry
Statistical Regression
Are the results of this therapeutic trial valid?
Appraisal Criterion
1.
2.
3.
4.
5.
6.
7.
8.
!
Did the investigators randomly assign subjects
to treatment groups?
a. If no, describe what was done
b. What are the potential consequences of
this assignment process for the study’s
results?
Did the investigators know who was being
assigned to which group prior to the allocation?
a. If they were not blind, what are the
potential consequences of this
knowledge for the study’s results?
Were the groups similar at the start of the trial?
Did they report the demographics of the study
groups?
a. If they were not similar – what
differences existed?
b. Do you consider these differences a
threat to the research validity? How
might the differences between groups
affect the results of the study?
Did the subjects know to which treatment group
they were assign?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s results
Did the investigators know to which treatment
group subjects were assigned?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s results
Were the groups managed equally, apart from
the actual experimental treatment?
a. If not, what are the potential
consequences of this knowledge for the
study’s results?
Was the subject follow-up time sufficiently long
to answer the question(s) posed by the
research?
a. If not, what are the potential
consequences of this knowledge for the
study’s results?
Did all the subjects originally enrolled complete
the study?
a. If not how many subjects were lost?
b. What, if anything, did the authors do
about this attrition?
Reader’s Comments
No. Assignment to group was determined by the hospital
subjects were admitted to. This may alter the type of
patient assigned to each group based on demographics
of each burn center.
The investigators were not blinded, however they were
only reviewing past medical records.
Yes, the groups were similar and demographics
reported.
Subjects followed the protocol of that particular hospital.
This study was retrospective so subjects were not in a
study at the time of their treatment.
Yes, however they are only reviewing data.
Most likely no because patient data was collected from
110 burn clinics across the country.
No, subjects were only followed up to the discharge from
the hospital.
Only those subjects with complete medical records were
included.
The 12 subjects who ambulated >30’ immediately postop and did not get referred to PT were most likely not
23!
!
c.
9.
What are the implications of the
attrition and the way it was handled
with respect to the study’s findings?
Were all patients analyzed in the groups to which
they were randomized (i.e. was there an intention
to treat analysis)?
a. If not, what did the authors do with the
data from these subjects?
b. If the data were excluded, what are the
potential consequences for this study’s
results?
included in the study. Those 12 subjects may be
healthier and not including them could skew the data.
Yes.
Are the valid results of this RCT important?
Appraisal Criterion
10. What were the statistical findings of this study?
a. When appropriate use the calculation
forms below to determine these values
b. Include: tests of differences With pvalues and CI
c. Include effect size with p-values and CI
d. Include ARR/ABI and RRR/RBI with pvalues and CI
e. Include NNT and CI
f. Other stats should be included here
11. What is the meaning of these statistical findings
for your patient/client’s case? What does this
mean to your practice?
12. Do these findings exceed a minimally important
difference? Was this brought up or discussed?
a. If the MCID was not met, will you still
use this evidence?
Reader’s Comments
Average graft take 96.4%
EAG vs survey:
Ambulate >30’ 1.7 vs 7.2 days (p<0.001)
D/C 6.9 vs 9.4 days (p<0.01)
LOS: 10.2 vs 12.6 days (p<0.012)
For uncomplicated patients early ambulation was not
found to affect graft take.
The MCID was not addressed.
Can you apply this valid, important evidence about an intervention in
caring for your patient/client? What is the external validity?
Appraisal Criterion
13. Does this intervention sound appropriate for use
(available, affordable) in your clinical setting? Do
you have the facilities, skill set, time, 3rd party
coverage to provide this treatment?
14. Are the study subjects similar to your patient/
client?
a. If not, how different? Can you use this
intervention in spite of the differences?
15. Do the potential benefits outweigh the potential
risks using this intervention with your
patient/client?
16. Does the intervention fit within your
patient/client’s stated values or expectations?
a. If not, what will you do now?
!
Reader’s Comments
Yes, the intervention sounds appropriate for use,
requires no additional skills, equipment, or costs.
Yes, some of my patients meet the inclusion criteria of
this study.
Benefits include patients able to walk further sooner, are
discharged sooner, and have shorter hospital length of
stays. The risk of graft failure was no different between
groups.
Yes. Patients want to walk and go home as soon as
possible.
24!
!
17. Are there any threats to external validity in this
study?
No.
What is the bottom line?
Appraisal Criterion
Reader’s Comments
PEDRO score (see scoring at end of form)
7/10
Summarize your findings and relate this back to clinical
significance
!
The results of this retrospective study indicate that for a
small proportion of burn patients an early ambulation
protocol may be advised. Those patients with limited
lower extremity burns requiring skin grafting to an
average of 4% TBSA, who do not have medical illnesses
that may impact wound healing, can begin ambulating
immediately upon recovery from anesthetic without
compromising graft healing. Another benefit includes
decreased hospital stays. This study, like literature
before it, has found that graft healing is not impacted by
ambulation protocols, therefore, patients can be
ambulated earlier, avoid potential secondary
complications of bed rest, and open up space in burn
centers for more complex patients.
25!
!
Pedro Scoring System:
Adapted from : Jewell, D. Guide to Evidence Based Physical Therapy Practice. Jones and Bartlett
Publishers, Sudbury, MA 2008
!
26!
!
Burnsworth B, Krob MJ, Langer-Schnepp M.
Immediate ambulation of patients with lower-extremity grafts.
J Burn Care Rehabil. 1992; 13: 89-92.
Level of Evidence: Oxford Level 4
Background: Patients following lower extremity graft surgeries are typically put on bed rest for an average
of 4.8 days despite the literature advocating for earlier ambulation protocols.
Purpose: The purpose of this study was to assess the effects of Mercy Hospital’s early ambulation
protocol for patients with lower extremity burns as compared to patients treated in other burn centers
following the standard ambulation protocol.
Methods: Patient records were reviewed for all patients admitted to Mercy Hospital with lower extremity
burns requiring skin grafting, and who had no medical illnesses that could affect wound healing. All patients
at Mercy Hospital followed the same surgical procedure; they were then encouraged to ambulate upon
recovery from anesthetic without assistive devices. Questionnaires were sent to 173 burn centers,
collecting information on dressing methods, ambulation practices, use of assistive devices, and hospital
length of stay.
Results: Fifty-eight Mercy patients were reviewed and 109 burn centers responded (63% response rate).
Average graft take was 96.4%. The statistically significant results between the early ambulation group and
the survey group are as follows: ambulating >30’ by 1.7 vs 7.2 days (p<0.001), discharge at 6.9 vs 9.4 days
(p<0.01), length of hospital stay of 10.2 vs 12.6 days (p<0.012).
Bottom Line: Early ambulation protocols may be followed for patients with limited lower extremity burns
requiring skin grafting, who do not have medical illnesses that may impact wound healing.
!
!
!
27!
!
Intervention – Evidence Appraisal Worksheet
Citation:
Harvey I, Smith S, Patterson I. The use of quilted full thickness skin grafts in the lower limb: reliable results
with early mobilization. J of Plastic, Reconstructive & Aesthetic Surgery. 2009; 62; 969-972.
Level of Evidence (Oxford scale): 4
Is the purpose and background information sufficient?
Appraisal Criterion
Study Purpose
Reader’s Comments
Stated clearly?
Usually stated briefly in abstract and in greater detail in
introduction. May be phrased as a question or
hypothesis.
A clear statement helps you determine if topic is
important, relevant and of interest to you. Consider how
the study can be applied to PT and/or your own situation.
What is the purpose of this study?
The purpose was not clearly stated.
The purpose was to show that using quilted full thickness
skin grafts on the lower limbs allows for early ambulation
without graft loss.
Literature
Background literature was provided and describes the
lack of research into using this particular graft type on
the lower extremities.
Relevant background presented?
A review of the literature should provide background for
the study by synthesizing relevant information such as
previous research and gaps in current knowledge, along
with the clinical importance of the topic.
Describe the justification of the need for this study
Does the research design have strong internal validity?
Appraisal Criterion
!
!
Discuss possible threats to internal validity in
the research design. Include:
! Assignment
! Attrition
! History
! Instrumentation
! Maturation
! Testing
! Compensatory Equalization of
treatments
Reader’s Comments
Assignment: There was no control group. 60 consecutive
patients had this procedure preformed.
Attrition: 5 patients (7 grafts) did not return for the 2 week
follow up.
History: Mean age, and number of patients on particular
medications was provided.
28!
!
!
!
Compensatory rivalry
Statistical Regression
Instrumentation: The surgery was described in detail. No
mention of how graft take was measured.
Are the results of this therapeutic trial valid?
Appraisal Criterion
18. Did the investigators randomly assign subjects
to treatment groups?
a. If no, describe what was done
b. What are the potential consequences of
this assignment process for the study’s
results?
19. Did the investigators know who was being
assigned to which group prior to the allocation?
a. If they were not blind, what are the
potential consequences of this
knowledge for the study’s results?
20. Were the groups similar at the start of the trial?
Did they report the demographics of the study
groups?
a. If they were not similar – what
differences existed?
b. Do you consider these differences a
threat to the research validity? How
might the differences between groups
affect the results of the study?
21. Did the subjects know to which treatment group
they were assign?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s results
22. Did the investigators know to which treatment
group subjects were assigned ?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s results
23. Were the groups managed equally, apart from
the actual experimental treatment?
a. If not, what are the potential
consequences of this knowledge for the
study’s results?
24. Was the subject follow-up time sufficiently long
to answer the question(s) posed by the
research?
a. If not, what are the potential
consequences of this knowledge for the
study’s results?
25. Did all the subjects originally enrolled complete
the study?
!
Reader’s Comments
N/A due to lack of control group
N/A due to lack of control group
N/A due to lack of control group
N/A due to lack of control group
Yes, as all the patients received the same treatment.
N/A due to lack of control group
Yes.
No. 5 patients, with 7 total grafts, did not return for the 2
29!
!
a.
b.
If not how many subjects were lost?
What, if anything, did the authors do
about this attrition?
c. What are the implications of the
attrition and the way it was handled
with respect to the study’s findings?
26. Were all patients analyzed in the groups to which
they were randomized (i.e. was there an intention
to treat analysis)?
a. If not, what did the authors do with the
data from these subjects?
b. If the data were excluded, what are the
potential consequences for this study’s
results?
week follow-up. These patients were not included in the
study.
N/A due to lack of control group
Are the valid results of this RCT important?
Appraisal Criterion
Reader’s Comments
27. What were the statistical findings of this study?
a. When appropriate use the calculation
forms below to determine these values
b. Include: tests of differences With pvalues and CI
c. Include effect size with p-values and CI
d. Include ARR/ABI and RRR/RBI with pvalues and CI
e. Include NNT and CI
f. Other stats should be included here
At 2nd week follow up:
100% graft take = 89.4%,
70-99% graft take = 5.9%,
50% graft take = 1.2%,
40% graft take = 1.2%,
0% graft take = 2.4%
28. What is the meaning of these statistical findings
for your patient/client’s case? What does this
mean to your practice?
This particular surgery was not performed on my patient,
my patient is much younger than the mean age in this
study, and the reason for grafting is different. The
findings are not relevant to my patient or practice.
MCID was not discussed.
29. Do these findings exceed a minimally important
difference? Was this brought up or discussed?
a. If the MCID was not met, will you still
use this evidence?
Can you apply this valid, important evidence about an intervention in
caring for your patient/client? What is the external validity?
Appraisal Criterion
30. Does this intervention sound appropriate for use
(available, affordable) in your clinical setting? Do
you have the facilities, skill set, time, 3rd party
coverage to provide this treatment?
31. Are the study subjects similar to your patient/
client?
a. If not, how different? Can you use this
intervention in spite of the differences?
32. Do the potential benefits outweigh the potential
risks using this intervention with your
patient/client?
!
Reader’s Comments
The current surgeons use alternative grafting
procedures. If they chose this type it would be easy to
implement the early ambulation and discharge done in
the study.
The subjects are much older and the graft reason was
different from my patient. No other information on the
patients was provided. The intervention could be carried
over.
Yes.
30!
!
33. Does the intervention fit within your
patient/client’s stated values or expectations?
a. If not, what will you do now?
Yes.
34. Are there any threats to external validity in this
study?
Yes.
What is the bottom line?
Appraisal Criterion
Reader’s Comments
PEDRO score (see scoring at end of form)
2/10
Summarize your findings and relate this back to clinical
significance
60 patients with a total of 92 lesions on their lower limbs
received quilted full thickness skin grafts. Of the 55
patients who returned at the 2 week follow up, 89.4%
were completely healed, with another 5.9% between 7099% healed. All patients had two layers of “tubigrip”
applied and were on bed rest with bathroom privileges
for POD 1. On POD 2 they were discharged home and
ambulated freely.
This study shows the graft take results from one
particular type of graft surgery with early ambulation and
compression wrapping performed. It is not the typical
surgery performed at my clinic, however the results may
be generalized with caution to other grafts and are
positive for an early ambulation protocol.
!
31!
!
Pedro Scoring System:
Adapted from : Jewell, D. Guide to Evidence Based Physical Therapy Practice. Jones and Bartlett
Publishers, Sudbury, MA 2008
!
32!
!
Harvey I, Smith S, Patterson I.
The use of quilted full thickness skin grafts in the lower limb: reliable results with early
mobilization. J of Plastic, Reconstructive & Aesthetic Surgery. 2009; 62; 969-972.
Level of Evidence: Oxford Level 4
Background: Grafts to the lower extremities present greater challenges due to the dependent positioning
and increased shear forces present during ambulation. Quilted full thickness skin grafts have been used
primarily for nipple reconstruction and in the oral cavity, with more recent use on the face and hands to
prevent seroms, hematomas, and shearing.
Purpose: To perform quilted full thickness skin grafts on patients with lower extremity lesions, followed by
early ambulation and assess graft healing.
Methods: 60 patients with a total of 92 lesions on their lower limbs received quilted full thickness skin
grafts. All patients had two layers of “tubigrip” applied and were on bed rest with bathroom privileges for
POD 1. On POD 2 they were discharged home and ambulated freely.
Results: Of the 55 patients/ 85 grafts who returned at the 2 week follow up, 89.4% were completely
healed, 5.9% were 70-99% healed, 1.2% were 50% healed, 1.2% were 40% healed, and 2.4% had total
graft loss.
Bottom Line: The use of quilted full thickness skin grafts on lower extremity lesions followed by early
ambulation in the older population had positive graft healing results in this study.
!
!
!
33!
!
Intervention – Evidence Appraisal Worksheet
Citation:
Lorello DJ, Peck M, Albrecht M, Richey KJ, Pressman MA. Results of a prospective randomized controlled
trial of early ambulation for patients with lower extremity autografts. J Burn Care & Research. 2014; 35, 5:
431-436.
Level of Evidence (Oxford scale): 1b
Is the purpose and background information sufficient?
Appraisal Criterion
Study Purpose
Stated clearly?
Usually stated briefly in abstract and in greater detail in
introduction. May be phrased as a question or
hypothesis.
A clear statement helps you determine if topic is
important, relevant and of interest to you. Consider how
the study can be applied to PT and/or your own situation.
What is the purpose of this study?
Literature
Relevant background presented?
A review of the literature should provide background for
the study by synthesizing relevant information such as
previous research and gaps in current knowledge, along
with the clinical importance of the topic.
Reader’s Comments
Yes.
Hypothesis: Patients who begin ambulation within 24
hours of lower extremity autografting will have no
increased risk of graft failure than those patients who
remain immobile until POD 5.
Past research uses the Unna boot for compression
instead of the current use of ace figure of 8 wrapping.
Research shows inherent risks of immobility.
No prior RCTs consisting solely of burn patients.
Describe the justification of the need for this study
Does the research design have strong internal validity?
Appraisal Criterion
!
!
Discuss possible threats to internal validity in
the research design. Include:
! Assignment
! Attrition
! History
! Instrumentation
! Maturation
! Testing
Reader’s Comments
Random assignment of subjects.
Attrition rate of 25%. 10 subjects either did not return
after discharge or ambulated prior to POD 5 but were
assigned to the standard ambulation group. Excluding
these subjects could skew the data.
34!
!
!
!
!
Compensatory Equalization of
treatments
Compensatory rivalry
Statistical Regression
No testing was conducted, only tracking ambulation
dates and times, and using VAS for pain ratings.
No compensation was provided to subjects for
participation.
Are the results of this therapeutic trial valid?
Appraisal Criterion
35. Did the investigators randomly assign subjects
to treatment groups?
a. If no, describe what was done
b. What are the potential consequences of
this assignment process for the study’s
results?
36. Did the investigators know who was being
assigned to which group prior to the allocation?
a. If they were not blind, what are the
potential consequences of this
knowledge for the study’s results?
37. Were the groups similar at the start of the trial?
Did they report the demographics of the study
groups?
a. If they were not similar – what
differences existed?
b. Do you consider these differences a
threat to the research validity? How
might the differences between groups
affect the results of the study?
38. Did the subjects know to which treatment group
they were assign?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s results
39. Did the investigators know to which treatment
group subjects were assigned ?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s results
40. Were the groups managed equally, apart from
the actual experimental treatment?
a. If not, what are the potential
consequences of this knowledge for the
study’s results?
41. Was the subject follow-up time sufficiently long
to answer the question(s) posed by the
research?
a. If not, what are the potential
!
Reader’s Comments
Yes. Randomized assignment into ambulation group at
completion of surgery. Randomized allocation decreases
risk for bias.
A burn surgeon who reviewed images of grafts to
determine if any graft loss occurred was blinded.
Yes the groups were similar with no statistically
significant difference between groups. Demographics
and burn histories were provided in a table.
Yes. Subjects were not blinded to group allocation.
Subjects may act differently depending upon which
group they are assigned and skew some of the results.
Yes.
Yes.
Yes. Patients seen weekly for 3 weeks after discharge.
35!
!
consequences of this knowledge for the
study’s results?
42. Did all the subjects originally enrolled complete
the study?
a. If not how many subjects were lost?
b. What, if anything, did the authors do
about this attrition?
c. What are the implications of the
attrition and the way it was handled
with respect to the study’s findings?
43. Were all patients analyzed in the groups to which
they were randomized (i.e. was there an intention
to treat analysis)?
a. If not, what did the authors do with the
data from these subjects?
b. If the data were excluded, what are the
potential consequences for this study’s
results?
No. 41 patients enrolled, however 10 subjects were not
included either because they did not return after
discharge or they were randomized to the standard
ambulation group, but ambulated before POD 5.
No. 10 subjects were not included in the study because
they either did not show up for follow-ups after discharge
or because they ambulated earlier than POD 5 and were
randomized into the standard ambulation group.
Excluding this data can skew the results in either
direction.
Are the valid results of this RCT important?
Appraisal Criterion
44. What were the statistical findings of this study?
a. When appropriate use the calculation
forms below to determine these values
b. Include: tests of differences With pvalues and CI
c. Include effect size with p-values and CI
d. Include ARR/ABI and RRR/RBI with pvalues and CI
e. Include NNT and CI
f. Other stats should be included here
45. What is the meaning of these statistical findings
for your patient/client’s case? What does this
mean to your practice?
46. Do these findings exceed a minimally important
difference? Was this brought up or discussed?
a. If the MCID was not met, will you still
use this evidence?
Reader’s Comments
No statistical difference in graft loss.
Percentage of graft loss: EAG 1.0% vs SAG 7.7%
(p=0.0376)
Mean minutes of ambulation on POD 5: EAG 23.4
minutes vs SAG 12.03 minutes (p=0.0235)
Donor and graft site pain: EAG 1.3/10 vs SAG 3.14/10
on the VAS (p=0.0243)
In patients that fit the inclusion criteria, it may be safe to
begin ambulation immediately following graft surgery
with no statistical affect on graft healing, but with benefits
of increased ambulation times and decreased pain.
The MCID was not mentioned, however the risks appear
low and this protocol may be beneficial for a select group
of patients.
Can you apply this valid, important evidence about an intervention in
caring for your patient/client? What is the external validity?
Appraisal Criterion
47. Does this intervention sound appropriate for use
(available, affordable) in your clinical setting? Do
you have the facilities, skill set, time, 3rd party
coverage to provide this treatment?
48. Are the study subjects similar to your patient/
!
Reader’s Comments
Yes. This intervention is simply providing the same
intervention sooner to patients instead of waiting 5 days.
Easy to implement.
The subjects of this study are non-complex burn patients
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client?
a. If not, how different? Can you use this
intervention in spite of the differences?
49. Do the potential benefits outweigh the potential
risks using this intervention with your
patient/client?
50. Does the intervention fit within your
patient/client’s stated values or expectations?
a. If not, what will you do now?
with a small TBSA% burned. They are a small minority of
the patients seen at my clinical site, but they are present.
Yes.
Yes. My patients want to go to the bathroom
independently, walk around, and go home as soon as
possible.
51. Are there any threats to external validity in this
study?
What is the bottom line?
Appraisal Criterion
Reader’s Comments
PEDRO score (see scoring at end of form)
8/10
Summarize your findings and relate this back to clinical
significance
No difference was found in graft loss between the early
ambulation group and the standard treatment group on
POD 5 or on follow-up visits. A significant difference was
found in the mean minutes each group could ambulate
on POD 5 (EAG: 23.4 minutes vs STG: 14.1, p=0.235).
The EAG reported decreased pain at the graft site during
rest (EAG: 1.3/10 vs STG 3.5/10, p=0.0243). There was
no difference in the length of stay for either group. These
findings suggest that non-complex burn patients may
ambulate on POD 1 without increased risk to graft
healing.
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Pedro Scoring System:
Adapted from : Jewell, D. Guide to Evidence Based Physical Therapy Practice. Jones and Bartlett
Publishers, Sudbury, MA 2008
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38!
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Lorello DJ, Peck M, Albrecht M, Richey KJ, Pressman MA.
Results of a prospective randomized controlled trial of early ambulation for patients with lower
extremity autografts. J Burn Care & Research. 2014; 35, 5: 431-436.
Level of Evidence: Oxford 1b
Background: Patients who undergo lower extremity skin grafting are commonly immobilized for five days
over concerns of graft failure due to edema or shearing forces during the revascularization stage between
4-6 days post-op. There are also risks to immobilization including decreases in strength, orthostatic
tolerance, and stroke volume and cardiac output. There are no prior randomized controlled trials on early
ambulation of patients with lower extremity autografts in the burn population.
Purpose: The objective of this study was to show that there is no change in graft healing between those
who ambulated within 24 hours of lower extremity autografting and those immobilized for five days.
Methods: 31 ambulatory patients over 18 years of age, without comorbidities affecting graft healing were
randomly allocated to either a standard treatment group (n=14) or an early ambulation group (n=17). The
early group (EAM) began ambulation on POD 1 versus POD 5 for the standard group (STG).
Results: No difference was found in graft healing between groups on POD 5 or on follow-up visits. A
significant difference was found in the mean minutes each group could ambulate on POD 5 (EAG: 23.4
minutes vs STG: 14.1, p=0.235). The EAG reported decreased pain at the graft site during rest (EAG:
1.3/10 vs STG 3.5/10, p=0.0243). There was no difference in the length of stay for either group.
Bottom Line: Graft healing was not shown to be impacted by ambulation protocols and therefore, burn
patients with lower extremity skin grafts can safely ambulate on POD 1.
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39!
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Intervention – Evidence Appraisal Worksheet
Citation:
Luczak B, Ha J, Gurfinkel R. Effect of early and late mobilisation on split skin graft outcome. Australas J of
Dermatol. 2012; 53: 19-21.
Level of Evidence (Oxford scale): 2b
Is the purpose and background information sufficient?
Appraisal Criterion
Study Purpose
Reader’s Comments
Stated clearly?
Usually stated briefly in abstract and in greater detail in
introduction. May be phrased as a question or
hypothesis.
A clear statement helps you determine if topic is
important, relevant and of interest to you. Consider how
the study can be applied to PT and/or your own situation.
What is the purpose of this study?
Yes. They hypothesize that early ambulation does not
impact negatively on graft take, wound healing or
adversely affect patient morbidity.
Literature
Relevant background presented?
A review of the literature should provide background for
the study by synthesizing relevant information such as
previous research and gaps in current knowledge, along
with the clinical importance of the topic.
There is a brief mention of the previous literature and the
emerging trend towards early ambulation protocols within
the research.
Describe the justification of the need for this study
Does the research design have strong internal validity?
Appraisal Criterion
!
!
Reader’s Comments
Discuss possible threats to internal validity in
the research design. Include:
! Assignment
! Attrition
! History
! Instrumentation
! Maturation
! Testing
! Compensatory Equalization of
treatments
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!
Compensatory rivalry
Statistical Regression
Are the results of this therapeutic trial valid?
Appraisal Criterion
52. Did the investigators randomly assign subjects
to treatment groups?
a. If no, describe what was done
b. What are the potential consequences of
this assignment process for the study’s
results?
53. Did the investigators know who was being
assigned to which group prior to the allocation?
a. If they were not blind, what are the
potential consequences of this
knowledge for the study’s results?
54. Were the groups similar at the start of the trial?
Did they report the demographics of the study
groups?
a. If they were not similar – what
differences existed?
b. Do you consider these differences a
threat to the research validity? How
might the differences between groups
affect the results of the study?
55. Did the subjects know to which treatment group
they were assign?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s results
56. Did the investigators know to which treatment
group subjects were assigned ?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s results
57. Were the groups managed equally, apart from
the actual experimental treatment?
a. If not, what are the potential
consequences of this knowledge for the
study’s results?
58. Was the subject follow-up time sufficiently long
to answer the question(s) posed by the
research?
a. If not, what are the potential
consequences of this knowledge for the
study’s results?
59. Did all the subjects originally enrolled complete
the study?
a. If not how many subjects were lost?
b. What, if anything, did the authors do
about this attrition?
!
Reader’s Comments
No, it was a retrospective notes review. Allocation to
group was determined by individual therapist.
No
Yes, the groups were similar. The only statistically
significant difference was the number of burn patients
allocated to the early mobilization group (18), compared
to late mobilization (4) p=0.0002.
N/A
N/A
Yes.
Yes. Follow up was at day 5, with weekly clinic follow up
until open wound care was achieved.
Yes.
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c.
What are the implications of the
attrition and the way it was handled
with respect to the study’s findings?
60. Were all patients analyzed in the groups to which
they were randomized (i.e. was there an intention
to treat analysis)?
a. If not, what did the authors do with the
data from these subjects?
b. If the data were excluded, what are the
potential consequences for this study’s
results?
Yes.
Are the valid results of this RCT important?
Appraisal Criterion
61. What were the statistical findings of this study?
a. When appropriate use the calculation
forms below to determine these values
b. Include: tests of differences With pvalues and CI
c. Include effect size with p-values and CI
d. Include ARR/ABI and RRR/RBI with pvalues and CI
e. Include NNT and CI
f. Other stats should be included here
Reader’s Comments
Significant differences in deconditioning: 0 vs 6
(p=0.008),
Post-op LOS: 3.92 vs 7.96 days (p=0.0001),
Total LOS: 7.72 vs 13.57 days.
No significant difference in graft loss: 88% vs 91%
(p=0.45), infection (p=0.22), hematoma (p~1), or
hypergranulation (p=0.24).
62. What is the meaning of these statistical findings
for your patient/client’s case? What does this
mean to your practice?
The findings of this study indicate my non-complicated
burn patient would benefit from early ambulation and the
graft would not be negatively affected.
63. Do these findings exceed a minimally important
difference? Was this brought up or discussed?
a. If the MCID was not met, will you still
use this evidence?
MCID was not mentioned
Can you apply this valid, important evidence about an intervention in
caring for your patient/client? What is the external validity?
Appraisal Criterion
64. Does this intervention sound appropriate for use
(available, affordable) in your clinical setting? Do
you have the facilities, skill set, time, 3rd party
coverage to provide this treatment?
65. Are the study subjects similar to your patient/
client?
a. If not, how different? Can you use this
intervention in spite of the differences?
66. Do the potential benefits outweigh the potential
risks using this intervention with your
patient/client?
67. Does the intervention fit within your
patient/client’s stated values or expectations?
a. If not, what will you do now?
!
Reader’s Comments
Yes, the intervention is appropriate for some patients
and requires no extra equipment or training.
Yes. The subjects of this study are very similar to my
patient.
Yes. According to the results, there are only statistically
significant benefits to this intervention.
Yes, the patient wants to walk and go home as soon as
possible without decreasing graft healing.
42!
!
68. Are there any threats to external validity in this
study?
No
What is the bottom line?
Appraisal Criterion
Reader’s Comments
PEDRO score (see scoring at end of form)
6/10
Summarize your findings and relate this back to clinical
significance
There was no difference found in graft loss 88% vs 91%
(p=0.45), wound healing, or patient morbidity between
groups, however the late mobilization group did have an
increased rate of deconditioning 0 vs 6 (p=0.008), and
increased length of hospital stay 3.92 vs 7.96 days
(p=0.0001).
Results suggest that early ambulation for lower extremity
burn patients does not negatively impact graft healing
and can decrease deconditioning and hospital stays.
!
43!
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Pedro Scoring System:
Adapted from : Jewell, D. Guide to Evidence Based Physical Therapy Practice. Jones and Bartlett
Publishers, Sudbury, MA 2008
!
44!
!
Luczak B, Ha J, Gurfinkel R.
Effect of early and late mobilisation on split skin graft outcome.
Australas J of Dermatol. 2012; 53: 19-21.
Level of Evidence: Oxford Scale 2b
Background: There is an assumption that graft take and wound healing will be impaired by early
ambulation, however there is an increasing amount of evidence to suggest this may not be the case.
Purpose: This study hypothesizes that early mobilization does not negatively impact graft take, wound
healing, or patient morbidity. They reviewed mobilization guidelines for patients with lower extremity splitthickness skin grafts by comparing early and late mobilization patients.
Methods: A retrospective notes review of 48 subjects with lower extremity split thickness skin grafts was
performed from Royal Perth Hospital over a 6-month period with patients placed into either an early or late
mobilization group. Early mobilization was defined as less than or equal to 3 days of bed rest, late
mobilization was defined as bed rest for greater than or equal to 4 days of bed rest with toilet privileges,
mobilization was defined as unrestricted walking, and deconditioning was defined as a delay of discharge
after an immobilization period secondary to poor mobility requiring rehab.
Results: There was no difference found in graft loss 88% vs 91% (p=0.45), wound healing, or patient
morbidity between groups, however the late mobilization group did have an increased rate of
deconditioning 0 vs 6 (p=0.008), and increased length of hospital stay 3.92 vs 7.96 days (p=0.0001).
Bottom Line: Results suggest that early ambulation for lower extremity burn patients does not negatively
impact graft healing and can decrease deconditioning and hospital stays.
!
45!
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Systematic Review – Evidence Appraisal Worksheet
Citation:
Nedelec B, Serghiou MA, Niszczak J, McMahon M, Healey T. Practice guidelines for early ambulation of
burn survivors after lower extremity grafts. J Burn Care Res. 2012; 33: 319-329. DOI:
10.1097/BCR.0b013e31823359d9
Level of Evidence (Oxford scale): 3a
Does the design follow the Cochrane method?
Appraisal Criterion
Reader’s Comments
Step 1 – formulating the question
• Do the authors identify the focus of the
review
• A clearly defined question should specify
the types of:
• people (participants),
• interventions or exposures,
• outcomes that are of interest
• studies that are relevant to
answering the question
Yes. Evaluate evidence of early ambulation of LE burns
requiring skin grafts on graft healing.
Step 2 – locating studies
• Should identify ALL relevant literature
• Did they include multiple databases?
• Was the search strategy defined and include:
o Bibliographic databases used as well
as hand searching
o Terms (key words and index terms)
o Citation searching: reference lists
o Contact with ‘experts’ to identify ‘grey’
literature (body of materials that cannot
be found easily through conventional
channels such as publishers)
o Sources for ‘grey literature’
Yes
Part 3:Critical Appraisal/Criteria for Inclusion
• Were criteria for selection specified?
• Did more than one author assess the
relevance of each report
• Were decisions concerning relevance
described; completed by non-experts,
or both?
• Did the people assessing the relevance
of studies know the names of the
authors, institutions, journal of
publication and results when they apply
Yes. Two independent reviewers with a third reviewer as
needed.
!
46!
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the inclusion criteria? Or is it blind?
Part 3 – Critically appraise for bias:
• Selection –
• Were the groups in the study selected
differently?
• Random? Concealed?
• Performance• Did the groups in the study receive
different treatment?
• Was there blinding?
• Attrition –
• Were the groups similar at the end of
the study?
• Account for drop outs?
• Detection –
• Did the study selectively report the
results?
• Is there missing data?
Part 4 – Collection of the data
• Was a collection data form used and is it
included?
• Are the studies coded and is the data coding
easy to follow?
• Were studies identified that were excluded & did
they give reasons why (i.e., which criteria they
failed).
Sample sizes ranged from 9-100. RCTs ranged from 4475 subjects.
The coding is clear. Reasons are provided for excluding
studies.
Are the results of this SR valid?
Appraisal Criterion
69. Is this a SR of randomized trials? Did they limit
this to high quality studies at the top of the
hierarchies
a. If not, what types of studies were
included?
b. What are the potential consequences of
including these studies for this review’s
results?
70. Did this study follow the Cochrane methods
selection process and did it identify all relevant
trials?
a. If not, what are the consequences for
this review’s results?
71. Do the methods describe the processes and
tools used to assess the quality of individual
studies?
a. If not, what are the consequences for
this review’s results?
72. What was the quality of the individual studies
included? Were the results consistent from study to
study? Did the investigators provide details about
the research validity or quality of the studies included
!
Reader’s Comments
No. There are 4 RCTs, 1 Case-control study, and 11
case series were included.
Yes
Yes
RCTs were Level 1b or 1c, Case series were Level 4.
Results were consistent from study to study.
47!
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in review?
73. Did the investigators address publication bias
Yes.
Are the valid results of this SR important?
Appraisal Criterion
74. Were the results homogenous from study to study?
a. If not, what are the consequences for
this review’s results?
75. If the paper is a meta-analysis did they report the
statistical results? Did they include a forest
plat? What other statistics do they include? Are
there CIs?
76. From the findings, is it apparent what the
cumulative weight of the evidence is?
Reader’s Comments
Yes
Not a meta-analysis
Isolating burns has a cumulative low weight of evidence
Can you apply this valid, important evidence from this SR in caring for
your patient/client? What is the external validity?
Appraisal Criterion
77. Is your patient different from those in this SR?
78. Is the treatment feasible in your setting? Do you
have the facilities, skill set, time, 3rd party
coverage to provide this treatment?
79. Does the intervention fit within your
patient/client’s stated values or expectations?
a. If not, what will you do now?
Reader’s Comments
No
Yes
Yes
What is the bottom line?
Appraisal Criterion
Reader’s Comments
Summarize your findings and relate this back to clinical
significance
An early postoperative ambulation protocol should be
initiated immediately, or as soon as possible, on patients
who were previously ambulatory, are medically and
psychologically stable, with wounds <300cm2 that are not
on the plantar surface of the foot. External compression
must be applied and any joints the graft crosses should
be immobilized until the first dressing change.
Adapted from : Jewell, D. Guide to Evidence Based Physical Therapy Practice. Jones and Bartlett
Publishers, Sudbury, MA 2008
!
48!
!
Nedelec B, Serghiou MA, Niszczak J, McMahon M, Healey T.
Practice guidelines for early ambulation of burn survivors after lower extremity grafts.
J Burn Care Res. 2012; 33: 319-329. DOI: 10.1097/BCR.0b013e31823359d9.
Level of Evidence: Oxford Level 3a
Background: Patients following lower extremity graft surgeries are typically put on bed rest for several
days despite the literature advocating for earlier ambulation protocols. Practice guidelines do not yet exist
and the reason for bed rest is most often fear of graft failure due to hematoma, shearing, or lack of graft
adherence.
Purpose: The purpose of this guideline was to review the evidence supporting early ambulation after lower
extremity skin grafts and to determine when burn patients should being ambulating after skin grafting.
Methods: To create practice guidelines they created a guideline development group, asked clinically
relevant questions, performed an electronic literature search, and appraised the twenty-two articles
included.
Results: 4 RCTs, 1 Case-control study, and 11 case series were included. No RCTs contained only burn
patients. All the studies contained elastic compression before ambulation. No studies found initiation of
ambulation to have an impact on graft healing.
Guidelines: An early postoperative ambulation protocol should be initiated immediately, or as soon as
possible, on patients who were previously ambulatory, are medically and psychologically stable, with
wounds <300cm2 that are not on the plantar surface of the foot. External compression must be applied and
any joints the graft crosses should be immobilized until the first dressing change.
!
!
49!
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Systematic Review – Evidence Appraisal Worksheet
Citation:
Smith TO. When should patients begin ambulating following lower limb split skin graft surgery? A
systematic review. Physiotherapy. 2006; 92: 135-145.
Level of Evidence (Oxford scale): 2a
Does the design follow the Cochrane method?
Appraisal Criterion
Reader’s Comments
Step 1 – formulating the question
• Do the authors identify the focus of the
review
• A clearly defined question should specify
the types of:
• people (participants),
• interventions or exposures,
• outcomes that are of interest
• studies that are relevant to
answering the question
Yes. The objective “was to determine when patients
should begin walking after lower extremity skin graft
surgery, with consideration given to graft healing,
duration to discharge, postoperative complications,
functional outcomes, quality of life and patient
satisfaction.”
Studies/Participants: All clinical trials in English with
human-subjects, no age or gender limitations.
Intervention: ambulation, debridement, split-thickness
skin graft, compression wrapping
Outcomes: graft healing, duration to discharge,
postoperative complications, functional outcomes, quality
of life and patient satisfaction
Step 2 – locating studies
• Should identify ALL relevant literature
• Did they include multiple databases?
• Was the search strategy defined and include:
o Bibliographic databases used as well
as hand searching
o Terms (key words and index terms)
o Citation searching: reference lists
o Contact with ‘experts’ to identify ‘grey’
literature (body of materials that cannot
be found easily through conventional
channels such as publishers)
o Sources for ‘grey literature’
Part 3:Critical Appraisal/Criteria for Inclusion
• Were criteria for selection specified?
• Did more than one author assess the
relevance of each report
• Were decisions concerning relevance
described; completed by non-experts,
or both?
• Did the people assessing the relevance
of studies know the names of the
!
Electronic database searches: AMED, Cinahl, Embase,
Medline via Ovid, PEDro, and Pubmed.
Search terms were given and strategy defined.
Hand search through the reference lists of identified
citations, as well as The British Journal of Plastic
Surgery, and the Annals of Plastic Surgery and
Physiotherapy from 1980-2006 for additional studies.
No mention of contacting “experts” for grey literature.
Did not include unpublished studies.
Yes: Inclusion and exclusion criteria stated.
No: A single, non-blinded reviewer performed the search
and extracted data.
50!
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authors, institutions, journal of
publication and results when they apply
the inclusion criteria? Or is it blind?
Part 3 – Critically appraise for bias:
• Selection –
• Were the groups in the study selected
differently?
• Random? Concealed?
• Performance• Did the groups in the study receive
different treatment?
• Was there blinding?
• Attrition –
• Were the groups similar at the end of
the study?
• Account for drop outs?
• Detection –
• Did the study selectively report the
results?
• Is there missing data?
Part 4 – Collection of the data
• Was a collection data form used and is it
included?
• Are the studies coded and is the data coding
easy to follow?
• Were studies identified that were excluded & did
they give reasons why (i.e., which criteria they
failed).
Selection: only 3 studies were randomized, none were
concealed.
Performance: no studies were blinded for subject or
clinicians.
Attrition: studies accounted for drop-outs
Detection: not all studies gave thorough description of
intervention protocols and other details that may skew
results.
A summary of the articles with key data including study
design, population characteristics, average wound size,
surgical and postoperative interventions undertaken,
outcome measures applied, follow-up period, and results
was included.
Articles were easily identified by a coding of last name
and a number.
Excluded articles were not individually listed.
Are the results of this SR valid?
Appraisal Criterion
80. Is this a SR of randomized trials? Did they limit
this to high quality studies at the top of the
hierarchies
a. If not, what types of studies were
included?
b. What are the potential consequences of
including these studies for this review’s
results?
81. Did this study follow the Cochrane methods
selection process and did it identify all relevant
trials?
a. If not, what are the consequences for
this review’s results?
82. Do the methods describe the processes and
tools used to assess the quality of individual
studies?
a. If not, what are the consequences for
this review’s results?
!
Reader’s Comments
No.
Designs included: Retrospective review (9),
Observational study (4), and RCT (4).
Articles were rated using Pedro scores, with the highest
receiving a 5. Overall the evidence was poor.
No. Only one reviewer was used which Introduces bias
during the article selection process.
Articles were rated using the PEDro (Physiotherapy
Evidence Database) scale, with the highest receiving a
5. Overall the evidence was poor. Studies were included
even with considerable methodological limitations in an
51!
!
attempt to evaluate the entirety of evidence.
83. What was the quality of the individual studies
included? Were the results consistent from study to
study? Did the investigators provide details about
the research validity or quality of the studies included
in review?
84. Did the investigators address publication bias
Overall the quality of the individual studies was poor.
Results were consistent from study to study. Details of
each study’s validity were discussed.
Yes. No attempt was made to identify unpublished
studies.
Are the valid results of this SR important?
Appraisal Criterion
85. Were the results homogenous from study to
study?
a. If not, what are the consequences for
this review’s results?
86. If the paper is a meta-analysis did they report the
statistical results? Did they include a forest
plat? What other statistics do they include? Are
there CIs?
87. From the findings, is it apparent what the
cumulative weight of the evidence is?
Reader’s Comments
Yes. Although the studies had a wide variety of in
regards to initiation of ambulation, the results were
homogenous in that graft healing was not significantly
effected by either early or late ambulation.
No meta-analysis due to paucity of trials for each
postoperative day that patients were mobilized, and the
heterogeneity of the study samples and data.
Yes. The weight of the evidence is low and greater
research is needed.
Can you apply this valid, important evidence from this SR in caring for
your patient/client? What is the external validity?
Appraisal Criterion
88. Is your patient different from those in this SR?
89. Is the treatment feasible in your setting? Do you
have the facilities, skill set, time, 3rd party
coverage to provide this treatment?
90. Does the intervention fit within your
patient/client’s stated values or expectations?
b. If not, what will you do now?
Reader’s Comments
No. The SR covered wide age range, and cause of
injury, similar to my patient population. More complex
patients were not included.
Yes, this treatment is feasible and could easily be
implemented.
Yes. Patients want to get out of bed, ambulate to the
bathroom independently immediately, and go home as
soon as possible.
What is the bottom line?
Appraisal Criterion
Reader’s Comments
Summarize your findings and relate this back to clinical
significance
The findings of this review suggest that patients should
begin walking immediately, or at the earliest opportunity,
after lower extremity split-thickness skin graft surgery.
Although there is no evidence to suggest early
ambulation improves graft healing, it does not jeopardize
graft take significantly. Economic benefits and decrease
activity restriction of patients also support early
!
52!
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ambulation. The conclusion of this review is based on
low level evidence and requires further RCTs and higher
level studies to determine the effectiveness of early
ambulation for lower extremity skin graft patients and
specific protocols, and contraindications.
Adapted from : Jewell, D. Guide to Evidence Based Physical Therapy Practice. Jones and Bartlett
Publishers, Sudbury, MA 2008
!
!
!
!
!
53!
!
Smith TO.
When should patients begin ambulating following lower limb split skin graft surgery?
A systematic review. Physiotherapy. 2006; 92: 135-145.
Level of Evidence: Oxford 2a
Background: Traditionally, patients are immobilized for several days following split-thickness skin graft
surgery. More recently there has been a push to ambulate patients earlier in order to avoid secondary
medical complications associated with bed rest and to facilitate hospital discharge.
Purpose: The purpose of this literature review was to determine when patients could begin ambulating
following lower extremity split-thickness skin graft surgery. Graft healing, duration until discharge,
postoperative complications, functional outcomes, quality of life, and patient satisfaction were considered.
Methods: A literature search was conducted using the following electronic databases: AMED, Cinahl,
Embase, Medline via Ovid, PEDro, and Pubmed. Reference lists of found articles were searched for further
studies. A hand-search was conducted of The British Journal of Plastic Surgery and the Annals of Plastic
Surgery and Physiotherapy from 1980-2006. From 1137 articles, 17 were chosen. A single reviewer
performed the search, extracted the data, and scored the articles using the PEDro scale.
Results: Articles were classified based upon earliest postoperative day ambulation, ranging from
immediate ambulation to greater than one week. The quality of the evidence is generally poor.
Bottom Line: The literature reviewed supports beginning ambulation immediately following lower
extremity split-thickness skin graft surgery, as it appears to neither jeopardize nor improve graft healing,
and may decrease hospital length of stay. Due to the poor quality of evidence, conclusions made from
these findings should be reviewed with care. Further, higher quality studies are needed to address current
weaknesses in the literature.
!
54!
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Systematic Review – Evidence Appraisal Worksheet
Citation
Southwell-Keely J, Vandervord J. Mobilisation versus bed rest after skin grafting pretibial lacerations: A
meta-analysis. Plast Surg Int. 2012; 2012: 207452. doi: 10.1155/2012/207452.
Level of Evidence (Oxford scale): 1a
Does the design follow the Cochrane method?
Appraisal Criterion
Reader’s Comments
Step 1 – formulating the question
• Do the authors identify the focus of the
review
• A clearly defined question should specify
the types of:
• people (participants),
• interventions or exposures,
• outcomes that are of interest
• studies that are relevant to
answering the question
Yes. The purpose of this study was to assess early
mobilization versus bed rest on lower extremity skin graft
healing.
Step 2 – locating studies
• Should identify ALL relevant literature
• Did they include multiple databases?
• Was the search strategy defined and include:
o Bibliographic databases used as well
as hand searching
o Terms (key words and index terms)
o Citation searching: reference lists
o Contact with ‘experts’ to identify ‘grey’
literature (body of materials that cannot
be found easily through conventional
channels such as publishers)
o Sources for ‘grey literature’
Yes. Medline, Embase, Cochrane, Cinahl, and Google
Scholar databases were used, as were the
bibliographies of selected studies cross-referenced.
Search terms were not included. Experts were contacted
in cases of missing data.
Part 3:Critical Appraisal/Criteria for Inclusion
• Were criteria for selection specified?
• Did more than one author assess the
relevance of each report
• Were decisions concerning relevance
described; completed by non-experts,
or both?
• Did the people assessing the relevance
of studies know the names of the
authors, institutions, journal of
publication and results when they apply
the inclusion criteria? Or is it blind?
Yes, criteria were specified. Not stated if more than one
author assessed each report.
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Part 3 – Critically appraise for bias:
• Selection –
• Were the groups in the study selected
differently?
• Random? Concealed?
• Performance• Did the groups in the study receive
different treatment?
• Was there blinding?
• Attrition –
• Were the groups similar at the end of
the study?
• Account for drop outs?
• Detection –
• Did the study selectively report the
results?
• Is there missing data?
Groups were randomized.
Interventions were the same between studies.
Part 4 – Collection of the data
• Was a collection data form used and is it
included?
• Are the studies coded and is the data coding
easy to follow?
• Were studies identified that were excluded & did
they give reasons why (i.e., which criteria they
failed).
No, collection data form is not included. There are only 4
studies so coding was not used. Yes, a flow diagram was
included with the reasoning behind excluded studies.
Are the results of this SR valid?
Appraisal Criterion
91. Is this a SR of randomized trials? Did they limit
this to high quality studies at the top of the
hierarchies
a. If not, what types of studies were
included?
b. What are the potential consequences of
including these studies for this review’s
results?
92. Did this study follow the Cochrane methods
selection process and did it identify all relevant
trials?
a. If not, what are the consequences for
this review’s results?
93. Do the methods describe the processes and
tools used to assess the quality of individual
studies?
a. If not, what are the consequences for
this review’s results?
94. What was the quality of the individual studies
included? Were the results consistent from study to
study? Did the investigators provide details about
the research validity or quality of the studies included
in review?
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Reader’s Comments
Four articles were analyzed including three randomized
controlled trials and one prospective cohort study.
Including the prospective cohort study may introduce
bias, however sensitivity analyses were performed and
the data results did not change.
It followed the guidelines set out in the QUORUM
statement and the CONSORT statement.
Yes
Not stated
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95. Did the investigators address publication bias
Are the valid results of this SR important?
Appraisal Criterion
96. Were the results homogenous from study to study?
a. If not, what are the consequences for
this review’s results?
97. If the paper is a meta-analysis did they report the
statistical results? Did they include a forest
plat? What other statistics do they include? Are
there CIs?
98. From the findings, is it apparent what the
cumulative weight of the evidence is?
Reader’s Comments
Yes
Yes. A forest plat, odds ratios and CIs are included.
Strength of evidence is not strong.
Can you apply this valid, important evidence from this SR in caring for
your patient/client? What is the external validity?
Appraisal Criterion
99. Is your patient different from those in this SR?
100. Is the treatment feasible in your setting? Do you
have the facilities, skill set, time, 3rd party
coverage to provide this treatment?
101. Does the intervention fit within your
patient/client’s stated values or expectations?
c. If not, what will you do now?
Reader’s Comments
Yes, his graft is a result of a burn not a laceration.
Yes.
Yes. The patient would like to ambulate as soon as
possible.
What is the bottom line?
Appraisal Criterion
Reader’s Comments
Summarize your findings and relate this back to clinical
significance
No difference in graft healing was found between the
early mobilization groups and bed rest groups of either 7
or 14 days. No difference found in hematoma, bleeding,
infection, or donor site healing rates between groups.
Systemic corticosteroids significantly delayed graft
healing.
Graft healing is not effected by ambulation interventions,
however the use of corticosteroids does have a
significant negative effect on graft healing.
Adapted from : Jewell, D. Guide to Evidence Based Physical Therapy Practice. Jones and Bartlett
Publishers, Sudbury, MA 2008
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Southwell-Keely J, Vandervord J.
Mobilisation versus bed rest after skin grafting pretibial lacerations:
A meta-analysis. Plast Surg Int. 2012; 2012: 207452. doi: 10.1155/2012/207452.
Level of Evidence: Oxford Level 1a
Background: Pretibial lacerations are most commonly managed with debridement and skin grafting
followed by several days of postoperative bed rest.
Purpose: The purpose of this study was to assess early mobilization versus bed rest on skin graft healing.
Methods: An electronic database literature search was conducted and bibliographies of selected studies
were cross-referenced. Four articles were analyzed including three randomized controlled trials and one
prospective cohort study.
Results: No difference in graft healing was found between the early mobilization groups and bed rest
groups of either 7 or 14 days. No difference found in hematoma, bleeding, infection, or donor site healing
rates between groups. Systemic corticosteroids significantly delayed graft healing.
Bottom Line: Graft healing is not effected by ambulation interventions, however the use of corticosteroids
does have a significant negative effect on graft healing.
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Intervention – Evidence Appraisal Worksheet
Citation:
Wallenberg L. Effect of early mobilization after skin grafting to lower limbs. Scand J Plast Reconstr Hand
Surg. 1999; 33: 411-413.
Level of Evidence (Oxford scale): 1c
Is the purpose and background information sufficient?
Appraisal Criterion
Study Purpose
Reader’s Comments
Stated clearly?
Usually stated briefly in abstract and in greater detail in
introduction. May be phrased as a question or
hypothesis.
A clear statement helps you determine if topic is
important, relevant and of interest to you. Consider how
the study can be applied to PT and/or your own situation.
What is the purpose of this study?
Yes. The purpose of this prospective, randomized study
was to determine whether strict bed rest is required after
split-thickness skin graft surgery to the lower extremities.
Literature
Only two previous studies are referenced. A thorough
review of the literature was not reported.
Relevant background presented?
A review of the literature should provide background for
the study by synthesizing relevant information such as
previous research and gaps in current knowledge, along
with the clinical importance of the topic.
Describe the justification of the need for this study
Does the research design have strong internal validity?
Appraisal Criterion
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Discuss possible threats to internal validity in
the research design. Include:
! Assignment
! Attrition
! History
! Instrumentation
! Maturation
! Testing
! Compensatory Equalization of
treatments
Reader’s Comments
Assignment was randomized.
Attrition rate was not mentioned.
History between groups was insignificant according to
Fisher’s exact test (p=0.7).
Maturation: Subjects were reviewed at 14 days post-op.
Testing: graft healing was evaluated by two blinded
nurses.
Compensation: no compensation was given to the
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Compensatory rivalry
Statistical Regression
subjects.
Are the results of this therapeutic trial valid?
Appraisal Criterion
102. Did the investigators randomly assign subjects
to treatment groups?
a. If no, describe what was done
b. What are the potential consequences of
this assignment process for the study’s
results?
103. Did the investigators know who was being
assigned to which group prior to the allocation?
a. If they were not blind, what are the
potential consequences of this
knowledge for the study’s results?
104. Were the groups similar at the start of the trial?
Did they report the demographics of the study
groups?
a. If they were not similar – what
differences existed?
b. Do you consider these differences a
threat to the research validity? How
might the differences between groups
affect the results of the study?
105. Did the subjects know to which treatment group
they were assign?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s results
106. Did the investigators know to which treatment
group subjects were assigned ?
a. If yes, what are the potential
consequences of the subjects’
knowledge for this study’s results
107. Were the groups managed equally, apart from
the actual experimental treatment?
a. If not, what are the potential
consequences of this knowledge for the
study’s results?
108. Was the subject follow-up time sufficiently long
to answer the question(s) posed by the
research?
a. If not, what are the potential
consequences of this knowledge for the
study’s results?
109. Did all the subjects originally enrolled complete
the study?
a. If not how many subjects were lost?
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Reader’s Comments
Yes. Subjects were assigned to a group the afternoon
after their operation by drawing paper slips from a box.
There were a total of 50 paper slips, 25 with E (early)
and 25 with L (late).
No. The investigators were blinded.
The groups were similar. They reported age, gender, and
diagnosis.
Unsure if the patients were told the study was looking at
ambulation date, because if they had then the patients
would obviously know what group they were assigned to.
No. The two nurses were blinded.
Yes, both groups were managed the same except for the
intervention.
Graft healing was assessed at 14 days post-op. Followup for a longer time would provide extra information,
especially due to the complexity of the systemic diseases
included in this study, however grafts would either be
adhered or not by day 14.
Not clearly stated, but it appears all subjects completed
the study.
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b.
What, if anything, did the authors do
about this attrition?
c. What are the implications of the
attrition and the way it was handled
with respect to the study’s findings?
110. Were all patients analyzed in the groups to which
they were randomized (i.e. was there an intention
to treat analysis)?
a. If not, what did the authors do with the
data from these subjects?
b. If the data were excluded, what are the
potential consequences for this study’s
results?
Not clearly stated, but it appears so.
Are the valid results of this RCT important?
Appraisal Criterion
111. What were the statistical findings of this study?
a. When appropriate use the calculation
forms below to determine these values
b. Include: tests of differences With pvalues and CI
c. Include effect size with p-values and CI
d. Include ARR/ABI and RRR/RBI with pvalues and CI
e. Include NNT and CI
f. Other stats should be included here
112. What is the meaning of these statistical findings
for your patient/client’s case? What does this
mean to your practice?
113. Do these findings exceed a minimally important
difference? Was this brought up or discussed?
a. If the MCID was not met, will you still
use this evidence?
Reader’s Comments
There was no statistical difference in graft healing
between the two groups.
The three subjects with arterial leg ulcers did not heal in
either group.
The reason for unsuccessful graft takes might be
explained by local factors or systemic diseases rather
than by the time ambulation begins.
The MCID was not mentioned.
Can you apply this valid, important evidence about an intervention in
caring for your patient/client? What is the external validity?
Appraisal Criterion
114. Does this intervention sound appropriate for use
(available, affordable) in your clinical setting? Do
you have the facilities, skill set, time, 3rd party
coverage to provide this treatment?
115. Are the study subjects similar to your patient/
client?
a. If not, how different? Can you use this
intervention in spite of the differences?
116. Do the potential benefits outweigh the potential
risks using this intervention with your
patient/client?
117. Does the intervention fit within your
patient/client’s stated values or expectations?
a. If not, what will you do now?
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Reader’s Comments
Yes the intervention is appropriate for my clinical setting.
Yes. This study included patients with a variety of
diseases with LE grafts which is similar to my patient
population.
Yes. This study did not show that a change in ambulation
practice impacts graft healing, so there is little risk.
Yes. Patients want their grafts to heal along with a short
hospital stay.
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118. Are there any threats to external validity in this
study?
Small sample size.
What is the bottom line?
Appraisal Criterion
Reader’s Comments
PEDRO score (see scoring at end of form)
7/10
Summarize your findings and relate this back to clinical
significance
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This study had a sample size of 50 subjects with a
variety of systemic diseases and reasons for requiring
lower extremity skin grafts. The early ambulation group
began a graded ambulation protocol on POD 1 whereas
the late ambulation group began walking after four days
of bed rest. There was no significant difference in graft
healing between the two groups. Three patients with
arterial leg ulcers did not heal after grafting and neither
did two patients with graft site infections. All trauma
wounds healed. It appears that the reason for
unsuccessful take of grafts might be explained by local
factors or systemic disease rather than by the time
ambulation began.
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Pedro Scoring System:
Adapted from : Jewell, D. Guide to Evidence Based Physical Therapy Practice. Jones and Bartlett
Publishers, Sudbury, MA 2008
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Wallenberg L.
Effect of early mobilization after skin grafting to lower limbs.
Scand J Plast Reconstr Hand Surg. 1999; 33: 411-413.
Level of Evidence: Oxford Level 1c
Background: The subject of ambulating subjects with lower extremity grafts has been studied before.
Wallenberg mentions two previous studies, one in which there was no late ambulation control group, and a
second small study that found no difference in graft healing between the early and late ambulation groups.
Purpose: The purpose of this prospective, randomized study was to determine whether strict bed rest for
four to eight days is required after split-thickness skin grafts to the lower extremity as is traditionally done.
Methods: Fifty consecutive patients requiring split-thickness skin grafting to areas below the inguinal
ligament were randomized into either an early ambulation or a late ambulation group. All types of skin
defects were included in the study including peripheral arterial circulation issues and diabetes. Subjects in
the early ambulation group began a graded protocol on the day after surgery. Day one the patients stood
and took steps for two minutes, three times a day. Day two, they ambulated for five minutes, three times a
day. On day three they ambulated for ten minutes, three times a day, and on day four they had unrestricted
ambulation. The late ambulation group was on bed rest for four days and on day five began the same
graded protocol. Graft healing was assessed by two blinded nurses on post-op day fourteen.
Results: There was no significant difference in graft healing between the two groups. Grafts were healed in
80% of the early ambulation group and 88% in the late ambulation group. Three patients with arterial leg
ulcers did not heal after grafting and neither did two patients with graft site infections. All trauma wounds
healed. Thirty-one subjects required antibiotics.
Bottom Line: The reason for unsuccessful graft take might be better explained by local factors or systemic
diseases rather than by the time ambulation begins.
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