Burn Injury Management Considerations for Rehabilitation Professionals

Original Editor - Carin Hunter based on the course by [TUTOR LINK/ TUTOR NAME]
Top Contributors - Jess Bell, Carin Hunter, Kim Jackson, Stacy Schiurring and Robin Tacchetti

Section 2: Burn Assessment

A burn is a unique injury to the individual patient. The assessment and management of an  initial burn by the multidisciplinary team is crucial to minimise long term injuries and  enhance optimal functioning.

For the purpose of this handbook the information detailed throughout the assessment of the  burn patient is a synopsis of the following papers:

ANZBA 2007; British Burn Association 2005; Eisenmann-Klein 2010; Hettiaratchy et al  2004; Settle 1986; Siemionow and Eisenmann-Klein 2010

Figure 9. Flow chart illustrating the assessment and management of the burn

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(Germann et al 1999)

Physiotherapy Assessment of the Burn Patient

The physiotherapist must be aware of the importance of an early and adequate assessment of  Burn patients for optimal functional and cosmetic outcomes to minimise the impact of the  trauma long term. They must have a concise knowledge of the assessment procedure through  from Accident and Emergency to the ward, onto the rehabilitation setting and out in the  community. The following information is gathered through assessment, and a treatment plan  is formulated, constantly reassessed and revised.

(ANZBA 2007; Hettiaratchy and Papini 2004)

Physiotherapy aims  

1. Prevent respiratory complications

2. Control Oedema

3. Maintain Joint ROM

4. Maintain Strength

5. Prevent Excessive Scarring

Patients are at high risk due to:  

1. Injury factors - Inhalation injury; burn area - systemic inflammatory reaction syndrome  involving the lungs; depth of burn and scarring

2. Patient factors - Reduced ambulation and mobility; increased bed rest; increased Pain; pre-existing co-morbidities

3. Iatrogenic factors – Skin reconstruction surgery; invasive monitoring and procedures,  management in critical care

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2.1 Database/Subjective Assessment

The following pieces of information should be included in the physiotherapists’ database.  2.11 Presenting Complaint

Inhalation injury

There should be a high index of suspicion if the patient was injured in an enclosed space and /  or had a reduced level of consciousness – aggressive respiratory treatment to commence  immediately (ANZBA 2007; British Burn Association 2005; Eisenmann-Klein 2010)

Total Body Surface Area (TBSA)

o The rule of nine or the Lund and Brower chart are used to assess the TBSA o The Lund and Brower Charts are considered to be more accurate than rule of  nines, but both are commonly used.  

Table ## Lund and Browder %TB

Figure 10a. Rule of Nine  Assessment Chart: Hettiaratchy  and Papini (2004)

Figure 10b. Hettiaratchy and  Papini (2004)

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Table 3: An adjustment for age: Hettiaratchy and Papini (2004)

Area	Age   0	1 year	5years	10   years	15 years	Adult
A= (½ of head) %	9 ½	8 ½	6 ½	5 ½	4 ½	3 ½
B= (½ of one thigh) %	2 ¾	3 ¼	4	4 ½	4 ½	4 ¾
C= (½ of one lower leg) %	2 ½	2 ½	2 ¾	3	3 ¼

∙ Measure burn wound areas by mapping wound – 1% TBSA ≅ patient’s hand (palm  and fingers included)

∙ Note: when calculating burn size area, oedema should not be included.

∙ A burn of > 20 – 25% TBSA creates a global or systemic inflammatory reaction  affecting all body organs and indicates a significant risk for the respiratory system

Burn Type and Depth

∙ It is important to monitor extent of tissue destruction as it alters for at least 48 hours  post burn injury

o Jacksons’ burn wound model.  

∙ It is rare that a burn will present with a single depth.  

∙ Likely to change depending on the early management e.g. appropriate first aid and  other patient factors. (ANZBA 2007; British Burn Association 2005; Eisenmann Klein 2010)

Burn Site and Impact

∙ Develop awareness of the implication of burn to special areas of the body.  the following require specialised treatment

o Hands

o Face  

o Perineum

o Joints

This is in consideration of the complexity of the post burn reconstruction and potential  functional impact of inappropriate management of these important body areas.

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2.12 History of Presenting Complaint

∙ History of the incident with specific attention paid to the mechanism of injury.  ∙ First aid – was adequate first aid given? - If not, suspect deeper burn injury ∙ Falls – was there any indication that the patient fell? From what height? – possible head  injury, sprains or fractures  

∙ Electrical injury – voltage involved? Parts of body in contact with earth? – suspect nerve  and deep muscle injury with high voltage current  

∙ Explosions – falls, high velocity injuries, possible tympanic membrane injury – loss of  hearing and difficulty communicating

∙ Passage to hospital and time to admission

ANZBA 2007; British Burn Association 2005; Eisenmann-Klein 2010;  2.13 Medical and Surgical History

∙ Any surgical or medical management

o Pain medication

o Debridement

o Escharectomy

o Flaps/grafts

o Any particular MDT instructions to be followed

ANZBA 2007; British Burn Association 2005; Hettiaratchy et al 2004

2.14 Past Medical/ Drug History

2.15 Social History ANZBA 2007; British Burn Association 2005; Eisenmann-Klein 2010

∙ Basic ADL e.g., dressing, bathing, eating and Instrumental ADL e.g., shopping,  driving, home maintenance

∙ Past physical function e.g., mobility, climbing stairs, reaching, lifting ∙ Past physical fitness e.g., strength, flexibility, endurance, balance

∙ Social support and home Situation

∙ Occupation

∙ Particularly important for hand burns

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2.16 Psychosocial/ Yellow Flags

∙ Self-image

∙ Coping style

∙ Mental health

∙ Emotional behaviour  

ANZBA 2007; British Burn Association 2005; Hettiaratchy et al 2004

2.2 Objective Assessment

2.21 Pain Intensity Assessment

∙ Observational behavioural pain assessment scales should be used to Measure pain in children aged 0 to 4 years e.g. The FLACC scale

∙ Faces pain rating scale can be used in children aged 5 years and older. E.g. The  Wong-Baker FACES pain rating scale

∙ VAS can be used in children aged 12 years and older and adults.

2.22 Inhalation Assessment

Physical signs to observe:

∙ Hoarse vocal quality  

∙ Singed facial / nasal hair  

∙ Oedema

∙ Erythema (Superficial reddening of the skin, usually in patches, as a result of injury  or irritation causing dilatation of the blood capillaries)

∙ Soot stained sputum  

∙ Stridor  

∙ Inspiratory and end expiratory crackles on auscultation  

∙ Chest x-ray changes (ANZBA 2007; British Burn Association 2005) 2.23 Oedema Assessment

Overview

An acute burn injury creates inflammation and swelling. After wound healing is complete,  scar tissue maturation and contraction may lead to sub-acute and chronic states of oedema  formation. With time, oedema fluid changes in its composition and creates greater stiffness  and resistance to movement within the tissues. This is particularly notable when surgical  reconstruction is required and if the burn is circumferential around limbs or other structures.  See table 4 for clinical stages of oedema. (ANZBA 2007; British Burn Association 2005;  Eisenmann-Klein 2010)

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Stage of Oedema	Appearance of Oedema
Stage 1	Soft, may pit on pressure
Stage 2	Firm, rubbery, non-pitting
Stage 3	Hard, fibrosed

Table 4: Clinical stages and Appearance of Oedema

2.34 Mobility Assessment

The assessment and treatment of mobility can be separated into two aspects - the limbs &  trunk, and general functional mobility (e.g. transferring and ambulation). A physiotherapist  must also consider factors such as increased bed rest, increased pain and pre-existing co morbidities. (ANZBA 2007; Hettiaratchy et al 2004; Settle 1986; Siemionow and Eisenmann Klein 2010)

2.341 Limb and Trunk

Assessment of limbs and trunk should include joint ROM and strength. Limiting factors may  include pain, muscle length, trans-articular burns, scar contracture and the individual  specificity of the burn.

2.342 General Functional Mobility

Assessment of general mobility is two-fold, prevention of complications associated with  prolonged bed rest and the restoration of function & independence. All functional transfers,  gait, endurance and balance should be assessed once the patient is medically stable.  Factors to consideration when assessing mobility:  

∙ Posture

∙ Demands of vocational roles and ADLs

∙ Cardiovascular response to mobilisation  

∙ Neurological status

∙ Pain

∙ Concomitant injuries/weight-bearing status

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2.4 Burn Outcome Measures

Limitless amount of outcome measures are used to assess burn injury with no unanimity  about what domains to measure or whether a range of measures are required to capture the  full extent of the burn, from the patient’s perspective to the clinician. Lack of consistency in  the use of instruments has resulted in a lack of clarity about the selection of instruments or  ‘how to measure’ (Brusselaers et al 2010; Wasiak et al 2011).  

Burns Specific OCMs:

1. Burn Specific Health Scale (BSHS) – Revised (BSHS-R) – Brief (BSHS-B) - Abbreviated (BSHS-A)

Burn Specific Health Scale (BSHS)

Use: BSHS is consistently and widely used within the area of burn to examine the  physical and psychosocial functioning of burn patients and their quality of life  (QOL) (Yoder et al 2010)

Reliability: While the BSHS is a valid and reliable tool used in the burn population, it is  critical to determine the purpose of using any one specific version. The BSHS  –B has good reliability and validity when compared with the BSHS –A and  revised versions (Yoder et al 2010).

Validity: Many studies have validate this scale while also trying to revise, abbreviated  and create brief versions of it to make it easier to use (Yoder et al 2010). Sensitivity: Limitations of this scale surrounds the clarity of some components,  interpretation of the answers by patients and the specific use of versions.  

When the BSHS – B is used in comparison with the SF -36 health questionnaire, the BSHS – B was seen to provide more useful information with fear avoidance and post-traumatic stress  disorder in relation to returning to work (McMahon 2008).

See ANZBA for a full list of outcome measures. Comply with local policy according to  evidence based practice. Many generic outcome measures (e.g. DASH) may be used with  burn patients, depending on site and extent of the burn.

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Section 3: Management of Burn Pain

3.1 Pharmacological Pain Management: (Richardson and Mustard 2009)

∙ During the first 48 hours

∙ Decreased organ blood supply alters the clearance of drugs

∙ The body then enters a hyper metabolic state,  

o Associated with increased clearance of analgesia.

∙ Variations in levels of acute phase plasma and total body water volume further  impact upon effectiveness an analgesia.  

∙ Regular and repeated pain assessments are used to monitor the effectiveness of  analgesia.  

Thus there is no standard treatment of burns patients, each requires individual assessment.  

Opioids: the cornerstone of pain management in burns, and are available in a variety of  potencies, methods of administration and duration of action. Opioids used to effectively  manage background pain, with well-timed and effective doses of opioids used separately to  manage procedural pain

Positive Effects	Side Effects	Examples of Opioids
Pain relief Increased comfort Morphine related to reduced  Post-traumatic stress disorder	Respiratory distress Itch Nausea and vomiting Opioid tolerance – requiring  increasing doses Opioid induced hyperalgesia  (OIH) – increased sensitivity,  throughout the body following  opioid exposure Provide poor defence against  central sensitisation Physical dependence – common in long term use 25	Morphine   Oxycodone Fentanyl: potent, rapid onset,  short acting opioid. Used for  procedural pain management.   Remifentaril: ultra-short acting  opiate.   Alfentaril: short acting, used for  post-procedural analgesia.   Table 5: side effects of opioidsMethadone: long acting

Simple analgesics: paracetamol can be used in conjunction with opioids, to give a synergistic  effect comparable to a higher opioid dose. Paracetamol is an effective anti-pyretic and has  few contra-indications.  

NSAIDS: synergistic with opioids and can reduce opioid dose and thus reduce side-effects.  Not used in wide spread burns due to already increased risk of renal failure and peptic  ulceration. There is potential to increase bleeding in large burns also, due to the anti-platelet  effect.

Other medications: see Richardson and Mustard 2009  

Possible side effects of analgesics:

- Drowsiness

- Adverse reaction

- Nausea and increased risk of aspiration

- Impaired memory and communication

- Postural hypotension, and fainting (ANZBA 2007) 3.2 Non-Pharmacological Management of Pain

The following is a synthesis of information form the following articles: Summer et al (2007),  Richardson and Mustard (2009), ANZBA (2007) and de Jong et al (2007)

Overall, the levels of evidence to support the use of alternative therapies for pain relief are of  poor quality. However, no negative side effects were reported in the literature reviews and these therapies are all used in conjunction with pharmacological management to optimize  pain relief for the individual.  

3.21 Psychological techniques: beneficial for reducing anxiety and providing patients with  coping methods for pain levels and durations. These include relaxation, distraction and  cognitive behavioural therapy (CBT). CBT is beneficial in the management of complex pain  problems and can reduce fear and anxiety associated with activities or environments.  

3.22 Hypnosis: a state of “increased suggestibility, attention and relaxation”. In the burn  patient hypnosis is used in the management of procedural pain and anxiety. The use of  hypnosis clinically is increasing but its usefulness is dependent on the individual’s hypnotic

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susceptibility, high baseline pain and the skill of the practitioner. The current best available  evidence for management of procedural pain was found for active hypnosis, rapid induction  analgesia and distraction relaxation.

3.23 Virtual Reality: immersing the patient in a virtual world has shown some effect on  procedural pain control and is better than hand-held gaming devices. However, the equipment  is costly and bulky and not always suitable for paediatric intervention. A paediatric  intervention, using hand-held game devices which provide augmented reality was trialled  among 3-14 year olds. This has shown significantly lower pain scores than standard  distraction and relaxation when undergoing dressing changes (Mott et al 2008).  

3.24 Sleep Normalisation: disrupted sleep occurs in up to 50% of burn patients and links  have been established between poor sleep quality and pain severity, as well as pain and  prolonged experiences of sleep disturbance. Normalisation of the 24hour day, with a bedtime  routine, within the limits of the hospital environment is aimed for to promote sleep, with the  use of analgesics and night sedation.

3.25 Music therapy: this is thought to target pain via the gate control theory. This suggests  that music serves as a distraction from noxious stimuli. Also, the anxiety related to the  rehabilitation of burns can increase the activation of the sympathetic nervous system. Music  uses all three cognitive strategies employed in pain and anxiety management (imagery –

envisioning events that are inconsistent with pain, self-statements and attention-diversion  devices to direct attention away from the pain ad redirects it to another event) (Ferusson and  Voll 2004; Presner et al 2001).  

A systematic review of music therapy among pregnant women, medical-surgical patients and  critical care patients showed statistically significant reductions in pain scores. Of the  seventeen studies reviewed by Cole and LoBiondo-Wood (2012), 13 studies demonstrated the  positive effects of music on pain. Other positive findings of the studies included reduced  anxiety, muscle tension, blood pressure and heart rate. A burn specific study included showed  reduced pain levels during and after the debridement, reduced anxiety and decreased muscle  tension during and after dressing changes.  

The Cochrane Review of music as an adjunct to pain relief concluded that “music and other  non-pharmacological therapies could have a synergistic effect to produce clinically important

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benefits on pain intensity or analgesic requirements” and thus requires further study. This is  based on the studies indicating that music resulted in reduced pain intensity and reduced  opioid requirements. The reported changes in both of these outcomes were small however,  and their clinical importance is unclear (Cepeda et al 2006).  

3.26 Paediatric Burn Pain (Richardson and Mustard 2009)

∙ children 0-4 years represent approx. 20% all hospitalised burn patients ∙ In preschool aged children the half-life of opioids (morphine and alfentanyl) are 50%  those in adults. Higher dosage required.

∙ Risk of accidental overdose due to difficulties with pain evaluation resulting in  overestimation of child’s pain

∙ Childs environment has huge effect on pain perception. Parents’ presence and aid  during dressing change can have beneficial for procedural pain and reducing anxiety.

3.3 Considerations Pre Physiotherapy Treatment

∙ Pain relief is key. Timing physiotherapy to correspond with analgesia is essential for the  patient, particularly to avoid the pain-anxiety avoided.  

∙ Knowledge of pain medications, short-acting pain relief may be required in addition to  long-acting background pain relief prior to physiotherapy. Also, the side-effects possible  due to the medications, and vigilance for signs of these.  

∙ Daily assessment of therapy input and pain management to ensure on-going management  of pain. (ANZBA 2007)

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Management of Oedema

5.121 Elevation

Elevation of the hand above heart level is the most simple and effective ways to prevent and  decrease oedema (Kamolz 2009). A Bradford sling can be used to facilitate elevation. This  type of sling facilitates both elevation and protection of wound area while still allowing  movement. Its foam design also reduces the risk of the development of pressure points or  friction (Glassey 2004).

Fig 21. Bradford sling in a position  

of elevation (Microsurgeon 2013)

When a patient is admitted with severe burns of a large TBSA they are at risk of systemic  inflammation. Therefore, not only must the affected limb be placed in elevation, the  following precautions should also be taken

∙ Elevation of the head: This aids chest clearance, reduces swelling of head, neck and  upper airways. It is important not place a pillow underneath the head in the case of  anterior neck burns as there is a risk of neck flexion contractures

∙ Elevate all limbs effected

∙ Feet should be kept at 90

∙ Neutral position of hips

∙ Care must be taken to reduce the risk of pressure sores. (Procter 2010) 5.122 Coban

Coban wrap can be used to decrease hand oedema. The main advantage of Coban wrap is  that it does not stick to underlying tissue, making it suitable for use in the acute stages of  burns (Lowell 2003). There is currently limited quantity of evidence to support the use of  Coban wrap in the treatment of Oedema. In 2003 Lowell et al carried out a case study  involving a subject with dorsal hand burns.

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Subject: 59 year old male with 46% TBSA thermal burn. Bilateral dorsal hand burns  included.

Intervention: Day 3 post skin grafting left hand wrapped in standard gauze dressing, right  hand wrapped in coban self-adherent wrap. On post-op day 11 coban wrap applied to both  hands.

Outcome measures: 1) Circumferential of oedema measurement at level of MCP, DIP and  PIP 2) Range of motion 3) Grip Strength 4) Nine hole peg dexterity test

Results: Significantly decreased oedema in the right hand versus control hand at 11 days post  op. Decreased oedema bilaterally post op day 17. Improved grip strength in right hand versus  control hand 17 days post op. Improved dexterity and ROM in right hand versus control  hand 21 days post op

Limitations: Hand dominance not established, single subject study

5.123 Oedema Glove/Digi Sleeve

These are hand specific oedema management products. There is currently no specific  evidence available to support the efficacy of oedema gloves or digi sleeves in the reduction of  oedema. However it is common practice in Irish hospital to provide these products to  patients with excessive hand and finger oedema. Their use is based on the principle of  compression to reduce oedema which is heavily supported by evidence (Latham and  Radomski 2008).

Scar Management

Abnormal scarring is the most common complication of burn injuries, with the estimated  prevalence of > 70% of those who suffer burn injuries (Anzarut et al, 2009). Not only do  hypertrophic scars cause psychosocial difficulties through their cosmetic appearance, they  may also be painful, pruritic, and they may limit range of motion where they occur on or near  a joint (Morien et al 2009; Polotto 2011).

Hypertrophic scars require a continuum of dedicated and specialised treatment from the acute  stage to many years post treatment (Procter, 2010, ANZBA 2007).

The following is an examination of the evidence and recommendations for use in the most  common of these, including silicone gel, pressure garment therapy, and massage. The  positioning and mobilisation advice above is all applicable, and should be continued in the  management of hypertrophic scars where necessary.

5.221 Scar Outcome Measures

1. Vancouver Burn Scar Scale (VBSS/VSS)

2. Patient and Observer Scar Assessment Scale (POSAS)

Vancouver Burn Scar Scale (VBSS/VSS)

Use: Most familiar burn scar assessment. Measures: pigmentation, pliability,  thickness and vascularisation (Fearmonti et al 2010).

Reliability: Not enough evidence to make it a ‘gold standard’ OCM. Moderate to high  overall inter rater reliability. Test- Retest and intra – rater reliability has not  been assessed for burn scars to date (Durani et al 2009).

Validity: When compared with POSAS scale, validity was evident (Durani et al 2009) Sensitivity: Most Scar OCM rely on categorical/ordinal data with few levels which  provides limited sensitivity and can only identify considerable differences  between scars (Fearmonti et al 2010).

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Patient and Observer Scar Assessment Scale (POSAS)

Use: Measures pigmentation, vascularity, thickness, relief, pliability and surface  area. Also includes assessment of patient pain, itching, colour, stiffness,  thickness and relief. The only scale to measure subjective aspects of pain and  pruritus (severe itching) (Fearmonti et al 2010).

Reliability: Good internal consistency and reliability (Durani et al 2009) Validity: Good concurrent validity (Durani et al 2009)

Sensitivity: Like the VBSS/VSS above, limited sensitivity due to categorical/ordinal data (Fearmonti et al 2010)

Further studies are required to validate the reliability and validity of these scales as they are  considered to be very subjective measures (Durani et al 2009). Scar scales like the Vancouver  Burn Scar Scale (VBSS/VSS) and the Patient and Observer Scar Assessment Scale (POSAS)  are cost effective and can be easily transferred within a clinical setting. To optimise the scar  scales, photographic evidence of the scar at timed intervals is of great value also to the  clinician (Brusselaers et al 2010)

5.222 Silicone

Silicone Overview

The use of silicone gel or sheeting to prevent and treat hypertrophic scarring is still relatively  new. It began in 1981 with treatment of burn scars (O’Brien & Pandit 2008). The  physiological effects of silicone in the treatment of scarring remain unclear. Below is a  summary of the current hypotheses surrounding the physiological effects of silicone. This  summary has been adapted from the most recently published literature on this topic.

1) Hydration Effect: Hydration can be caused by the occlusion of the underlying skin. It  decreases capillary activity and collagen production, through inhibition of the  proliferation of fibroblasts

2) Increase in temperature: A rise in temperature increases collagenase activity thus  increased scar breakdown.

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3) Polarized Electric Fields: The negative charge within silicone causes polarization of  the scar tissue, resulting in involution of the scar.

4) Presence of silicone oil: The presence of silicone has been detected in the stratum  corneum of skin exposed to silicone. However other researchers suggest occlusive  products without silicone show similar results.

5) Oxygen tension: After silicone treatment the hydrated stratum corneum is more  permeable to oxygen and thus oxygen tension in the epidermis and upper dermis rises.  Increased oxygen tension will inhibit the ‘‘hypoxia signal’’ from this tissue. Hypoxia  is a stimulus to angiogenesis and tissue growth in wound healing, as a consequence  removing the hypoxia stops new tissue growth. This theory has been contraindicated  by other researchers.

6) Mast cells: It is suggested that silicone results in an increase of mast cells in the  cellular matrix of the scar with subsequent accelerated remodelling of the tissue. 7) Static electricity: Static electricity on silicone may influence the alignment of collagen  deposition (negative static electric field generated by friction between silicone  gel/sheets and the skin could cause collagen realignment and result in the involution  of scars. (Bloemen et al 2009; Momeni et al 2009)

Evidence

Momeni et al 2009: RCT, double blind placebo controlled trial

Subjects: N=38, with hypertrophic scars post thermal burn. All were 2-4 months post burn,  with areas including upper limb (n=14) lower limb (n=8) trunk (n=3) and face (n=9).  

Intervention: Patients acted as their own control, with the scar area being randomly divided  into two sections: one received silicone sheets, and the other a placebo. Both were applied for  4hrs/day initially, with this incrementally increased to 24 hrs/day over the course of the study,  for a four month period.  

Outcome measures: assessed at one and four months, by a blinded assessor using the  Vancouver Scar Scale and by Clinical Appearance.

Results: No significant differences in baseline characteristics. At one month the silicone  group had lower scar scores than the placebo group, however they were not statistically

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significant. At four months, the silicone group had significantly lower scores on VSS for all  dimensions except pain compared to placebo.

Limitations: Small heterogeneous cohort. No discussion of clinical significance of the  reduction in scar scales. 4 subjects lost to follow up with no intention to treat analysis.  

Brien and Pandit 2008: Cochrane Systematic Review Investigating the Efficacy of  Silicone Gel Sheeting in Preventing and Treating Hypertrophic and Keloid Scars

Studies Included: 15 RCTs, n=615, only 3 studies specific to burn patients. 12 compared  silicone to no treatment, and the remainder silicone was compared to placebo or laser  treatment.  

Outcome Measures: Primary outcome measures included scar length, width and thickness; secondary outcomes include scar appearance, colour, elasticity, relief of itching/pain

Results: No significant difference between silicone gel sheeting and control in reducing scar  length and width. Significant results for reducing scar thickness, though these were thought  not to be clinically relevant. No statistically significant difference between silicone gel and controls in secondary outcomes.  

Limitations: Large age range, heterogeneous sample, poor quality of trials in general, with  most at high risk of selection and detection bias. Only three studies used blinded outcome  measures. 6 studies lost >10% of participants to follow up.  

Conclusion on Silicone

It is unclear whether silicone gel help prevent scarring. Many of the studies advocating the  use of silicone gel are of poor quality and are susceptible to bias. However, it is currently  common practice in Ireland to administered silicone gel as an adjunct to treatment of  scarring. Silicone gel as opposed to sheets is the preferred product to use as it is easier to  apply can be used on more areas of the body and gives a higher patient compliance (Bloemen  et al 2009).

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5.223 Pressure Garment Therapy (PGT)

Though the effectiveness of PGT has never been proven, it is a common treatment modality  for reducing oedema and managing hypertrophic scars (Procter, 2010).  

Aims

o Reduce scarring by hastening maturation  

o Pressure decreases blood flow

o Local hypoxia of hypervascular scars

o Reduction in collagen deposition

o Therefore

o Decreases scar thickness

o Decreases scar redness  

o Decreases swelling

o Reduces itch

o Protects new skin/grafts

o Maintains contours (Procter 2010)

The exact physiological effects of how pressure positively influences the maturation of  hypertrophic scars remain unclear. Below is a summary of the current hypotheses  surrounding the physiological effects of pressure garments. This summary has been adapted  from the most recently published literature on

1) Hydration effect: decreased scar hydration results in mast cell stabilization and a  subsequent decrease in neurovascularisation and extracellular matrix production.  However this hypothesis is in contrast with a mechanism of action of silicone, in  which an increase of mast cells causes scar maturation.

2) Blood flow: a decrease in blood flow causes excessive hypoxia resulting in fibroblast  degeneration and decreased levels of chondroitin-4-sulfate, with a subsequent increase  in collagen degradation.  

3) Prostaglandin E2 release: Induction of prostaglandin E2 release, which can block  fibroblast proliferation as well as collagen production

(MacIntyre & Baird 2006)

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Evidence

The evidence for PGT is limited.

∙ Early studies found significant benefit from their use in terms of scar maturation and  necessity of surgery for correction

∙ These were not RCTs, and were conducted in a time where inefficient surgical  debridement resulted in scar loads much worse than those seen today (Engrav et al  2010)

Article citation and  design	Anzarut et al (2009) Systematic Review+ Meta-Analysis	Engrav et al (2010)   Within wound RCT
Selection criteria	6 trials with 316 patients located  3 between-subject design 3 studies within-subject design Adult and paediatric populations	54 patients recruited over 12 years Forearm burn requiring >3 weeks  to heal/skin grafting. Mean age,  36 yrs, mean length of follow up,  9.5 months
Intervention	3 studies wore pressure garments for  23h/day 3 studies did not describe length of  pressure garment treatment	Randomised normal compression  (17- 25mmHg) and low   compression (<5 mmHg) to  proximal/distal area of scar. 23  hrs/ day to wound maturity, or up  to 1 yr
Outcome measures	Primary Outcome: Global scar score Secondary outcome: Scar height, vascularity, pliability,  colour	Durometry (hardness)   colorimetry (colour)   ultrasonography (thickness)  Clinical appearance: judged by a  panel of 11 experts in burn care
Results	Global Scar Score: ∙ No significant differences   between PGT & control   interventions Secondary Outcome:	∙ Statistically significant  decrease in scar hardness   and height ∙ 3/19 and 5/28 patients   respectively achieved a   decrease which could be

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	∙ Scar height showed a small but  statistically significant decrease  in height for pressure garment   therapy. ∙ Questionable if this is clinically  significant. ∙ Scar vascularity, pliability and  colour failed to demonstrate a   different between groups	clinically detected ∙ In only 3/41 patients   could the zone of normal   and low compression be   identified correctly by a   panel of 11 experts However, the authors concluded  by recommending that PGT  should continue to be used.
Limitations	Publication bias present with only 1  trial reported negative effect In 5 of the 6 studies, concealment of  allocation was unclear All studies had inadequate reporting of  randomisation and did not comment on  withdrawals and dropouts.	Some data lost for different  parameters over the space of 12  years. Noted that in this time,  staff and equipment changed,  which could have confounded  results. Evidence of bias in  interpretation of results. Low risk  of bias from randomisation, not  all assesors blinded.

Table 9 Available Evidence for PGT

∙ The authors’ bias was evident in both of the above articles. Though their results were  similar, Anzarut et al, 2009 concluded that there was no evidence to justify this  ‘expensive source of patient discomfort’, while Engrav et al, 2010 concluded that its  use was justified.

Patient Adherence to Pressure Garment Therapy  

In 2009 Ripper et al carried out a quantitative study on adult burn patient’s adherence to  pressure garment therapy.

Subjects: 21 participates interviewed concerning their experiences with pressure garments.  Time since burn ranged from 5months to 4years and 2 months.

Methodology: Randomised selection of patients 21 patients segregated into 3 groups:  Patients who had completed PGT, Patients who were still in the course of therapy, and  Patients who refused to wear the garments and had stopped PTG completely.

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Results: Complaints most frequently mentioned were: “Physical and Functional limitations”  caused by garments. “Additional effort” created by the need to care for the garment.  Motivating factors for the patients: ‘expectation of success’ ‘emotional support’ ‘practical  support’ and experiencing ‘good outcome’.

Limitation: Unclear method of randomised selection, variation in time elapsed since burns,  body parts affected by burns not established

Careful considerations of cost, compliance, patient discomfort, possible complications and  the perceived benefits before prescribing this treatment.  

Recommendations for practice and safety considerations

Pressure: 15 mmHg has been noted as the minimum to elicit change, and pressures of  above 40 mmHg have been found to cause complications. Both Anzarut et al (2009) and  Engrav et al (2010) used pressures of between 15 and 25 mmHg.

Time: It is recommended that garments are worn for up to 23 hours a day, with removal for  cleaning of the wound and garment, and moisturisation of the wound. (Procter 2010; Anzarut  et al 2009 and Bloeman et al 2009).

Duration: garments can be worn as soon as wound closure has been obtained, and the scar is  stable enough to tolerate pressure. Post grafting, 10-14 days wait is recommended, at the  discretion of the surgeon (Bloeman et al 2009). Garments should be worn for up to one year,  or until scar maturation (Anzarut et al 2009; Engrav et al 2010 and Bloeman et al 2009).

Possible complications/ confounding factors for use of PGT

∙ Lack of a scientific evidence to established optimum pressure

∙ Non-Compliance ( due to comfort, movement, appearance)

∙ Heat and perspiration

∙ Swelling of extremities caused by inhibited venous return

∙ Skin breakdown

∙ Web space discomfort

∙ Inconvenience

∙ Personal hygiene difficulties possibility of infection

∙ Allergies to material (MacIntyre & Baird 2006; Glassey 2004)

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5.224 Massage

Five principles of scar massage:

1. Prevent adherence

2. Reduce redness

3. Reduce elevation of scar tissue

4. Relieve pruritus

5. Moisturise (Glassey 2004) Scar Massage Techniques

∙ Retrograde massage to aid venous return, increase lymphatic drainage, mobilise fluid  ∙ Effleurage to increase circulation

∙ Static pressure to reduce pockets of swelling

∙ Finger and thumb kneading to mobilise the scar and surrounding tissue ∙ Skin rolling to restore mobility to tissue interfaces

∙ Wringing the scar to stretch and promote collagenous remodelling

∙ Frictions to loosen adhesions

(Holey and Cook 2003)

Guidelines for Massage during 3 Stages of healing
Inflammatory Phase	gentle massage to decrease oedema and increase blood supply  (currently no high level evidence to support this)
Proliferative Phase	Massage that applies gentle stress to the healing scar is recommended  to ensure collagen is aligned correctly.
Remodelling Phase	Massage should be progressed to include prolonged stretching to  minimise adhesions. This is proposed to aid in scar tissue breakdown

Table 10 Guidelines for scar massage during healing stages (Glassey 2004)

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Table 11. Evidence for the use of massage in scar management

Article	Field et al 2000 RCT	Morien et al 2008 Pilot Study	Shin and Bordeaux,  2012 Lit review
Subjects	20 subjects in remodelling phase of  wound healing.  Randomly assigned into  2 groups Massage Vs Control	8 Children   Mean age 13.5 years  (10-17years) All thermal burns  including hand burns	Not burn specific,  though the majority  of scars were of this  origin 10 articles: n=144  adult and children
Intervention	Massage Therapy Group: 30minutes massage with  cocoa butter twice  weekly for 5 weeks Control Group: Standard Treatment	20-25 minute  massage session  once daily for 5 days (effleurage,   petrissage, friction,  lengthening rolling) Session followed by  discussion of  psychosocial issues	Time to Rx: mean  4.3 months. +  variation in  protocols. 20  mins/day- 30 mins 2x  weekly. 1 Rx-6  months Rx
Outcome   measures	Itching: VAS Pain: McGill Pain Questionnaire Anxiety: State Trait  Anxiety Inventory Mood: Profile of Mood  States	Likert pictorial scale   Goniometry Range of  Motion	Patient and observer  scar assessment  scale, Vancouver  scar scale, thickness,  vascularity, colour,  pain, pruritus, mood,  anxiety, and  depression.
Results	Massage Therapy Group  Reported: decreased  itching, pain, anxiety and  increased mood   Ratings improved from  the 1st-last day of the  study	Increased ROM in  massaged tissue.  Decreased ROM in  unmassaged tissue No significant  difference in mood  across time	45.7% improved in at  least one of the above  parameters. 54.7%  had no improvement.   Noted massage was  more economical  than silicone/PGT.

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Limitations

Small Sample Size No follow up

Paediatric   population. Mood Instrument may have  been influenced by  other factors.  Recruitment and area  to be massaged not  random Small sample size No follow up

No discussion of  quality or statistical  tests.

Conclusion on Scar Massage

Evidence suggests that burn patients receive psychological benefits from massage in terms of  altered mood (decreased depression, anger), decreased pain, and anxiety (Field et al 1998).  Evidence also indicates that massage increases ROM in non-burned patients, but little  evidence exist examining the effect of massage on ROM in burn patients (Morien et al 2008).

Recommendations for practice and safety considerations.

Insufficient consistency in literature with regards to protocols on frequency or duration of  treatment. Suggestions for practice include (Shin and Bordeaux, 2012, Morien et al, 2008)  

∙ Clean hands essential

∙ Use non irritating lubricant, free of any known sensitisers.  

∙ Modify practice according to patient stage of healing, sensitivity and pain levels. Contraindications: Shin and Bordeaux 2012

∙ Compromised integrity of epidermis

∙ Acute infection

∙ Bleeding

∙ Wound dehiscence,  

∙ Graft failure

∙ Intolerable discomfort

∙ Hypersensitivity to emollient

Section 4: Reconstruction Post Burn Injury

The impact of reconstructive surgery post burn injury has a major impact on a patient. As an  allied health professional, we must work as part of an MDT in order to ensure successful  surgery while at the same time ensuring long term health and function. Timely burn wound  excision and skin grafting form the cornerstone for acute burn surgical management (Klein  2010).Surgery for burned patients is not normally indicated until 48 hours after injury, when  the depth of the burn has been established. The only exception is when necrotic tissue is  evident then early excision may be required. A plastic surgeon must reconstruct the injured  body part in a way that is extensible, sensate and cosmetically acceptable (Glassey 2004). In  addition to this, they must rebuild or replace muscles, tendons, joints and nerves to ensure  they are appropriately intact.  

4.1 Aims

1. Achieve would closure

2. Prevent infection

3. Re-establish the function and properties of an intact skin

4. Reduce the effect of burn scars causing joint contractures

5. Reduce the extent of a cosmetically unacceptable scar

(Glassey 2004; BBA Standard 6 2005)

4.2 Choosing the Correct Method of Reconstruction

The simplest management involves conservative wound care and dressings, while the most  complex is free-flap reconstruction. When deciding on the most appropriate intervention, a  surgeon must consider the extent of the missing tissue and the structures effected (Glassey  2004). Generally, a superficial partial thickness burn will heal with conservative treatment  (secondary intention) in 10 days to 3 weeks, unless infection occurs. Primary intention occurs  if a wound is of such size that it can be closed directly without producing undue tension at the  wound site. Delayed primary closure occurs once a suspected infection has been cleared.  Deep partial and full thickness burns both require surgical intervention. Surgery normally  takes place within the first 5 days post injury to prevent infection which could extend the  depth of the tissue loss (Glassey 2004).

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Figure11. The reconstructive ladder, procedures ranging from simplest to most complex. (Ataturk University School of Medicine 2009)

4.3 Skin Grafts

“A skin graft is the transportation of skin from one area of the body to another.” (Glassey 2004)  

A graft is an area of skin that is separated from its own blood supply and requires a highly  vascular recipient bed in order for it to be successful. Prior to grafting, the process of wound  debridement must take place. Wound debridement involves removing necrotic tissue, foreign  debris, and reducing the bacterial load on the wound surface (Cardinal et al 2009).This is  believed to encourage better healing. The following are the methods available for grafting  onto a debrided wound to obtain closure:

∙ Autograft (‘split skin graft’) (own skin)

∙ Allograft (donor skin)

∙ Heterograft or xenografts (animal skin)

∙ Cultured skin

∙ Artificial skin (Glassey 2004)  

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4.31 Meshed vs. Sheet Grafts

Sheet grafts are those which are not altered once they  have been taken from the donor site.  

Meshed grafts are those which are passed through a  machine that places fenestrations (small holes) in the  graft. Meshed grafts have advantages over sheet  grafts of 1) allowing the leakage of serum and blood  which prevents haematomas and seromas and 2) they  can be expanded to cover a larger surface area.

(Klein 2010)

4.311 Criteria to be met Pre- Grafting

∙ Diagnosis of DEEP tissue loss

∙ Patient is systemically fit for surgery

∙ Patient has no coagulation abnormalities ∙ Sufficient donor sites available

Figure12. Diagrams illustrating the process  of mesh graft procedure (www.beltina .org)

∙ Would clear of streptococcus (Glassey 2004) 4.312 The Donor Site

The thigh is the most common donor site for split thickness skin grafts (STSG). A split  thickness graft involves a portion of the thickness of the dermis while a full thickness skin  graft (FTSG) involves the entire thickness of the dermis (Klein 2010). The most common site  for full thickness skin grafts is the groin. Cosmetic areas such as the face should be avoided  for graft donation.

The donor site should just be left with a superficial or a superficial partial thickness wound  which will heal in 10-14 days and may be reused if necessary. Often, the donor site can be  more painful than the recipient due to exposure of nerve endings (Glassey 2004).  

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4.313 Skin Substitutes

“Skin Substitutes are defined as a heterogeneous group of wound cover materials that aid in  wound closure and replace the functions of the skin either temporarily or permanently”

(Halim et al 2010)

Conventionally, STSG and FTSG have been found to be the best option for burn wound  coverage (Halim et al 2010). However, in cases of extensive burn injury, the supply of  autografts is limited by additional wound or scarring at donor sites. For this reason, skin  substitutes will be required. Skin substitutes require higher cost, expertise and experience  than autografts. However, they also offer numerous advantages in the form of rapid wound  coverage requiring a less vascularised wound bed, an increase in the dermal component of a  healed wound, reduced inhibitory factors of wound healing, reduced inflammatory response  and reduced scarring (Halim et al 2010).  

Currently, there are various skin substitutes on the market but scientists and engineers are  working towards producing the optimal skin substitute. As a general rule, skin substitutes are  classified as either temporary or permanent and synthetic or biological. A very clear and  concise overview of the different skin substitutes available for burn injuries is provided in  Halim et al (2010).  

4.314 The Recipient Site

The graft should take within 5 days and will provide a permanent covering of the injury. A  graft should always be placed over bleeding, healthy tissue to ensure it is vascularised for  survival (Glassey 2004).  

Post-operatively the graft site is dressed to ensure pressure is created over the graft to limit  haematoma formation. The body part is immobilised in an anti- deformity position at first in  order to prevent shearing forces that could disrupt the graft (Edgar and Brereton 2004). Some  very mobile body parts, such as the hand, may require splinting to ensure joint immobility.

4.315 Process of Graft ‘Take’

∙ Serum Inhibition (24-48hrs): fibrin layer formation and diffusion of fluid from the  wound bed

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∙ Inoscultation (day 3): capillary budding from the wound bed up into the base of the  graft

∙ Capillary in-growth and remodelling (Glassey 2004) 4.316 Reasons for Graft Failure

∙ Inadequate blood supply to wound bed

∙ Graft movement

∙ Collection of fluid beneath graft (e.g. haematoma)

∙ Infection (e.g. streptococcus)

∙ The grafts properties (e.g. vascularity of donor site) (Glassey 2004)

4.4 Skin Flaps

The difference between a skin graft and a skin flap is that “a skin flap contains its own  vasculature and therefore can be used to take over a wound bed that is avascular”. A skin  graft does not have this ability (Glassey 2004). When speaking about grafts and flaps in the  research, skin flaps is often incorporated into the term ‘skin grafts’.  

Fig 13: skin flaps  

(MicroSurgeon, 2012)

Tissues which a skin graft will not take over include and which a skin flap will include:

∙ Bone without periosteum

∙ Tendon without paratenon

∙ Cartilage without perichondrium (Glassey 2004)

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4.41 Categorisation of Skin Flaps

Based on three factors:

1. Vascularity

2. Anatomical composition

3. Method of relocation (Glassey 2004)