Burn Injury Management Considerations for Rehabilitation Professionals: Difference between revisions

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== Introduction ==
== Introduction ==
When managing a patient with a burn, there are four main categories to consider:
Burn injuries are a major cause of pain and disability.<ref name=":2">Norman AT, Judkins KC. [https://academic.oup.com/bjaed/article/4/2/57/271658 Pain in the patient with burns.] Continuing Education in Anaesthesia, Critical Care & Pain. 2004 Apr 1;4(2):57-61.</ref> Optimal rehabilitation care for individuals with burn injuries requires a multifaceted, multidisciplinary approach. This page explores some of the key elements that must be considered in a rehabilitation plan when working with individuals with burns, including pain management, oedema management, scar management and surgical considerations.


# Pain
''It is essential to remember that every intervention discussed on this page must be coordinated with the medical / surgical team to ensure tailored management protocols for each patient.''
# Oedema
# Scar
# Reconstruction


== 1. Management of Burn Pain ==
== Pain Management for Individuals with Burn Injuries ==
There are many factors to consider when when treating burn pain. Initially, the clinician should understand the cause of the current pain. Pain can be controlled either with standard pharmacological management strategies or with alternative methods.   
There are many factors to consider when treating pain associated with burn injuries.<ref name=":13">Hale A, O’Donovan R, Diskin S, McEvoy S, Keohane C, Gormley G. Impairment and Disability Short Course. [https://www.physio-pedia.com/File:Burns_and_Plastics.pdf Physiotherapy in Burns, Plastics and Reconstructive Surgery], 2013.</ref> [[General Assessment of a Patient with Burns#Key Aspects of the Objective Assessment of a Patient with a Burn Injury|Pain assessments]] should be performed during each phase of care,<ref name=":7">Romanowski KS, Carson J, Pape K, Bernal E, Sharar S, Wiechman S, et al. [https://academic.oup.com/jbcr/article/41/6/1129/5900438 American Burn Association Guidelines on the management of acute pain in the adult burn patient: a review of the literature, a compilation of expert opinion and next steps]. J Burn Care Res. 2020 Nov 30;41(6):1152-1164. </ref> and both pharmacological and alternative management strategies can be used to manage pain in patients with burn injuries.   


Initially the acute pain experienced is due to the burning tissues. The burn should be cooled with tepid water, not ice water as ice water can cause further damage to the affected area. Tepid water helps to end the burning and decrease the pain experienced. The clinician should always be aware that cooling the burn combined with the evaporation of oedema fluid can lead to hypothermia. Due to this, the patient should be given a blanket or alternative source of warmth to prevent hypothermia.  
=== General Points on Pharmacology for Individuals with Burn Injuries ===
<blockquote>"Pain distress is common during the acute phase [of a burn injury] despite the use of opioids and/or ketamine."<ref name=":8">Stapelberg F. [https://journals.sagepub.com/doi/full/10.1177/0310057X20914908 Challenges in anaesthesia and pain management for burn injuries]. Anaesth Intensive Care. 2020 Mar;48(2):101-113. </ref></blockquote>The general consensus is that "opioid therapy is an essential tool for pain management in thermal injuries",<ref name=":8" /> and patients with burn injuries are often given opioids in higher doses and for longer durations than typical dosing guidelines. However, many patients with burns continue to experience pain and are at risk for opioid tolerance.<ref name=":7" /><ref name=":8" /><ref name=":9">Emery MA, Eitan S. Drug-specific differences in the ability of opioids to manage burn pain. Burns. 2020 May;46(3):503-513.</ref>


Once hospitalised, there are four main pain contributing factors which should be considered by the clinicians. These being:
Romanowski et al.<ref name=":7" /> include the following recommendations in their guidelines on pain management in adult patients with burn injuries:


# Pain associated with procedures.
* opioid therapy needs to be individualised to each patient and continuously adjusted during their care (considering individual responses, adverse effects, and narrow therapeutic windows)<ref name=":7" />
#* Surgery
* while the reasonable use of opioids is supported to manage severe pain, attempts should be made to use "as few opiate equivalents as needed"<ref name=":7" />
#* Dressing Changes and Wound Cleaning
* opioid pain medications should be used in conjunction with other treatments, including non-opioid medications and non-pharmacological treatments<ref name=":7" />
#* Physiotherapy
For more information, please see: [https://academic.oup.com/jbcr/article/41/6/1129/5900438 American Burn Association Guidelines on the Management of Acute Pain in the Adult Burn Patient: A Review of the Literature, a Compilation of Expert Opinion, and Next Steps]<ref name=":7" />
# Resting pain
# Itching or Pruritus
# Chronic pain


==== 1. Pain Associated with Procedures ====
=== '''Pain Management in Individuals with Burn Injuries Admitted to Hospital''' ===
Procedural pain is usually of short duration but a high intensity. Each procedure will trigger a fresh painful stimulus and further stress response. major or prolonged procedures should always be carried out under general anesthesia. The majority of smaller procedures are predictable, and thus analgesics should be administered as a preventative measure. Therefore, analgesia should be preventive, as some of these events are predictable. Pain can often interfere with sleep which is important to the healing process. Pain associated with procedures can also affect the rapport and trust of the patient with the clinician which can pose a barrier to trust of the clinician.  
<blockquote>"Burn injury is widely considered one of the most painful injuries that a person can sustain. In addition to the intrinsic pain caused by the burn itself, the proper treatment of a burn injury requires painful procedures including debridement of the wound, daily wound care, and surgery, followed by aggressive physical and occupational therapy."<ref name=":7" /></blockquote>In the initial phases, pain associated with burn injuries tends to be described as background pain, breakthrough pain and procedural pain. Patients may go on to experience persistent or chronic pain, as well as specific types of pain such as post-burn pruritus (itching).<ref name=":8" /><ref name=":2" />


===== Surgery =====
The management for each type of pain can differ.<ref name=":9" /> Pain management, especially in the hospital setting will be affected by the depth of burn injury and what structures are still intact and functioning. To learn more about burn wound classification by depth and size please see: [[Introduction to Burns#Burn Wound Classification|Burn Wound Classification]].  
Large raw areas, usually as a result of harvesting tissue from the donor site, can be comfortably managed by the surgeon applying a local anaesthetic gel before applying the dressings.


Early postoperative pain management is often with the use of opioids. Alternative analgesic methods that can possibly be used, depending n the extent of the injury and site of the graft area, would be a regional block or NSAIDs. Opioids can be administered transdermally, orally, intramuscularly and intravenously with a combination of background infusion and boluses.
==== Background Pain ====
This type of pain is defined as "pain at rest that is almost always present and not caused by specific medical procedures".<ref name=":9" /> Thus, it is persistent but usually low-grade.<ref name=":2" /> It can be present at the injury site and in other areas (i.e. primary and secondary pain). Background pain tends to be managed with moderate-potency opioids (preferably given orally).<ref name=":9" /> 


Intramuscular administration may be difficult due to the site of surgery, the extent of dressings, injection site discomfort and unpredictable absorption. There is a vogue for patient-controlled analgesia (PCA), which has been found to be effective in burnsin severalstudies. However, thisis not ideal, asit requires a cooperative patient able to use the device (not possible with burned hands) and plasma opioid concentrations may fall during sleep. A background infusion will reduce the likelihood of this; however, opioids have a tendency to accumulate, leading to undesirable side-effects. Nursing vigilance must be maintained and protocols must be in place to prevent or deal with these events. Similar constraints apply to the use of opioids by continuous infusion, which is an effective approach immediately after operation if carefully monitored. The inflammatory component of pain and opioid use can be reduced by regular NSAID analgesia, unless the risk of haematoma formation outweighs the benefits.  
==== Breakthrough Pain ====
Breakthrough pain is a transient increase in pain in individuals who are experiencing background pain.<ref name=":9" /> It can indicate worsening background pain or can be from another source.<ref name=":10">McGovern C, Puxty K, Paton L. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9073309/ Major burns: part 2. Anaesthesia, intensive care and pain management]. BJA Educ. 2022 Apr;22(4):138-45. </ref>


===== Dressings Changes and Wound Cleaning =====
==== Pain Associated with Procedures ====
The management of pain during dressings changes is the most extensively investigated aspect of burn pain management, yet no single technique has been shown to be better than any other. A large burn dressing may take 1--2 h and may include active wound debridement or postoperative removal of items such as staples. General anaesthesia is often appropriate; deep intravenous sedation may be given and supervised by an anaesthetist. For smaller dressings, analgesia is commenced before the procedure takes place by a bolus of opioid or local anaesthetic; time is Pain in the patient with burns Continuing Education in Anaesthesia, Critical Care & Pain | Volume 4 Number 2 2004 59 Downloaded from <nowiki>https://academic.oup.com/bjaed/article/4/2/57/271658</nowiki> by guest on 14 June 2022 allowed for onset of the analgesia. Depending on the level of stimulus, further doses can be used during the procedure supplemented by a benzodiazepine. Entonox is useful for short procedures to supplement opioids, reduce breakthrough pain and avoid prolonged sedation. Ideally, easily titratable sedative and analgesic agents with few side-effects and short half-lives are required. Few drugs have all these properties. Sedation with many agents has been reported, including lidocaine infusions, benzodiazepines and volatile inhalation agents. Ketamine is analgesic and sedative. Although loss of airway is unlikely at normal doses, its use islimited in adults by side-effects including hallucinations. The latter can be mitigated by adding a small dose of a benzodiazepine. Boluses orinfusions ofshorter-acting opioidssuch as alfentanil and fentanyl are suitable for short procedures. They can nevertheless accumulate and may result in respiratory depression, particularly if given to a patient already receiving opioids. Combination with a low-dose infusion of propofol (administered by an anaesthetist) gives adequate conditions for dressings changes. The effects of propofol terminate within minutes if a target-controlled infusion at a dose range of 1--2 mg mlÿ1 is used. Further flexibility can be introduced by adding remifentanil. Because the half-life of remifentanil is short, supplementation with opioids, NSAIDs, or both, is necessary to control pain in the post-procedural period. The requirement for procedures can be reduced by using suitable dressings, such as a synthetic temporary skin substitute, especially in children. Biobrane1 (a porcine collagen-based material) and similar synthetics are used on superficial wounds that are expected to heal; they are left in place until healthy skin has formed, thus reducing distress and infection risk and also allowing early mobilization.  
Individuals with burn injuries often require a number of procedures (e.g. mobilisation, skin grafts, debridement, dressing changes, etc). These procedures can add to a patient's pain experience, often causing high-intensity pain that is short to medium in duration.<ref name=":2" />


===== Physiotherapy =====
'''Important considerations''':<ref name=":2" /> 
Physiotherapy is an important part of rehabilitation. Moving damaged areas causes pain and further exacerbation of the stress response. On the other hand, the patient is engaged in the process and therefore motivated. This type of pain is predictable and again amenable to multimodal management using oral analgesics. The scope of strong painkillers and anaesthesia is limited because of the requirement for cooperation; however, the physiotherapists will often take the opportunity of a visit to theatre or the dressings station to perform passive range of movement exercises in the early stages.


==== 2. Resting Pain ====
* each procedure causes a new, painful stimulus, which adds to the stress response
Usually of low intensity but longer duration. After initial treatment and between procedures, the patient most commonly suffers low-grade but persistent discomfort, the nature of which has been repeatedly shown to be under-appreciated even by experienced staff. This is difficult to treat adequately while minimizing the patient’s exposure to side-effects, but adequate treatment is essential to patient well-being. A multimodal approach using low-dose oral opioids in combination with NSAIDs provides best results. Careful titration by measuring the extent of pain relief regularly and adjusting doses accordingly is essential; it can be integrated into the work of the Acute Pain Team or managed by the burns nurses according to well-designed protocols. Pre-emptive, regular dosing with supplemental prescriptions for breakthrough pain is most effective in practice.
* analgesia should be given at an appropriate time to ensure maximum benefit<ref name=":10" />
* analgesia should be used in a preventive way, especially as some procedures can be predicted
* general anaesthetic may be used for prolonged procedures


==== 3. Itching ====
===== Pain Associated with Surgery =====
Pruritus is another disabling condition that is poorly understood. It may disrupt normal physiology, and scratching may cause damage to forming skin. The mechanism is thought to involve histamine and prostaglandin release. Treatment is again difficult and usually involves combinations of antihistamines and NSAIDs. Empirical observation that heat may trigger the reaction has led to treatment by cold compresses and control of the environmental temperature.
Early post-operative pain tends to be managed with opioids and other non-opioid medications:<ref name=":2" /> 


==== 4. Chronic Pain ====
* patient-controlled analgesia (PCA) can be used (particularly for breakthrough pain after a procedure<ref name=":9" />), but the patient must be conscious and alert<ref name=":10" /> and be able to understand how to use the device
This can be due to changes experienced in nerve fibres. Damaged and regenerating nerve tissues can give rise to complex neuropathic pain syndromes whereby the sensation of the painful stimulus far outlives its expected duration. This can destroy the sleep pattern, result in depressive symptoms and impair rehabilitation. There may be hyperalgesia (an increased response to a painful stimulus) and allodynia (a painful response to a normally innocuous stimulus). This may be a significant problem starting quite early in the post-injury course and persisting for many years afterthe initial injury (Table 1). Thistype of pain is very difficult to treat using conventional analgesics, unlessthere is ongoing inflammation or tissue damage. The severity of chronic symptoms is often related to the size of the burn and the number of skin grafts performed. Treatment includes antidepressants (amitriptyline), anticonvulsants (gabapentin and sodium valproate), regional nerve block and cognitive behavioural therapy.
* non-steroidal anti-inflammatory drugs (NSAIDs) have been used to help manage pain after surgery:
** however, they are used infrequently in individuals who are critically ill<ref name=":10" />
** they "should be used with extreme caution especially in patients with bigger burns and those on intensive care"<ref name=":6" />
* local anaesthetic gels may be applied after surgery to large, raw areas, such as donor sites, before the dressing is applied


Norman AT, Judkins KC. Pain in the patient with burns. Continuing education in anaesthesia, critical care & pain. 2004 Apr 1;4(2):57-61.
===== Pain Associated with Dressing Changes and Wound Cleaning =====
Pain management during dressing changes and wound care is a significant consideration:<ref name=":2" /> 


https://watermark.silverchair.com/mkh016.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAsIwggK-BgkqhkiG9w0BBwagggKvMIICqwIBADCCAqQGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQM8hBBA3-YleMTDlsLAgEQgIICdaNAQVJfJDXcu9y0Y_dLG_C_Su3imINuxNtMid7BeV7VT9rtL9o9euY-mwSUdTEVnCO2xjqPweYwsL6sF-SkYZr0QOEYmJg3ZTjsmnykvzHl0s9XDtY73ZsP4nUBpX8beCegifVCpgfpl7238bm93vKnT4oMttbBOfwXyBZif8AUI7IhkyMYb890IRVxaZiLj8UN7rY-9ALP8ZR1rfe_7y3jHxZdWlVyMO-0HVN-KzLVdQ8_5wr7dnVdTuSdHbK91ndOk6DpwTXygibQHglcxDWHlnaA3CgAsu47xSWVMDUJP2-7cKieAt02f55qzv8alYc98u6t-M0t7L4r5ApZX5H8KBj8WLJx3FcVedfItDElgO4T-HsghazGvYaQvkeOiYNwHk0tT72NMs9OJX3b-XS7MIDFnshUN5Zq3K9eFI-YTrNAP1-AeDBDlhuy33b6ezHrvM44fEbkuDm9rDiEyX2E6aXKXG1OQh21TqgR_01zkpNNtFNkZLbZ2RER8fDVz2renloBa9KBLFPeaN0bCxnc-zMpy64mOH737Ol0Ntg5akv7b2du4BlOileiIFkXZt9vI6CdLgGVd0yNvq6wcfxdBiaH_LL2Ana-RU49w-_YWxIOFx0xvOusFTQVwhelH-sC5oF7_rwxt6XJhZTtFqYywuDgCxjmY08BP1ePmRBfIRkrDUk-bsoaDWCfIx7OFafHhK0Hnm4MJGRDj2NyIGk1_6UjRcbUwZy5pj2UUa5Iw-ceqh95Fkf3teP4wpWNPr7PZoT51v-1bqB4Myz-2ra6C070sAN_axjJe_eIbDsca0ZOj04RqHEewNqZmS5BrGPTWeJP
* a general anaesthetic or deep intravenous sedation may be required while dressing large, deep burns
* smaller dressings can be managed by administering analgesia (e.g. opioids, local anaesthetics) before starting the procedure
* nitrous oxide (e.g. Entonox) and opioids can be used for short procedures to help reduce breakthrough pain and avoid long periods of sedation
* using appropriate dressings can help reduce the requirement for procedures - please see [[Burn Wound Injury Dressing Selection]] and [[Advanced Dressing Selection for Burn Wound Injuries]] for more information on burn wound dressings


Judkins KC. Pain management in the burned patient. Pain Rev 1998; 5: 133--46
===== Pain Associated with Rehabilitation =====
Physiotherapists and occupational therapists commonly work with patients with burn injuries in primary healthcare settings. However, moving the affected area/s can exacerbate pain and trigger the stress response. Rehabilitation interventions are, therefore, often scheduled after pain relief has been administered:<ref name=":2" /> 


Kidd BL, Urban LA. Mechanisms of inflammatory pain. Br J Anaesth 2001; 87: 3--11
* during the acute phase, physiotherapists and occupational therapists may perform passive range of motion exercises or create splints while a patient is in theatre or having their dressings changed
* during the subacute and chronic phases, oral analgesics are commonly used to ensure patients can actively participate in treatment


MalenfantA, ForgetR, Papillon J,AmselR, Frigon J, ChoiniereM. Prevalence and characteristics of chronic sensory problemsin burn patients. Pain 1996; 67: 493--500
==== Post-burn Pruritus ====
'''Post-burn pruritus''' (itching sensations on or around the burn, graft, or donor site) is a common issue after burn injury, affecting up to 93% of individuals by the day of their discharge.<ref name=":11">Andrade LF, Abdi P, Kooner A, Eldaboush AM, Dhami RK, Natarelli N, Yosipovitch G. Treatment of post-burn pruritus - A systematic review and meta-analysis. Burns. 2024 Mar;50(2):293-301. </ref> It can have a significant impact on recovery, causing distress and affecting quality of life. Patients can also potentially cause trauma to their wounds by scratching, which can delay healing.<ref>Beecher SM, Hill R, Kearney L, Dorairaj J, Kumar A, Clover AJ. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8310874/ The pruritus severity scale-a novel tool to assess itch in burns patients]. Int J Burns Trauma. 2021 Jun 15;11(3):156-62. </ref>   


Pal KS, Cortiella J, Herndon D. Adjunctive methods of pain control in burns. Burns 1997; 23: 404--12
Please note that the use of restraints to prevent a patient from itching are considered an absolute last resort. Depending on your location, the use of restraints may require specific medical orders that need to be regularly reviewed. Other options to try first include:  


Thurber CA, Martin-Herz SP, Patterson DR. Psychological principles of burn wound pain in children. 1: Theoretical framework. J Burn Care Rehab 2000; 21: 376--86
* extra layers of fluffy bandages to protect the primary dressings (but it is essential to ensure that proper air exchange can occur)
* gloves (with fingers) or mitts (without figures)


==== Alternative Pain Management Techniques: ====
Current treatments for post-burn pruritus have not been found to have clinically significant benefits, so further research on post-burn pruritus management is required.<ref name=":11" /> Treatments include:<ref>Chung BY, Kim HB, Jung MJ, Kang SY, Kwak IS, Park CW, Kim HO. [https://www.mdpi.com/1422-0067/21/11/3880 Post-burn pruritus]. Int J Mol Sci. 2020 May 29;21(11):3880. </ref> 
Alternative pain management techniques entail:
# Psychological techniques
# Hypnosis
# Virtual Reality
# Sleep Normalisation
# Music therapy
===== 1. 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.  


===== 2. Hypnosis: =====
* topical treatments
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 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.
* systemic treatments, such as antihistamines, opioid receptor agonists or antagonists, gabapentin or pregabalin, antidepressants, etc
* extracorporeal shockwave therapy (ESWT)
* pressure therapy
* massage therapy
* education
* cold compresses in the subacute phase<ref name=":2" />
* moisturisers<ref name=":6" />
For more information on post-burn pruritus, please see: [[Burn Wound Healing Considerations and Recovery Care Interventions#Post Burn Wound Injury Care and Rehabilitation|Burn Wound Injury Special Concern: Post-burn Pruritus]]


===== 3. Virtual Reality: =====
==== Persistent / Chronic Pain ====
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).  
Some individuals after a burn injury will develop chronic or persistent pain, affecting quality of life, sleep, increasing morbidity and decreasing functional recovery. Chronic neuropathic pain after burn injury has a reported prevalence of 7.3% to 18%.<ref name=":12">Klifto KM, Dellon AL, Hultman CS. [https://academic.oup.com/burnstrauma/article/doi/10.1093/burnst/tkaa011/5818502 Prevalence and associated predictors for patients developing chronic neuropathic pain following burns]. Burns Trauma. 2020 May 1;8:tkaa011. </ref> It develops as a result of partial or complete peripheral nerve injuries.<ref name=":12" /> Individuals with burn injuries may develop hyperalgesia or allodynia. There is a strong correlation between the severity of chronic pain symptoms and the total burn surface area and number of skin grafts performed.<ref>Braza ME, Fahrenkopf MP. [https://www.ncbi.nlm.nih.gov/books/NBK551561/ Split-thickness skin grafts]. 2019.</ref>


===== 4. Sleep Normalisation: =====
Treatments for persistent pain following a burn injury might include:<ref name=":2" />
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.


===== 5. Music therapy: =====
* analgesics
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 –
* antidepressants
* anticonvulsants
* regional nerve block
* cognitive behavioural therapy


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).  
===== Alternative Pain Management Techniques for Burn Injuries =====
<blockquote>Romanowski et al. recommend "that every patient be offered a nonpharmacological pain control technique, at least as an adjunctive measure to their pain control regimen".<ref name=":7" /></blockquote>There are four broad categories of nonpharmacological techniques:<ref name=":7" />


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.  
# '''cognitive-behavioral therapy''' (CBT)
#* "most effective when decatastrophizing and reinterpreting pain signals were targeted"<ref name=":7" />
# '''hypnosis'''
#* can be used to help manage procedural pain and anxiety
#* "most effective when the affective component of pain was targeted in posthypnotic suggestions and for patients who had high pain"
# '''distraction'''
#* i.e. redirecting the patient's attention from the pain sensation
#* virtual reality has the most robust evidence
#** the patient is immersed in a virtual world
#** patients who "feel more “present” in the virtual world have lower pain scores during wound care and physiotherapy"<ref name=":7" />
#** patients using virtual reality can have lower pain scores during dressing changes<ref>de Jesus Catalã CA, Pan R, Rossetto Kron-Rodrigues M, de Oliveira Freitas N. [https://academic.oup.com/jbcr/article-abstract/43/4/880/6425063 Virtual reality therapy to control burn pain: systematic review of randomized controlled trials]. Journal of Burn Care & Research. 2022 Jul;43(4):880-8.</ref><ref>Mott J, Bucolo S, Cuttle L, Mill J, Hilder M, Miller K, Kimble RM. The efficacy of an augmented virtual reality system to alleviate pain in children undergoing burns dressing changes: a randomised controlled trial. Burns. 2008 Sep 1;34(6):803-8.</ref>
# '''relaxation''' (breathing, music,<ref>Monsalve-Duarte S, Betancourt-Zapata W, Suarez-Cañon N, Maya R, Salgado-Vasco A, Prieto-Garces S, Marín-Sánchez J, Gómez-Ortega V, Valderrama M, Ettenberger M. [https://www.sciencedirect.com/science/article/abs/pii/S0305417921003107 Music therapy and music medicine interventions with adult burn patients: A systematic review and meta-analysis.] Burns. 2021 Nov 16.</ref> stress inoculation, aromatherapy, massage)


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 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).  
'''Rehabilitation strategies to help with pain, post-burn pruritus and altered sensation include:'''<ref name=":6" />


== 2. Management of Oedema  ==
* education, reassurance, distraction
When oedema occurs in the acute phase of a burn wound, there are two commonly used options for management, these being elevation and compression.
* splinting
* exercise
* massage
* sensory re-education / desensitisation


===== Elevation =====
'''Sleep normalisation''' also plays a role in pain management:
When elevating a limb to assist with decreasing oedema, we should aspire to elevate the part above the level of the heart. This means that gravity will assist the removal of oedema<ref>Tuca AC, Winter R, Kamolz LP. [https://link.springer.com/chapter/10.1007/978-3-030-39193-5_3 Acute Burn Surgery.] InBurn Care and Treatment 2021 (pp. 27-35). Springer, Cham.</ref> . Sometimes this is not always possible due to pain and discomfort. Raise the limb as high as possible. A sling can be used to facilitate elevation. An added benefit of using a sling is it will protect the burn site while allowing a degree of movement. This means the blood flow can be actively increased. 


If a patient is experiencing systemic inflammation, which can be common with large, severe burns, consider the following precautions:<ref name=":1" />  
* a night of poor sleep predicts increased pain and greater analgesia use the next day
* increased pain during the day predicts poor sleep quality that night<ref>Rampes S, Ma K, Divecha YA, Alam A, Ma D. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7386412/ Postoperative sleep disorders and their potential impacts on surgical outcomes]. J Biomed Res. 2019 Aug 29;34(4):271-280. </ref>


* Elevate the head. In the case of an anterior neck burn, do not place a pillow under the head as it could cause a contracture to develop.  
== Oedema Management for Individuals with Burn Injuries  ==
* Elevate all affected limbs 
Burn injuries induce oedema.<ref name=":23">Agency for Clinical Innovation. Statewide Burn Injury Service. Burn physiotherapy and occupational therapy guidelines, 2017. Available from: https://aci.health.nsw.gov.au/__data/assets/pdf_file/0018/236151/ACI-Burn-physiotherapy-occupational-therapy-guidelines.pdf [accessed 12 April 2024].</ref> Two interventions for oedema management in burn injuries include elevation and compression.
* Maintain feet in neutral
* Maintain hips in a neutral position
* Monitor constantly for pressure sores


===== Compression =====
Whenever implementing interventions for burn injuries, remember that all post-operative, consultant and multidisciplinary team advice must be followed.<ref name=":23" /> Care must be taken to reduce the risk of skin breakdown and contracture development, and all indications and contraindications must be considered.
There is little evidence supporting using compression as a form of oedema relief, but it is commonly used and many therapists will advocate for this technique. When using a wrap or sleeve, make sure the material is self adhesive and will not stick to the tissue below as this could severely impact the healing process. There is evidence that a wrap can decrease oedema, improve dexterity, range of motion and grip strength in hands<ref>Godleski M, Yelvington ML. [https://link.springer.com/chapter/10.1007/978-3-030-39193-5_10 Rehabilitation and Therapy of the Burn Patient.] InBurn Care and Treatment 2021 (pp. 137-145). Springer, Cham.</ref>.


{{pdf|Coban - English.pdf|Burns and Plastic Surgery Occupational Therapy}}
===== Elevation =====
In order to decrease oedema, a limb should ideally be elevated above the level of the heart.<ref>Tuca AC, Winter R, Kamolz LP. [https://link.springer.com/chapter/10.1007/978-3-030-39193-5_3 Acute Burn Surgery.] InBurn Care and Treatment 2021 (pp. 27-35). Springer, Cham.</ref> Sometimes, this may not be possible due to pain and discomfort or lack of range of motion. In these cases, it is important to raise the limb as high as possible through positioning and other adjuncts, such as pillows, towels, splints and slings.<ref name=":23" /><ref name=":13" /><ref>The Royal Children's Hospital Melbourne. Burns. Available from: https://www.rch.org.au/trauma-service/manual/Burns/ (last accessed 12 April 2024).</ref> 


== 3. Management of the Scar  ==
Patients with severe burns that cover a large Total Body Surface Area (TBSA) are at risk of systematic inflammation. In these cases, the following precautions should be considered:<ref name=":1" />  
Scarring is a common complication following a severe burn wound and affects approximately 70% of patients.<ref>Anzarut A, Olson J, Singh P, Rowe BH, Tredget EE. T[https://www.sciencedirect.com/science/article/abs/pii/S1748681507006535 he effectiveness of pressure garment therapy for the prevention of abnormal scarring after burn injury: a meta-analysis.] Journal of Plastic, Reconstructive & Aesthetic Surgery. 2009 Jan 1;62(1):77-84.</ref> Hypertrophic scars (HTSs) are defined as visible and elevated scars that do not spread into surrounding tissues and that often regress spontaneously.<ref>Rabello FB, Souza CD, Farina Júnior JA. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4129552/ Update on hypertrophic scar treatment.] Clinics. 2014;69:565-73.</ref> The difficulties experienced by many individuals with hypertrophic scars is that often have a psychosocial effect on the individual. They can cause: <ref>Morien A, Garrison D, Smith NK. [https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.600.1039&rep=rep1&type=pdf Range of motion improves after massage in children with burns: a pilot study.] Journal of bodywork and movement therapies. 2008 Jan 1;12(1):67-71.</ref><ref>Polotto S. [http://www.embj.org/wp-content/uploads/2011/12/images_ISSUE_2011_polotto_17_06_11.pdf USE OF SILICONE DRESSINGS IN POST-BURN HYPERTROPHIC SCAR THERAPY: A SYSTEMATIC REVIEW.] Capsula Eburnea. 2011 Dec 1;6.</ref>  


* Self image difficulties due to cosmetic changes 
* elevate the head: in the case of anterior neck burns, do not place a pillow under the head, as this can cause a contracture to develop
* Pain
* elevate all affected limbs
* Itchiness
* maintain the feet at 90 degrees
* Limited range of motion, particularly where they occur on or near  a joint
* maintain the hips in a neutral position
* monitor for pressure sores


A hypertrophic scar requires treatment from the early stages in hospital, and this can continue with dedicated and specialised treatment many years post injury. <ref name=":1" /> When managing a scar passively with pressure garment therapy and massage, it is important to remember continue with correct positioning, massage and mobilisations.
===== Compression =====
Compression is commonly used to help manage oedema in burn injuries:<ref>Edger-Lacoursière Z, Deziel E, Nedelec B. Rehabilitation interventions after hand burn injury in adults: A systematic review. Burns. 2023 May;49(3):516-53. </ref>  


==== Scar Outcome Measures ====
* pressure garment therapy (discussed below) has been shown to be beneficial in burn injures<ref name=":1" /> - it can be used for both oedema and scar management, depending on the age of the burn and the initial depth of injury 
* coban wrap is often used for burn injuries of the hand and is useful in the acute stage of a burn injury because it does not stick to the underlying tissue<ref>Hale A, O’Donovan R, Diskin S, McEvoy S, Keohane C, Gormley G. Impairment and Disability Short Course. [[:File:Burns and Plastics.pdf|Physiotherapy in Burns, Plastics and Reconstructive Surgery]], 2013.</ref>


# '''Vancouver Burn Scar Scale (VBSS/VSS)'''
For more information on Coban wraps, please see: {{pdf|Coban - English.pdf|Burns and Plastic Surgery Occupational Therapy}}.
##<u>Aim:</u> Assessment of the scar in 4 categories: Vascularity, height/thickness, pliability, and pigmentation, relief, 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).(Fearmonti et al 2010)(Durani et al 2009)(Brusselaers et al 2010)
## Method: [[Burns Scar Index (Vancouver Scar Scale)]]
# '''Patient and Observer Scar Assessment Scale (POSAS)'''
## <u>Aim:</u> Assessment of the scar from the patient and the observers perspective
## <u>Method:</u> [https://www.posas.nl/about/ About POSAS]
# '''Burn Specific Health Scale -Brief (BSHS-B)'''
## <u>Aim:</u>  Assessment of general, physical, mental, and social health aspects of the burn survivor
## <u>Method:</u> [[Burn Specific Health Scale -Brief (BSHS-B)]]


==== Management Options ====
== Scar Management for Individuals with Burn Injuries  ==
When working with Burns scars, there are three common options selected for the most effective treatment. These being:
Hypertrophic scarring is a common complication in burn injuries, affecting up to 70% of patients.<ref>Finnerty CC, Jeschke MG, Branski LK, Barret JP, Dziewulski P, Herndon DN. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5380137/ Hypertrophic scarring: the greatest unmet challenge after burn injury]. Lancet. 2016 Oct 1;388(10052):1427-36. </ref> Hypertrophic scars are visible, elevated scars. Unlike keloid scars, they do not spread into surrounding tissues, and they often regress spontaneously.<ref>Rabello FB, Souza CD, Farina Júnior JA. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4129552/ Update on hypertrophic scar treatment.] Clinics. 2014;69:565-73.</ref> Hypertrophic scars can have a significant impact on an individual with burn injuries, potentially causing:<ref name=":14">Nischwitz SP, Rauch K, Luze H, Hofmann E, Draschl A, Kotzbeck P, Kamolz LP. [https://onlinelibrary.wiley.com/doi/full/10.1111/wrr.12839 Evidence-based therapy in hypertrophic scars: An update of a systematic review]. Wound Repair Regen. 2020 Sep;28(5):656-65. </ref><ref>Morien A, Garrison D, Smith NK. [https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.600.1039&rep=rep1&type=pdf Range of motion improves after massage in children with burns: a pilot study.] Journal of bodywork and movement therapies. 2008 Jan 1;12(1):67-71.</ref><ref>Polotto S. [http://www.embj.org/wp-content/uploads/2011/12/images_ISSUE_2011_polotto_17_06_11.pdf Use of silicone dressings in post-burn hypertrophic scar therapy: a systematic review]. Capsula Eburnea. 2011 Dec 1;6.</ref>


# '''Silicone'''
* pain
# '''Pressure Garment Therapy (PGT)'''
* pruritus
# '''Massage'''
* reduced range of motion (particularly when they occur on or near a joint)
 
* psychosocial / psychological effects
===== '''<u>1. Silicone</u>''' =====
* cosmetic effects  
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<ref name=":0">McCarty M. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2989813/ An evaluation of evidence regarding application of silicone gel sheeting for the management of hypertrophic scars and keloids.] The Journal of clinical and aesthetic dermatology. 2010 Nov;3(11):39.</ref>. 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.
* altered self-image
 
==== Scar Outcome Measures ====
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). 
'''Vancouver Burn Scar Scale (VBSS/VSS):'''
 
*assesses vascularity, height, pliability, and pigmentation of the scar
Silicone gel sheets can be washed and reused, limiting financial burden to the patient over the 2- to 3-month treatment course.<ref name=":0" />
*does not measure a patient's subjective assessment of the scar, such as pain, itching, functional or psychological impact<ref>Park JW, Koh YG, Shin SH, Choi Y, Kim W, Yoo HH, et al. [https://www.jkslms.or.kr/journal/view.html?uid=263&vmd=Full Review of scar assessment scales]. Medical Lasers. 2022;11:1-7.</ref>
 
*for more information, please see: [[Burns Scar Index (Vancouver Scar Scale)]]
'''Physiological effects of Silicone:'''
'''Patient and Observer Scar Assessment Scale (POSAS):'''
 
* measures pigmentation, vascularity, thickness, relief, pliability and surface area, as well as pain, itching, colour, stiffness, thickness and relief
# 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<ref name=":0" />
* for more information, please see: [https://www.posas.nl/about/ About POSAS]
# simulate the physiological skin barrier and decrease transepidermal water loss<ref name=":0" />
==== Management Options for Hypertrophic Scars ====
# Increase in temperature: A rise in temperature increases collagenase activity thus  increased scar breakdown.
The following sections discuss approaches used to help manage hypertrophic scars, such as silicone, compression / pressure garment therapy (PGT) and massage. Other treatments include:
# Polarized Electric Fields: The negative charge within silicone causes polarization of  the scar tissue, resulting in involution of the scar.
# 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.
# 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.
# 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)
 
===== '''<u>2. Pressure Garment Therapy (PGT)</u>''' =====
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'''<ref name=":1">Procter F. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3038404/ Rehabilitation of the burn patient.] Indian journal of plastic surgery: official publication of the Association of Plastic Surgeons of India. 2010 Sep;43(Suppl):S101.</ref>  
 
# Reduce scarring by hastening maturation  
# Pressure decreases blood flow
# Local hypoxia of hyper vascular scars
# Reduction in collagen deposition
## Decreases scar thickness
## Decreases scar redness  
## Decreases swelling
## Reduces itch
## Protects new skin/grafts
## Maintains contours (Procter 2010)
 
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
 
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)
 
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)
 
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.<ref>Macintyre L, Baird M. [https://www.sciencedirect.com/science/article/abs/pii/S0305417905003463 Pressure garments for use in the treatment of hypertrophic scars—a review of the problems associated with their use.] Burns. 2006 Feb 1;32(1):10-5.</ref> This summary has been adapted  from the most recently published literature on
 
# 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.
# 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.  
# Prostaglandin E2 release: Induction of prostaglandin E2 release, which can block  fibroblast proliferation as well as collagen production
 
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)
 
∙ 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  
 
* Physical and Functional limitations caused by garments
* Additional effort” created by the need to care for the garment
* Careful considerations of cost, compliance, patient discomfort, possible complications and  the perceived benefits before prescribing this treatment.
 
'''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)
 
===== '''<u>3. Massage</u>''' =====
Five principles of scar massage:
 
# Prevent adherence
# Reduce redness
# Reduce elevation of scar tissue
# Relieve pruritus
# 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)  
{| class="wikitable"
| colspan="2" |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
|}
Guidelines for scar massage during healing stages (Glassey 2004)
 
Morien et al 2008
 
Field et al 2000
 
Shin and Bordeaux,  2012 Lit review
 
'''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
 
== 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.  
 
=== 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).
 
29


Figure11. The reconstructive ladder, procedures ranging from simplest to most complex. (Ataturk University School of Medicine 2009)
* intralesional injection<ref name=":14" /><ref>Choi C, Mukovozov I, Jazdarehee A, Rai R, Sachdeva M, Shunmugam M, et al. [https://onlinelibrary.wiley.com/doi/abs/10.1111/ajd.13790 Management of hypertrophic scars in adults: A systematic review and meta-analysis]. Australas J Dermatol. 2022 May;63(2):172-89.</ref>
* laser and light therapies<ref name=":14" /><ref>Klifto KM, Asif M, Hultman CS. [https://academic.oup.com/burnstrauma/article/doi/10.1093/burnst/tkz002/5706921 Laser management of hypertrophic burn scars: a comprehensive review]. Burns Trauma. 2020 Jan 16;8:tkz002.</ref>
* topical steroids<ref>Shirakami E, Yamakawa S, Hayashida K. [https://academic.oup.com/burnstrauma/article/doi/10.1093/burnst/tkz003/5706922 Strategies to prevent hypertrophic scar formation: a review of therapeutic interventions based on molecular evidence]. Burns Trauma. 2020 Jan 27;8:tkz003. </ref>
* moisturisers<ref name=":6">Whitaker IS, Shokrollahi K, Dickson WA. Burns. Oxford: OUP Oxford, 2019. </ref>


==== 4.3 Skin Grafts ====
===== '''Silicone''' =====
“A skin graft is the transportation of skin from one area of the body to another.” (Glassey 2004)  
Silicone can be applied in the form of a gel or sheeting. While some randomised controlled trials have found that topical silicone gel can be effective in preventing post-operative scarring,<ref name=":15">Wang F, Li X, Wang X, Jiang X. [https://onlinelibrary.wiley.com/doi/full/10.1111/iwj.13337 Efficacy of topical silicone gel in scar management: A systematic review and meta-analysis of randomised controlled trials]. Int Wound J. 2020 Jun;17(3):765-73. </ref> a 2020 Cochrane review notes "there is currently limited rigorous RCT [randomised controlled trial] evidence available about the clinical effectiveness of SGS [silicone gel sheeting] in the treatment of hypertrophic scars"<ref name=":16">Jiang Q, Chen J, Tian F, Liu Z. [https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013357.pub2/full Silicone gel sheeting for treating hypertrophic scars]. Cochrane Database Syst Rev. 2021 Sep 26;9(9):CD013357.</ref> and further research is required.<ref name=":16" /> Nischwitz et al.<ref name=":14" /> note that silicone gel appears to be mainly beneficial for post-burn pruritus and pain.<ref name=":14" /> Some important clinical points:


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:  
* silicone gels tend to be easier to apply than sheets and can also be used on more areas of the body<ref name=":13" />
* silicone gel sheets can be washed and reused, which reduces the financial burden on the patient<ref name=":0">McCarty M. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2989813/ An evaluation of evidence regarding application of silicone gel sheeting for the management of hypertrophic scars and keloids.] The Journal of clinical and aesthetic dermatology. 2010 Nov;3(11):39.</ref>
For more information on silicone products, including procedures for sheet silicone, precautions and considerations, please see page 18 of [https://aci.health.nsw.gov.au/__data/assets/pdf_file/0018/236151/ACI-Burn-physiotherapy-occupational-therapy-guidelines.pdf Burn Physiotherapy and Occupational Therapy Guidelines].


∙ Autograft (‘split skin graft’) (own skin)  
===== '''Pressure Garment Therapy (PGT)''' =====
Compression therapy aims to "keep developing scars flat and prevent raised scarring [...]. The type of compression used depends on wound healing, area of body affected, time since healing and individual patient needs."<ref name=":23" />


∙ Allograft (donor skin)  
Compression can be achieved in different ways, such as pressure garments (off-the-shelf or customised), cohesive flexible bandages, tubular elasticised stockings and bandaging.<ref name=":23" />


∙ Heterograft or xenografts (animal skin)  
'''Pressure garment therapy (PGT)''' is widely used in the management of hypertrophic scars.<ref name=":1" /> There have been a number of studies on pressure garment therapy, but they often have different outcomes and may contradict each other.<ref>Merwarth D. Burn Wound Healing and Recovery Care Course. Plus, 2024.</ref> Some recent research suggests:


∙ Cultured skin
* there is "sufficient evidence to support the prophylactic and curative use of pressure therapy for scar management"<ref name=":3">De Decker I, Beeckman A, Hoeksema H, De Mey K, Verbelen J, De Coninck P, et al. Pressure therapy for scars: Myth or reality? A systematic review. Burns. 2023 Jun;49(4):741-56.</ref>
* PGT can help improve a scar's colour, thickness and quality and reduce pain<ref name=":3" />
* De Decker et al.<ref name=":3" /> recommend that PGT should be started ''sooner than'' two months post-burn, but ideally as early as possible
* the wound must have closed and be '''stable enough to tolerate pressure before starting PGT''' (always check with the surgeon)<ref name=":13" />
* PGT should be worn while the scar remains active<ref name=":23" />
* De Decker et al.<ref name=":3" /> PGT should continue for at least 12 months, preferably for up to 18-24 months<ref name=":3" />
* recommended pressures for PGT vary
** De Decker et al.<ref name=":3" /> recommend minimal pressures of around 20-25 mmHg
** Shirakami et al.<ref name=":24">Shirakami E, Yamakawa S, Hayashida K. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7175766/ Strategies to prevent hypertrophic scar formation: a review of therapeutic interventions based on molecular evidence]. Burns Trauma. 2020 Jan 27;8:tkz003. </ref> recommend that pressure should be between 20-30 mmHg (above capillary pressure)
** please note that pressures exceeding 30-40 mmHg can have adverse effects (again figures given in the literature vary)<ref name=":24" /><ref name=":13" />
* it is typically recommended that pressure garments be worn at all times apart from showering or bathing, massage and moisturising (i.e. around 23 hours every day)<ref name=":23" />
* adherence can be an issue for pressure garment therapy - it can be uncomfortable to wear the garment, especially in warm weather, and it can cause overheating, wound breakdown and itching<ref>Moiemen N, Mathers J, Jones L, et al. Pressure garment to prevent abnormal scarring after burn injury in adults and children: the PEGASUS feasibility RCT and mixed-methods study. Southampton (UK): NIHR Journals Library; 2018 Jun. (Health Technology Assessment, No. 22.36.) Chapter 1, Introduction and background.Available from: https://www.ncbi.nlm.nih.gov/books/NBK507759/</ref>


∙ Artificial skin (Glassey 2004)  
'''How does pressure garment therapy work?'''<ref name=":1">Procter F. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3038404/ Rehabilitation of the burn patient.] Indian journal of plastic surgery: official publication of the Association of Plastic Surgeons of India. 2010 Sep;43(Suppl):S101.</ref>


30
Applying pressure to a burn injury is believed to reduce scarring by "hastening scar maturation and encouraging reorientation of collagen fibres into uniform, parallel patterns as opposed to the whorled pattern seen in untreated scars."<ref name=":1" /> It potentially creates localised hypoxia to the scar, thus reducing blood flow to hyper-vascular scars. This reduces the influx of collagen and decreases scar formation.


===== 4.31 Meshed vs. Sheet Grafts =====
Pressure garment therapy is believed to help:<ref name=":1" />
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.
* reduce scar thickness
* reduce redness
* decrease swelling
* reduce post-burn pruritus
* improve the protection of healed skin grafts
* maintain contours and prevent contractures


(Klein 2010)
{{#ev:youtube| UCq9JreucIM |300}}<ref>Occupational Therapy UiTM. Pressure Garment Therapy. Available from: https://www.youtube.com/watch?v=UCq9JreucIM [last accessed 31/3/2024]</ref><blockquote>'''Pressure Garment Care'''


4.311 Criteria to be met Pre- Grafting
It is important to educate patients on how to look after their pressure garments.


∙ Diagnosis of DEEP tissue loss
Two sets of garments are recommended for hygiene purposes (one in the wash and one being worn).<ref name=":23" />


∙ Patient is systemically fit for surgery
* Washing instructions:<ref name=":5">Nationwide Children's. Burns: Wearing a Pressure Garment. Available from: https://www.nationwidechildrens.org/family-resources-education/health-wellness-and-safety-resources/helping-hands/burns-wearing-a-pressure-garment (last accessed 11 April 2024).</ref><ref name=":22">Chelsea and Westminster Hospital. NHS Foundation Trust. Pressure garments. Available from: https://www.chelwest.nhs.uk/your-visit/patient-leaflets/burns/pressure-garments (last accessed 11 April 2024).</ref>
** hand wash:
*** soak pressure garment in cool water and mild soap
*** rinse well with clean, cool water
*** roll the garment in a towel to soak up excess water
** machine wash:
*** use a mild soap or detergent
*** wash with cool water on a gentle / delicate cycle
* Drying instructions:<ref name=":5" /><ref name=":22" />
** air-dry only: pressure garments cannot be placed in a heated dryer as this will destroy their elasticity and compression ability
** do not put the garment in sunlight or in front of a heater
Pressure garments need to be re-tensioned or remeasured and replaced every three to six months, depending on the level of wear and tear.<ref name=":23" /></blockquote>For more information on compression and pressure garment therapy, including procedures, precautions and contraindications, please see pages 14-17 of [https://aci.health.nsw.gov.au/__data/assets/pdf_file/0018/236151/ACI-Burn-physiotherapy-occupational-therapy-guidelines.pdf Burn Physiotherapy and Occupational Therapy Guidelines].


∙ Patient has no coagulation abnormalities ∙ Sufficient donor sites available
===== '''Scar Massage''' =====
Scar massage is routinely used in many burn rehabilitation units around the world. Reported clinical benefits include:<ref name=":4">Ault P, Plaza A, Paratz J. Scar massage for hypertrophic burns scarring-A systematic review. Burns. 2018 Feb;44(1):24-38. </ref>


Figure12. Diagrams illustrating the process  of mesh graft procedure (www.beltina .org)
* improved pliability and range of motion of the scar
* reduced pain and skin sensitivity
* reduced post-burn pruritus
* decreased anxiety
* changes in scar characteristics and reduction in scar thickness


∙ Would clear of streptococcus (Glassey 2004) 4.312 The Donor Site
Recent research suggests:


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.
* there is low-to-moderate quality evidence that massage can ''reduce pain and the intensity of post-burn scar pruritus''<ref name=":25">Santuzzi CH, Gonçalves Liberato FM, Fachini de Oliveira NF, Sgrancio do Nascimento A, Nascimento LR. [https://www.sciencedirect.com/science/article/pii/S1836955323001169 Massage, laser and shockwave therapy improve pain and scar pruritus after burns: a systematic review]. J Physiother. 2024 Jan;70(1):8-15.</ref>
* there is low-to-moderate quality evidence that massage has "negligible or unclear effects for improving scar elasticity and vascularisation"<ref name=":25" />
* another review by Barnes et al.<ref name=":18">Barnes SP, Ma Y, Patel B, Muthayya P. Efficacy of massage techniques for hypertrophic burn scars - a systematic review of literature. J Burn Care Res. 2024 Mar 4;45(2):356-65.</ref> found that scar massage can help with symptoms associated with hypertrophic burn scars, even when different massage techniques are used
** when used together, friction and oscillation can improve scar function
** longer sessions of effleurage and petrissage can help with scar visibility and pain 
** each massage technique helped with scar pruritus
** "massage techniques should be tailored to the patients’ symptoms"
* further research is required<ref name=":17">Lin TR, Chou FH, Wang HH, Wang RH. Effects of scar massage on burn scars: A systematic review and meta-analysis. J Clin Nurs. 2023 Jul;32(13-14):3144-54. </ref><ref name=":18" />
'''Massage treatment considerations:'''
* there is insufficient evidence to determine protocols on the frequency or duration of treatment
* clean hands are essential
* use a lubricant or lotion that is free of irritants  
* clinicians must adapt treatment based on the patient's stage of healing, sensitivity and pain levels


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).  
'''Massage contraindications''':<ref name=":13" /><ref>Shin TM, Bordeaux JS. [https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1524-4725.2011.02201.x The role of massage in scar management: a literature review.] Dermatologic Surgery. 2012 Mar;38(3):414-23.</ref>


31
* open wound
* acute infection
* bleeding
* graft failure
* intolerable discomfort
* hypersensitivity to emollient


4.313 Skin Substitutes
{{#ev:youtube| hmTLWVBIoBo |300}}<ref>Children's Burns Trust. Scar massage after a burn injury - Children's Burns Trust. Available from: https://www.youtube.com/watch?v=hmTLWVBIoBo [last accessed 31/3/2024]</ref>


“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”
For more information on massage, including procedures, precautions and considerations, please see page 20 of [https://aci.health.nsw.gov.au/__data/assets/pdf_file/0018/236151/ACI-Burn-physiotherapy-occupational-therapy-guidelines.pdf Burn Physiotherapy and Occupational Therapy Guidelines].


(Halim et al 2010)  
== Surgical Management for Individuals with Burn Injuries ==
<blockquote>“In deep partial thickness and full thickness burns, the entire epidermis and much of the dermis is lost, dramatically limiting the ability to heal spontaneously.”<ref name=":19">Palackic A, Duggan RP, Campbell MS, Walters E, Branski LK, Ayadi AE, Wolf SE. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9192152/ The role of skin substitutes in acute burn and reconstructive burn surgery: an updated comprehensive review]. Semin Plast Surg. 2022 Apr 12;36(1):33-42. </ref> These burns require surgical intervention to remove devitalised tissue and to promote regeneration by providing the injured skin with a new source of epidermis.<ref name=":19" /></blockquote>Since the 1970s, the acute management of burn injuries has included early excision and grafting, it is the current standard of care for burn wound injuries. This approach has led to improved survival rates and decreased length of hospital stay.<ref name=":20">Jeschke MG, van Baar ME, Choudhry MA, Chung KK, Gibran NS, Logsetty S. [https://www.nature.com/articles/s41572-020-0145-5 Burn injury]. Nat Rev Dis Primers. 2020 Feb 13;6(1):11.</ref>


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).  
=== Early Excision ===
Early excision is considered the gold-standard treatment:<ref name=":20" />


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).  
* there is debate over the optimal timing for early excision
* surgery aims to ensure there is no full-thickness necrotic tissue with debridement down to viable tissue


4.314 The Recipient Site
=== Skin Grafts ===
A skin graft is an area of skin that is moved from one area of the body to another area.  


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).  
Early autografting (i.e. transplanting skin from a healthy donor site to the burned area) rapidly closes excised wounds, which reduces infection risk and pain and facilitates earlier mobilisation. Allografting (i.e. using skin from another person) is used to temporarily cover debrided tissue when:<ref name=":20" />


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.
* there are issues with the viability or bacterial load of the wound bed
* the patient is not sufficiently medically stable


4.315 Process of Graft ‘Take’
'''Autologous split-thickness skin grafts''' are the gold standard management approach for deep partial and full-thickness acute burns.<ref name=":19" /><ref name=":20" /> Autologous skin grafts can be split-thickness skin grafts (STSGs) or  full-thickness skin grafts (FTSGs).<ref name=":21">Anyanwu JA, Cindass R. Burn Debridement, Grafting, and Reconstruction. [Updated 2023 May 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551717/</ref>


∙ Serum Inhibition (24-48hrs): fibrin layer formation and diffusion of fluid from the  wound bed
'''Split-thickness skin grafts (STSG)''':<ref name=":21" />


32
* most commonly used for wound coverage
* include the epidermis and the upper layer of the dermis
* are beneficial when patients have extensive TBSA burns, as the same donor sites can be re-harvested after one to two weeks (this can, however, lead to hypopigmentation)
* '''mesh grafts''' can increase the total surface area of the mesh, but can result in significant scarring<ref name=":20" />
** mesh grafts are processed to "punch" holes or apertures into the graft; this increases its size, allows topical agents through the graft and serous fluid or blood out
** STSGs are often meshed and expanded for burns of more than 30-40%TBSA
** meshed grafts are more commonly used for the back, trunk, legs and arms
* '''sheet grafts''' (i.e. “donor sites that are excised and used as-is”) are used for more cosmetic areas, such as the face, hands and neck<ref name=":20" />
For more information on STSGs, please see: [https://www.nature.com/articles/s41572-020-0145-5 Burn injury].<ref name=":20" />


∙ Inoscultation (day 3): capillary budding from the wound bed up into the base of the  graft
'''Full-thickness skin grafts (FTSG)''':<ref name=":21" />


∙ Capillary in-growth and remodelling (Glassey 2004) 4.316 Reasons for Graft Failure
* the epidermis and the dermis to the underlying fat layer are harvested using a scalpel
* associated with decreased scar and contracture formation, so they are useful in areas of cosmetic importance and across joints
* however, they lead to full-thickness wounds at the donor site; these must be closed primarily or have reconstructive flap closure
* have a higher failure rate


∙ Inadequate blood supply to wound bed
The following short, optional video shows the skin graft procedure.
{{#ev:youtube|er9YxF_C60A|300}}<ref>MotionLit. Skin Graft Procedure - Flash Fire Injury. Available from: http://www.youtube.com/watch?v=er9YxF_C60A [last accessed 1/4/2024]</ref>


∙ Graft movement
===== Graft Failure =====
A graft should be stable within five days. It should be placed over bleeding, healthy tissue to ensure adequate vascularity.<ref name=":13" />


∙ Collection of fluid beneath graft (e.g. haematoma)
Post-operatively, the graft site will be dressed with sufficient pressure to limit haematoma formation but without causing damage to the delicate tissue. ''It is essential to consider the dressing pressure needed for successful graft stability and healing. Too much pressure can cause damage to the fragile tissue and a newly placed skin graft to fail.''


∙ Infection (e.g. streptococcus)
The area should be immobilised in an “anti-deformity” position to prevent shearing forces that might disrupt the graft. Areas that are highly mobile, such as the hand, might require splinting to ensure immobility.<ref name=":13" />


∙ The grafts properties (e.g. vascularity of donor site) (Glassey 2004)
Skin grafts are more likely to fail if:<ref name=":20" />


==== 4.4 Skin Flaps ====
* excision of the recipient site is insufficient
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’.  
* there is shear stress
* there is wound infection
Other causes of graft failure include:<ref name=":13" />


Fig 13: skin flaps  
* inadequate blood supply to the wound bed
* collection of fluid beneath the graft (e.g. haematoma)
* the properties of the donor site (e.g. level of vascularity)


(MicroSurgeon, 2012)  
===== Skin Substitutes =====
If the excised area requires more skin than is available, temporary skin cover is required. There are many types of skin substitutes (biomaterial and engineered tissue grafts).<ref name=":19" /><ref name=":20" />


Tissues which a skin graft will not take over include and which a skin flap will include:  
If you would like more information on skin substitutes, please see:


∙ Bone without periosteum
* [https://www.nature.com/articles/s41572-020-0145-5 Burn injury]<ref name=":20" />
* [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9192152/ The role of skin substitutes in acute burn and reconstructive burn surgery: an updated comprehensive review]<ref name=":19" />
<blockquote>There are differences in how a newly placed graft is managed versus a healed graft. You will need to consult with the surgeon and medical team for specific management protocols.</blockquote>


∙ Tendon without paratenon
=== Skin Flaps ===
Skin flaps are also used in patients with burn injuries. Unlike skin grafts which are vascularised by the recipient site, a skin flap has its own vasculature (i.e. it brings its own blood supply from the donor site).<ref name=":13" />


∙ Cartilage without perichondrium (Glassey 2004)
Skin flaps might be used on areas such as:<ref name=":13" />


33
* bone without periosteum
* tendon without paratenon
* cartilage without perichondrium
The following optional video explains more about skin flaps and shows different types of flap surgery. You can only view this video on YouTube. {{#ev:youtube|T5LOCl0JYbY|300}}<ref>K's Surgery. SKIN FLAP LIVE SURGERY [PLASTIC AND RECONSTRUCTIVE SURGERY]. Available from: http://www.youtube.com/watch?v=T5LOCl0JYbY [last accessed 1/4/2024]</ref>


==== 4.41 Categorisation of Skin Flaps ====
=== Reconstruction Surgery ===
Based on three factors:  
<blockquote>“Overall survival of the skin graft is important, but cosmetic outcomes and body image cannot be ignored when treating burn patients.”<ref name=":21" /></blockquote>Burn scars that develop after skin grafting and can lead to:<ref name=":21" />


1. Vascularity
* anxiety
* depression
* pain
* itching
* altered pigmentation
* temperature intolerance
* decreased range of motion (from contractures)


2. Anatomical composition
Surgical scar revision is “the standard of care” for individuals with burn injuries who develop contractures or who have poor cosmetic outcomes. Around 5-20% of individuals with burn injuries go on to have reconstructive surgery.<ref>van Baar ME. [https://link.springer.com/chapter/10.1007/978-3-030-44766-3&#x20;5 Epidemiology of scars and their consequences: burn scars]. Textbook on Scar Management: State of the Art Management and Emerging Technologies. 2020:37-43.</ref> Surgical scar revision can involve skin substitutes, laser therapy, flaps, biomaterials, etc.<ref name=":21" />


3. Method of relocation (Glassey 2004)
== References ==
[[Category:Course Pages]]
[[Category:Course Pages]]
[[Category:Plus Content]]
[[Category:Burns]]
[[Category:Burns]]
<references />
[[Category:SRSHS Course Pages]]
[[Category:Integumentary System]]

Latest revision as of 12:35, 1 May 2024

Original Editor - Carin Hunter
Top Contributors - Jess Bell, Carin Hunter, Kim Jackson, Stacy Schiurring and Robin Tacchetti

Introduction[edit | edit source]

Burn injuries are a major cause of pain and disability.[1] Optimal rehabilitation care for individuals with burn injuries requires a multifaceted, multidisciplinary approach. This page explores some of the key elements that must be considered in a rehabilitation plan when working with individuals with burns, including pain management, oedema management, scar management and surgical considerations.

It is essential to remember that every intervention discussed on this page must be coordinated with the medical / surgical team to ensure tailored management protocols for each patient.

Pain Management for Individuals with Burn Injuries[edit | edit source]

There are many factors to consider when treating pain associated with burn injuries.[2] Pain assessments should be performed during each phase of care,[3] and both pharmacological and alternative management strategies can be used to manage pain in patients with burn injuries.

General Points on Pharmacology for Individuals with Burn Injuries[edit | edit source]

"Pain distress is common during the acute phase [of a burn injury] despite the use of opioids and/or ketamine."[4]

The general consensus is that "opioid therapy is an essential tool for pain management in thermal injuries",[4] and patients with burn injuries are often given opioids in higher doses and for longer durations than typical dosing guidelines. However, many patients with burns continue to experience pain and are at risk for opioid tolerance.[3][4][5]

Romanowski et al.[3] include the following recommendations in their guidelines on pain management in adult patients with burn injuries:

  • opioid therapy needs to be individualised to each patient and continuously adjusted during their care (considering individual responses, adverse effects, and narrow therapeutic windows)[3]
  • while the reasonable use of opioids is supported to manage severe pain, attempts should be made to use "as few opiate equivalents as needed"[3]
  • opioid pain medications should be used in conjunction with other treatments, including non-opioid medications and non-pharmacological treatments[3]

For more information, please see: American Burn Association Guidelines on the Management of Acute Pain in the Adult Burn Patient: A Review of the Literature, a Compilation of Expert Opinion, and Next Steps[3]

Pain Management in Individuals with Burn Injuries Admitted to Hospital[edit | edit source]

"Burn injury is widely considered one of the most painful injuries that a person can sustain. In addition to the intrinsic pain caused by the burn itself, the proper treatment of a burn injury requires painful procedures including debridement of the wound, daily wound care, and surgery, followed by aggressive physical and occupational therapy."[3]

In the initial phases, pain associated with burn injuries tends to be described as background pain, breakthrough pain and procedural pain. Patients may go on to experience persistent or chronic pain, as well as specific types of pain such as post-burn pruritus (itching).[4][1]

The management for each type of pain can differ.[5] Pain management, especially in the hospital setting will be affected by the depth of burn injury and what structures are still intact and functioning. To learn more about burn wound classification by depth and size please see: Burn Wound Classification.

Background Pain[edit | edit source]

This type of pain is defined as "pain at rest that is almost always present and not caused by specific medical procedures".[5] Thus, it is persistent but usually low-grade.[1] It can be present at the injury site and in other areas (i.e. primary and secondary pain). Background pain tends to be managed with moderate-potency opioids (preferably given orally).[5]

Breakthrough Pain[edit | edit source]

Breakthrough pain is a transient increase in pain in individuals who are experiencing background pain.[5] It can indicate worsening background pain or can be from another source.[6]

Pain Associated with Procedures[edit | edit source]

Individuals with burn injuries often require a number of procedures (e.g. mobilisation, skin grafts, debridement, dressing changes, etc). These procedures can add to a patient's pain experience, often causing high-intensity pain that is short to medium in duration.[1]

Important considerations:[1]

  • each procedure causes a new, painful stimulus, which adds to the stress response
  • analgesia should be given at an appropriate time to ensure maximum benefit[6]
  • analgesia should be used in a preventive way, especially as some procedures can be predicted
  • general anaesthetic may be used for prolonged procedures
Pain Associated with Surgery[edit | edit source]

Early post-operative pain tends to be managed with opioids and other non-opioid medications:[1]

  • patient-controlled analgesia (PCA) can be used (particularly for breakthrough pain after a procedure[5]), but the patient must be conscious and alert[6] and be able to understand how to use the device
  • non-steroidal anti-inflammatory drugs (NSAIDs) have been used to help manage pain after surgery:
    • however, they are used infrequently in individuals who are critically ill[6]
    • they "should be used with extreme caution especially in patients with bigger burns and those on intensive care"[7]
  • local anaesthetic gels may be applied after surgery to large, raw areas, such as donor sites, before the dressing is applied
Pain Associated with Dressing Changes and Wound Cleaning[edit | edit source]

Pain management during dressing changes and wound care is a significant consideration:[1]

  • a general anaesthetic or deep intravenous sedation may be required while dressing large, deep burns
  • smaller dressings can be managed by administering analgesia (e.g. opioids, local anaesthetics) before starting the procedure
  • nitrous oxide (e.g. Entonox) and opioids can be used for short procedures to help reduce breakthrough pain and avoid long periods of sedation
  • using appropriate dressings can help reduce the requirement for procedures - please see Burn Wound Injury Dressing Selection and Advanced Dressing Selection for Burn Wound Injuries for more information on burn wound dressings
Pain Associated with Rehabilitation[edit | edit source]

Physiotherapists and occupational therapists commonly work with patients with burn injuries in primary healthcare settings. However, moving the affected area/s can exacerbate pain and trigger the stress response. Rehabilitation interventions are, therefore, often scheduled after pain relief has been administered:[1]

  • during the acute phase, physiotherapists and occupational therapists may perform passive range of motion exercises or create splints while a patient is in theatre or having their dressings changed
  • during the subacute and chronic phases, oral analgesics are commonly used to ensure patients can actively participate in treatment

Post-burn Pruritus[edit | edit source]

Post-burn pruritus (itching sensations on or around the burn, graft, or donor site) is a common issue after burn injury, affecting up to 93% of individuals by the day of their discharge.[8] It can have a significant impact on recovery, causing distress and affecting quality of life. Patients can also potentially cause trauma to their wounds by scratching, which can delay healing.[9]

Please note that the use of restraints to prevent a patient from itching are considered an absolute last resort. Depending on your location, the use of restraints may require specific medical orders that need to be regularly reviewed. Other options to try first include:

  • extra layers of fluffy bandages to protect the primary dressings (but it is essential to ensure that proper air exchange can occur)
  • gloves (with fingers) or mitts (without figures)

Current treatments for post-burn pruritus have not been found to have clinically significant benefits, so further research on post-burn pruritus management is required.[8] Treatments include:[10]

  • topical treatments
  • systemic treatments, such as antihistamines, opioid receptor agonists or antagonists, gabapentin or pregabalin, antidepressants, etc
  • extracorporeal shockwave therapy (ESWT)
  • pressure therapy
  • massage therapy
  • education
  • cold compresses in the subacute phase[1]
  • moisturisers[7]

For more information on post-burn pruritus, please see: Burn Wound Injury Special Concern: Post-burn Pruritus

Persistent / Chronic Pain[edit | edit source]

Some individuals after a burn injury will develop chronic or persistent pain, affecting quality of life, sleep, increasing morbidity and decreasing functional recovery. Chronic neuropathic pain after burn injury has a reported prevalence of 7.3% to 18%.[11] It develops as a result of partial or complete peripheral nerve injuries.[11] Individuals with burn injuries may develop hyperalgesia or allodynia. There is a strong correlation between the severity of chronic pain symptoms and the total burn surface area and number of skin grafts performed.[12]

Treatments for persistent pain following a burn injury might include:[1]

  • analgesics
  • antidepressants
  • anticonvulsants
  • regional nerve block
  • cognitive behavioural therapy
Alternative Pain Management Techniques for Burn Injuries[edit | edit source]

Romanowski et al. recommend "that every patient be offered a nonpharmacological pain control technique, at least as an adjunctive measure to their pain control regimen".[3]

There are four broad categories of nonpharmacological techniques:[3]

  1. cognitive-behavioral therapy (CBT)
    • "most effective when decatastrophizing and reinterpreting pain signals were targeted"[3]
  2. hypnosis
    • can be used to help manage procedural pain and anxiety
    • "most effective when the affective component of pain was targeted in posthypnotic suggestions and for patients who had high pain"
  3. distraction
    • i.e. redirecting the patient's attention from the pain sensation
    • virtual reality has the most robust evidence
      • the patient is immersed in a virtual world
      • patients who "feel more “present” in the virtual world have lower pain scores during wound care and physiotherapy"[3]
      • patients using virtual reality can have lower pain scores during dressing changes[13][14]
  4. relaxation (breathing, music,[15] stress inoculation, aromatherapy, massage)

Rehabilitation strategies to help with pain, post-burn pruritus and altered sensation include:[7]

  • education, reassurance, distraction
  • splinting
  • exercise
  • massage
  • sensory re-education / desensitisation

Sleep normalisation also plays a role in pain management:

  • a night of poor sleep predicts increased pain and greater analgesia use the next day
  • increased pain during the day predicts poor sleep quality that night[16]

Oedema Management for Individuals with Burn Injuries[edit | edit source]

Burn injuries induce oedema.[17] Two interventions for oedema management in burn injuries include elevation and compression.

Whenever implementing interventions for burn injuries, remember that all post-operative, consultant and multidisciplinary team advice must be followed.[17] Care must be taken to reduce the risk of skin breakdown and contracture development, and all indications and contraindications must be considered.

Elevation[edit | edit source]

In order to decrease oedema, a limb should ideally be elevated above the level of the heart.[18] Sometimes, this may not be possible due to pain and discomfort or lack of range of motion. In these cases, it is important to raise the limb as high as possible through positioning and other adjuncts, such as pillows, towels, splints and slings.[17][2][19]

Patients with severe burns that cover a large Total Body Surface Area (TBSA) are at risk of systematic inflammation. In these cases, the following precautions should be considered:[20]

  • elevate the head: in the case of anterior neck burns, do not place a pillow under the head, as this can cause a contracture to develop
  • elevate all affected limbs
  • maintain the feet at 90 degrees
  • maintain the hips in a neutral position
  • monitor for pressure sores
Compression[edit | edit source]

Compression is commonly used to help manage oedema in burn injuries:[21]

  • pressure garment therapy (discussed below) has been shown to be beneficial in burn injures[20] - it can be used for both oedema and scar management, depending on the age of the burn and the initial depth of injury
  • coban wrap is often used for burn injuries of the hand and is useful in the acute stage of a burn injury because it does not stick to the underlying tissue[22]

For more information on Coban wraps, please see: Burns and Plastic Surgery Occupational Therapy.

Scar Management for Individuals with Burn Injuries[edit | edit source]

Hypertrophic scarring is a common complication in burn injuries, affecting up to 70% of patients.[23] Hypertrophic scars are visible, elevated scars. Unlike keloid scars, they do not spread into surrounding tissues, and they often regress spontaneously.[24] Hypertrophic scars can have a significant impact on an individual with burn injuries, potentially causing:[25][26][27]

  • pain
  • pruritus
  • reduced range of motion (particularly when they occur on or near a joint)
  • psychosocial / psychological effects
  • cosmetic effects
  • altered self-image

Scar Outcome Measures[edit | edit source]

Vancouver Burn Scar Scale (VBSS/VSS):

  • assesses vascularity, height, pliability, and pigmentation of the scar
  • does not measure a patient's subjective assessment of the scar, such as pain, itching, functional or psychological impact[28]
  • for more information, please see: Burns Scar Index (Vancouver Scar Scale)

Patient and Observer Scar Assessment Scale (POSAS):

  • measures pigmentation, vascularity, thickness, relief, pliability and surface area, as well as pain, itching, colour, stiffness, thickness and relief
  • for more information, please see: About POSAS

Management Options for Hypertrophic Scars[edit | edit source]

The following sections discuss approaches used to help manage hypertrophic scars, such as silicone, compression / pressure garment therapy (PGT) and massage. Other treatments include:

Silicone[edit | edit source]

Silicone can be applied in the form of a gel or sheeting. While some randomised controlled trials have found that topical silicone gel can be effective in preventing post-operative scarring,[32] a 2020 Cochrane review notes "there is currently limited rigorous RCT [randomised controlled trial] evidence available about the clinical effectiveness of SGS [silicone gel sheeting] in the treatment of hypertrophic scars"[33] and further research is required.[33] Nischwitz et al.[25] note that silicone gel appears to be mainly beneficial for post-burn pruritus and pain.[25] Some important clinical points:

  • silicone gels tend to be easier to apply than sheets and can also be used on more areas of the body[2]
  • silicone gel sheets can be washed and reused, which reduces the financial burden on the patient[34]

For more information on silicone products, including procedures for sheet silicone, precautions and considerations, please see page 18 of Burn Physiotherapy and Occupational Therapy Guidelines.

Pressure Garment Therapy (PGT)[edit | edit source]

Compression therapy aims to "keep developing scars flat and prevent raised scarring [...]. The type of compression used depends on wound healing, area of body affected, time since healing and individual patient needs."[17]

Compression can be achieved in different ways, such as pressure garments (off-the-shelf or customised), cohesive flexible bandages, tubular elasticised stockings and bandaging.[17]

Pressure garment therapy (PGT) is widely used in the management of hypertrophic scars.[20] There have been a number of studies on pressure garment therapy, but they often have different outcomes and may contradict each other.[35] Some recent research suggests:

  • there is "sufficient evidence to support the prophylactic and curative use of pressure therapy for scar management"[36]
  • PGT can help improve a scar's colour, thickness and quality and reduce pain[36]
  • De Decker et al.[36] recommend that PGT should be started sooner than two months post-burn, but ideally as early as possible
  • the wound must have closed and be stable enough to tolerate pressure before starting PGT (always check with the surgeon)[2]
  • PGT should be worn while the scar remains active[17]
  • De Decker et al.[36] PGT should continue for at least 12 months, preferably for up to 18-24 months[36]
  • recommended pressures for PGT vary
    • De Decker et al.[36] recommend minimal pressures of around 20-25 mmHg
    • Shirakami et al.[37] recommend that pressure should be between 20-30 mmHg (above capillary pressure)
    • please note that pressures exceeding 30-40 mmHg can have adverse effects (again figures given in the literature vary)[37][2]
  • it is typically recommended that pressure garments be worn at all times apart from showering or bathing, massage and moisturising (i.e. around 23 hours every day)[17]
  • adherence can be an issue for pressure garment therapy - it can be uncomfortable to wear the garment, especially in warm weather, and it can cause overheating, wound breakdown and itching[38]

How does pressure garment therapy work?[20]

Applying pressure to a burn injury is believed to reduce scarring by "hastening scar maturation and encouraging reorientation of collagen fibres into uniform, parallel patterns as opposed to the whorled pattern seen in untreated scars."[20] It potentially creates localised hypoxia to the scar, thus reducing blood flow to hyper-vascular scars. This reduces the influx of collagen and decreases scar formation.

Pressure garment therapy is believed to help:[20]

  • reduce scar thickness
  • reduce redness
  • decrease swelling
  • reduce post-burn pruritus
  • improve the protection of healed skin grafts
  • maintain contours and prevent contractures

[39]

Pressure Garment Care

It is important to educate patients on how to look after their pressure garments.

Two sets of garments are recommended for hygiene purposes (one in the wash and one being worn).[17]

  • Washing instructions:[40][41]
    • hand wash:
      • soak pressure garment in cool water and mild soap
      • rinse well with clean, cool water
      • roll the garment in a towel to soak up excess water
    • machine wash:
      • use a mild soap or detergent
      • wash with cool water on a gentle / delicate cycle
  • Drying instructions:[40][41]
    • air-dry only: pressure garments cannot be placed in a heated dryer as this will destroy their elasticity and compression ability
    • do not put the garment in sunlight or in front of a heater

Pressure garments need to be re-tensioned or remeasured and replaced every three to six months, depending on the level of wear and tear.[17]

For more information on compression and pressure garment therapy, including procedures, precautions and contraindications, please see pages 14-17 of Burn Physiotherapy and Occupational Therapy Guidelines.

Scar Massage[edit | edit source]

Scar massage is routinely used in many burn rehabilitation units around the world. Reported clinical benefits include:[42]

  • improved pliability and range of motion of the scar
  • reduced pain and skin sensitivity
  • reduced post-burn pruritus
  • decreased anxiety
  • changes in scar characteristics and reduction in scar thickness

Recent research suggests:

  • there is low-to-moderate quality evidence that massage can reduce pain and the intensity of post-burn scar pruritus[43]
  • there is low-to-moderate quality evidence that massage has "negligible or unclear effects for improving scar elasticity and vascularisation"[43]
  • another review by Barnes et al.[44] found that scar massage can help with symptoms associated with hypertrophic burn scars, even when different massage techniques are used
    • when used together, friction and oscillation can improve scar function
    • longer sessions of effleurage and petrissage can help with scar visibility and pain
    • each massage technique helped with scar pruritus
    • "massage techniques should be tailored to the patients’ symptoms"
  • further research is required[45][44]

Massage treatment considerations:

  • there is insufficient evidence to determine protocols on the frequency or duration of treatment
  • clean hands are essential
  • use a lubricant or lotion that is free of irritants  
  • clinicians must adapt treatment based on the patient's stage of healing, sensitivity and pain levels

Massage contraindications:[2][46]

  • open wound
  • acute infection
  • bleeding
  • graft failure
  • intolerable discomfort
  • hypersensitivity to emollient

[47]

For more information on massage, including procedures, precautions and considerations, please see page 20 of Burn Physiotherapy and Occupational Therapy Guidelines.

Surgical Management for Individuals with Burn Injuries[edit | edit source]

“In deep partial thickness and full thickness burns, the entire epidermis and much of the dermis is lost, dramatically limiting the ability to heal spontaneously.”[48] These burns require surgical intervention to remove devitalised tissue and to promote regeneration by providing the injured skin with a new source of epidermis.[48]

Since the 1970s, the acute management of burn injuries has included early excision and grafting, it is the current standard of care for burn wound injuries. This approach has led to improved survival rates and decreased length of hospital stay.[49]

Early Excision[edit | edit source]

Early excision is considered the gold-standard treatment:[49]

  • there is debate over the optimal timing for early excision
  • surgery aims to ensure there is no full-thickness necrotic tissue with debridement down to viable tissue

Skin Grafts[edit | edit source]

A skin graft is an area of skin that is moved from one area of the body to another area.

Early autografting (i.e. transplanting skin from a healthy donor site to the burned area) rapidly closes excised wounds, which reduces infection risk and pain and facilitates earlier mobilisation. Allografting (i.e. using skin from another person) is used to temporarily cover debrided tissue when:[49]

  • there are issues with the viability or bacterial load of the wound bed
  • the patient is not sufficiently medically stable

Autologous split-thickness skin grafts are the gold standard management approach for deep partial and full-thickness acute burns.[48][49] Autologous skin grafts can be split-thickness skin grafts (STSGs) or full-thickness skin grafts (FTSGs).[50]

Split-thickness skin grafts (STSG):[50]

  • most commonly used for wound coverage
  • include the epidermis and the upper layer of the dermis
  • are beneficial when patients have extensive TBSA burns, as the same donor sites can be re-harvested after one to two weeks (this can, however, lead to hypopigmentation)
  • mesh grafts can increase the total surface area of the mesh, but can result in significant scarring[49]
    • mesh grafts are processed to "punch" holes or apertures into the graft; this increases its size, allows topical agents through the graft and serous fluid or blood out
    • STSGs are often meshed and expanded for burns of more than 30-40%TBSA
    • meshed grafts are more commonly used for the back, trunk, legs and arms
  • sheet grafts (i.e. “donor sites that are excised and used as-is”) are used for more cosmetic areas, such as the face, hands and neck[49]

For more information on STSGs, please see: Burn injury.[49]

Full-thickness skin grafts (FTSG):[50]

  • the epidermis and the dermis to the underlying fat layer are harvested using a scalpel
  • associated with decreased scar and contracture formation, so they are useful in areas of cosmetic importance and across joints
  • however, they lead to full-thickness wounds at the donor site; these must be closed primarily or have reconstructive flap closure
  • have a higher failure rate

The following short, optional video shows the skin graft procedure.

[51]

Graft Failure[edit | edit source]

A graft should be stable within five days. It should be placed over bleeding, healthy tissue to ensure adequate vascularity.[2]

Post-operatively, the graft site will be dressed with sufficient pressure to limit haematoma formation but without causing damage to the delicate tissue. It is essential to consider the dressing pressure needed for successful graft stability and healing. Too much pressure can cause damage to the fragile tissue and a newly placed skin graft to fail.

The area should be immobilised in an “anti-deformity” position to prevent shearing forces that might disrupt the graft. Areas that are highly mobile, such as the hand, might require splinting to ensure immobility.[2]

Skin grafts are more likely to fail if:[49]

  • excision of the recipient site is insufficient
  • there is shear stress
  • there is wound infection

Other causes of graft failure include:[2]

  • inadequate blood supply to the wound bed
  • collection of fluid beneath the graft (e.g. haematoma)
  • the properties of the donor site (e.g. level of vascularity)
Skin Substitutes[edit | edit source]

If the excised area requires more skin than is available, temporary skin cover is required. There are many types of skin substitutes (biomaterial and engineered tissue grafts).[48][49]

If you would like more information on skin substitutes, please see:

There are differences in how a newly placed graft is managed versus a healed graft. You will need to consult with the surgeon and medical team for specific management protocols.

Skin Flaps[edit | edit source]

Skin flaps are also used in patients with burn injuries. Unlike skin grafts which are vascularised by the recipient site, a skin flap has its own vasculature (i.e. it brings its own blood supply from the donor site).[2]

Skin flaps might be used on areas such as:[2]

  • bone without periosteum
  • tendon without paratenon
  • cartilage without perichondrium

The following optional video explains more about skin flaps and shows different types of flap surgery. You can only view this video on YouTube.

[52]

Reconstruction Surgery[edit | edit source]

“Overall survival of the skin graft is important, but cosmetic outcomes and body image cannot be ignored when treating burn patients.”[50]

Burn scars that develop after skin grafting and can lead to:[50]

  • anxiety
  • depression
  • pain
  • itching
  • altered pigmentation
  • temperature intolerance
  • decreased range of motion (from contractures)

Surgical scar revision is “the standard of care” for individuals with burn injuries who develop contractures or who have poor cosmetic outcomes. Around 5-20% of individuals with burn injuries go on to have reconstructive surgery.[53] Surgical scar revision can involve skin substitutes, laser therapy, flaps, biomaterials, etc.[50]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 Norman AT, Judkins KC. Pain in the patient with burns. Continuing Education in Anaesthesia, Critical Care & Pain. 2004 Apr 1;4(2):57-61.
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 Hale A, O’Donovan R, Diskin S, McEvoy S, Keohane C, Gormley G. Impairment and Disability Short Course. Physiotherapy in Burns, Plastics and Reconstructive Surgery, 2013.
  3. ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 Romanowski KS, Carson J, Pape K, Bernal E, Sharar S, Wiechman S, et al. American Burn Association Guidelines on the management of acute pain in the adult burn patient: a review of the literature, a compilation of expert opinion and next steps. J Burn Care Res. 2020 Nov 30;41(6):1152-1164.
  4. ↑ 4.0 4.1 4.2 4.3 Stapelberg F. Challenges in anaesthesia and pain management for burn injuries. Anaesth Intensive Care. 2020 Mar;48(2):101-113.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 5.5 Emery MA, Eitan S. Drug-specific differences in the ability of opioids to manage burn pain. Burns. 2020 May;46(3):503-513.
  6. ↑ 6.0 6.1 6.2 6.3 McGovern C, Puxty K, Paton L. Major burns: part 2. Anaesthesia, intensive care and pain management. BJA Educ. 2022 Apr;22(4):138-45.
  7. ↑ 7.0 7.1 7.2 7.3 Whitaker IS, Shokrollahi K, Dickson WA. Burns. Oxford: OUP Oxford, 2019.
  8. ↑ 8.0 8.1 Andrade LF, Abdi P, Kooner A, Eldaboush AM, Dhami RK, Natarelli N, Yosipovitch G. Treatment of post-burn pruritus - A systematic review and meta-analysis. Burns. 2024 Mar;50(2):293-301.
  9. ↑ Beecher SM, Hill R, Kearney L, Dorairaj J, Kumar A, Clover AJ. The pruritus severity scale-a novel tool to assess itch in burns patients. Int J Burns Trauma. 2021 Jun 15;11(3):156-62.
  10. ↑ Chung BY, Kim HB, Jung MJ, Kang SY, Kwak IS, Park CW, Kim HO. Post-burn pruritus. Int J Mol Sci. 2020 May 29;21(11):3880.
  11. ↑ 11.0 11.1 Klifto KM, Dellon AL, Hultman CS. Prevalence and associated predictors for patients developing chronic neuropathic pain following burns. Burns Trauma. 2020 May 1;8:tkaa011.
  12. ↑ Braza ME, Fahrenkopf MP. Split-thickness skin grafts. 2019.
  13. ↑ de Jesus Catalã CA, Pan R, Rossetto Kron-Rodrigues M, de Oliveira Freitas N. Virtual reality therapy to control burn pain: systematic review of randomized controlled trials. Journal of Burn Care & Research. 2022 Jul;43(4):880-8.
  14. ↑ Mott J, Bucolo S, Cuttle L, Mill J, Hilder M, Miller K, Kimble RM. The efficacy of an augmented virtual reality system to alleviate pain in children undergoing burns dressing changes: a randomised controlled trial. Burns. 2008 Sep 1;34(6):803-8.
  15. ↑ Monsalve-Duarte S, Betancourt-Zapata W, Suarez-Cañon N, Maya R, Salgado-Vasco A, Prieto-Garces S, Marín-Sánchez J, Gómez-Ortega V, Valderrama M, Ettenberger M. Music therapy and music medicine interventions with adult burn patients: A systematic review and meta-analysis. Burns. 2021 Nov 16.
  16. ↑ Rampes S, Ma K, Divecha YA, Alam A, Ma D. Postoperative sleep disorders and their potential impacts on surgical outcomes. J Biomed Res. 2019 Aug 29;34(4):271-280.
  17. ↑ 17.0 17.1 17.2 17.3 17.4 17.5 17.6 17.7 17.8 Agency for Clinical Innovation. Statewide Burn Injury Service. Burn physiotherapy and occupational therapy guidelines, 2017. Available from: https://aci.health.nsw.gov.au/__data/assets/pdf_file/0018/236151/ACI-Burn-physiotherapy-occupational-therapy-guidelines.pdf [accessed 12 April 2024].
  18. ↑ Tuca AC, Winter R, Kamolz LP. Acute Burn Surgery. InBurn Care and Treatment 2021 (pp. 27-35). Springer, Cham.
  19. ↑ The Royal Children's Hospital Melbourne. Burns. Available from: https://www.rch.org.au/trauma-service/manual/Burns/ (last accessed 12 April 2024).
  20. ↑ 20.0 20.1 20.2 20.3 20.4 20.5 Procter F. Rehabilitation of the burn patient. Indian journal of plastic surgery: official publication of the Association of Plastic Surgeons of India. 2010 Sep;43(Suppl):S101.
  21. ↑ Edger-Lacoursière Z, Deziel E, Nedelec B. Rehabilitation interventions after hand burn injury in adults: A systematic review. Burns. 2023 May;49(3):516-53.
  22. ↑ Hale A, O’Donovan R, Diskin S, McEvoy S, Keohane C, Gormley G. Impairment and Disability Short Course. Physiotherapy in Burns, Plastics and Reconstructive Surgery, 2013.
  23. ↑ Finnerty CC, Jeschke MG, Branski LK, Barret JP, Dziewulski P, Herndon DN. Hypertrophic scarring: the greatest unmet challenge after burn injury. Lancet. 2016 Oct 1;388(10052):1427-36.
  24. ↑ Rabello FB, Souza CD, Farina Júnior JA. Update on hypertrophic scar treatment. Clinics. 2014;69:565-73.
  25. ↑ 25.0 25.1 25.2 25.3 25.4 Nischwitz SP, Rauch K, Luze H, Hofmann E, Draschl A, Kotzbeck P, Kamolz LP. Evidence-based therapy in hypertrophic scars: An update of a systematic review. Wound Repair Regen. 2020 Sep;28(5):656-65.
  26. ↑ Morien A, Garrison D, Smith NK. Range of motion improves after massage in children with burns: a pilot study. Journal of bodywork and movement therapies. 2008 Jan 1;12(1):67-71.
  27. ↑ Polotto S. Use of silicone dressings in post-burn hypertrophic scar therapy: a systematic review. Capsula Eburnea. 2011 Dec 1;6.
  28. ↑ Park JW, Koh YG, Shin SH, Choi Y, Kim W, Yoo HH, et al. Review of scar assessment scales. Medical Lasers. 2022;11:1-7.
  29. ↑ Choi C, Mukovozov I, Jazdarehee A, Rai R, Sachdeva M, Shunmugam M, et al. Management of hypertrophic scars in adults: A systematic review and meta-analysis. Australas J Dermatol. 2022 May;63(2):172-89.
  30. ↑ Klifto KM, Asif M, Hultman CS. Laser management of hypertrophic burn scars: a comprehensive review. Burns Trauma. 2020 Jan 16;8:tkz002.
  31. ↑ Shirakami E, Yamakawa S, Hayashida K. Strategies to prevent hypertrophic scar formation: a review of therapeutic interventions based on molecular evidence. Burns Trauma. 2020 Jan 27;8:tkz003.
  32. ↑ Wang F, Li X, Wang X, Jiang X. Efficacy of topical silicone gel in scar management: A systematic review and meta-analysis of randomised controlled trials. Int Wound J. 2020 Jun;17(3):765-73.
  33. ↑ 33.0 33.1 Jiang Q, Chen J, Tian F, Liu Z. Silicone gel sheeting for treating hypertrophic scars. Cochrane Database Syst Rev. 2021 Sep 26;9(9):CD013357.
  34. ↑ McCarty M. An evaluation of evidence regarding application of silicone gel sheeting for the management of hypertrophic scars and keloids. The Journal of clinical and aesthetic dermatology. 2010 Nov;3(11):39.
  35. ↑ Merwarth D. Burn Wound Healing and Recovery Care Course. Plus, 2024.
  36. ↑ 36.0 36.1 36.2 36.3 36.4 36.5 De Decker I, Beeckman A, Hoeksema H, De Mey K, Verbelen J, De Coninck P, et al. Pressure therapy for scars: Myth or reality? A systematic review. Burns. 2023 Jun;49(4):741-56.
  37. ↑ 37.0 37.1 Shirakami E, Yamakawa S, Hayashida K. Strategies to prevent hypertrophic scar formation: a review of therapeutic interventions based on molecular evidence. Burns Trauma. 2020 Jan 27;8:tkz003.
  38. ↑ Moiemen N, Mathers J, Jones L, et al. Pressure garment to prevent abnormal scarring after burn injury in adults and children: the PEGASUS feasibility RCT and mixed-methods study. Southampton (UK): NIHR Journals Library; 2018 Jun. (Health Technology Assessment, No. 22.36.) Chapter 1, Introduction and background.Available from: https://www.ncbi.nlm.nih.gov/books/NBK507759/
  39. ↑ Occupational Therapy UiTM. Pressure Garment Therapy. Available from: https://www.youtube.com/watch?v=UCq9JreucIM [last accessed 31/3/2024]
  40. ↑ 40.0 40.1 Nationwide Children's. Burns: Wearing a Pressure Garment. Available from: https://www.nationwidechildrens.org/family-resources-education/health-wellness-and-safety-resources/helping-hands/burns-wearing-a-pressure-garment (last accessed 11 April 2024).
  41. ↑ 41.0 41.1 Chelsea and Westminster Hospital. NHS Foundation Trust. Pressure garments. Available from: https://www.chelwest.nhs.uk/your-visit/patient-leaflets/burns/pressure-garments (last accessed 11 April 2024).
  42. ↑ Ault P, Plaza A, Paratz J. Scar massage for hypertrophic burns scarring-A systematic review. Burns. 2018 Feb;44(1):24-38.
  43. ↑ 43.0 43.1 Santuzzi CH, Gonçalves Liberato FM, Fachini de Oliveira NF, Sgrancio do Nascimento A, Nascimento LR. Massage, laser and shockwave therapy improve pain and scar pruritus after burns: a systematic review. J Physiother. 2024 Jan;70(1):8-15.
  44. ↑ 44.0 44.1 Barnes SP, Ma Y, Patel B, Muthayya P. Efficacy of massage techniques for hypertrophic burn scars - a systematic review of literature. J Burn Care Res. 2024 Mar 4;45(2):356-65.
  45. ↑ Lin TR, Chou FH, Wang HH, Wang RH. Effects of scar massage on burn scars: A systematic review and meta-analysis. J Clin Nurs. 2023 Jul;32(13-14):3144-54.
  46. ↑ Shin TM, Bordeaux JS. The role of massage in scar management: a literature review. Dermatologic Surgery. 2012 Mar;38(3):414-23.
  47. ↑ Children's Burns Trust. Scar massage after a burn injury - Children's Burns Trust. Available from: https://www.youtube.com/watch?v=hmTLWVBIoBo [last accessed 31/3/2024]
  48. ↑ 48.0 48.1 48.2 48.3 48.4 Palackic A, Duggan RP, Campbell MS, Walters E, Branski LK, Ayadi AE, Wolf SE. The role of skin substitutes in acute burn and reconstructive burn surgery: an updated comprehensive review. Semin Plast Surg. 2022 Apr 12;36(1):33-42.
  49. ↑ 49.0 49.1 49.2 49.3 49.4 49.5 49.6 49.7 49.8 49.9 Jeschke MG, van Baar ME, Choudhry MA, Chung KK, Gibran NS, Logsetty S. Burn injury. Nat Rev Dis Primers. 2020 Feb 13;6(1):11.
  50. ↑ 50.0 50.1 50.2 50.3 50.4 50.5 Anyanwu JA, Cindass R. Burn Debridement, Grafting, and Reconstruction. [Updated 2023 May 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551717/
  51. ↑ MotionLit. Skin Graft Procedure - Flash Fire Injury. Available from: http://www.youtube.com/watch?v=er9YxF_C60A [last accessed 1/4/2024]
  52. ↑ K's Surgery. SKIN FLAP LIVE SURGERY [PLASTIC AND RECONSTRUCTIVE SURGERY]. Available from: http://www.youtube.com/watch?v=T5LOCl0JYbY [last accessed 1/4/2024]
  53. ↑ van Baar ME. Epidemiology of scars and their consequences: burn scars. Textbook on Scar Management: State of the Art Management and Emerging Technologies. 2020:37-43.
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