Burn Injury Management Considerations for Rehabilitation Professionals: Difference between revisions

No edit summary
No edit summary
 
(47 intermediate revisions by 2 users not shown)
Line 1: Line 1:
<div class="editorbox"> '''Original Editor '''- [[User:Carin Hunter|Carin Hunter]]<br>'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>
<div class="editorbox"> '''Original Editor '''- [[User:Carin Hunter|Carin Hunter]]<br>'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>


<div class="noeditbox">This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! ({{REVISIONDAY}}/{{REVISIONMONTH}}/{{REVISIONYEAR}})</div>
== Introduction ==
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.


== Introduction ==
''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.''
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> particularly in low- and middle-income countries.<ref>Opriessnig E, Luze H, Smolle C, Draschl A, Zrim R, Giretzlehner M, et al. Epidemiology of burn injury and the ideal dressing in global burn care - Regional differences explored. Burns. 2023 Feb;49(1):1-14. </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 Management for Individuals with Burn Injuries ==
== Pain Management for Individuals with Burn Injuries ==
There are many factors to consider when treating pain associated with burn injuries, and the clinician must understand the cause of the current pain. There is no standardised treatment for patients with burn injuries.<ref>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> Pain assessments should be performed throughout the day and during different phases 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> Both pharmacological and alternative management strategies can be used to manage pain in patients with burn injuries.   
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.   


=== General Points on Pharmacology for Individuals with Burn Injuries ===
=== 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 / longer doses and 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>  
<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>  


Romanowski et al. include the following recommendations in their guidelines on pain management in adult patients with burn injuries:<ref name=":7" />
Romanowski et al.<ref name=":7" /> 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)
* 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" />
* 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" />
* 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" />
* opioid pain medications should be used in conjunction with other treatments, including non-opioid medications and non-pharmacological treatments
* opioid pain medications should be used in conjunction with other treatments, including non-opioid medications and non-pharmacological treatments<ref name=":7" />
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" />
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" />


=== Initial Acute Pain ===
=== '''Pain Management in Individuals with Burn Injuries Admitted to Hospital''' ===
<blockquote>"The energy from the burn source causes cell damage and release of inflammatory mediators [...] Descending pathways from the thalamus and release of endorphins and other neurotransmitters in the spinal cord may result in there being little or no pain for the first few hours after injury".<ref name=":2" /></blockquote>'''First aid strategies:'''<ref name=":2" />  
<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" />
 
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]].


* cool the burn with tepid or cold water to end the burning process and decrease pain (do not use ice water, as this causes further damage to the affected area)
==== Background Pain ====
* prevent general heat loss: hypothermia can be caused by cooling the burn and evaporation of oedema fluid, so provide the patient with a blanket or alternative source of warmth
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" /> 


=== '''Pain Management in Individuals with Burn Injuries Admitted to Hospital''' ===
==== Breakthrough Pain ====
<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 (e.g. associated with surgery, dressing changes, wound cleaning, rehabilitation). Patients may go on to experience persistent or chronic pain, as well as specific types of pain such as pruritus (itching).<ref name=":8" /><ref name=":2" /> The management for each type of pain can differ.<ref name=":9" />
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>  


==== Pain Associated with Procedures ====
==== Pain Associated with Procedures ====
Individuals with burn injuries often require a number of procedures (e.g. 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" />  
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" />  


'''Important considerations''':<ref name=":2" />   
'''Important considerations''':<ref name=":2" />   


* each procedure causes a new, painful stimulus, which adds to the stress response
* each procedure causes a new, painful stimulus, which adds to the stress response
* analgesia can be used in a preventive way, especially as some of these procedures can be predicted
* analgesia should be given at an appropriate time to ensure maximum benefit<ref name=":10" />
* general anaesthesia may be used for prolonged procedures  
* analgesia should be used in a preventive way, especially as some procedures can be predicted
* it is important to consider the impact of pain on sleep - sleep is important for healing, so appropriate pain management is also essential
* general anaesthetic may be used for prolonged procedures


===== Surgery =====
===== Pain Associated with Surgery =====
Early post-operative pain tends to be managed with opioids and other non-opioid medications. Opioids may be given transdermally, orally, intramuscularly or intravenously:<ref name=":2" />   
Early post-operative pain tends to be managed with opioids and other non-opioid medications:<ref name=":2" />   


* intramuscular administration can be difficult because of the extent of dressings, surgical site, pain at the site of injection, unpredictable absorption
* 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
* patient-controlled analgesia (PCA) can be used, but the patient must have a good level of understanding, be adequately responsive and be able to use the device - this can prevent its use in individuals with hand burns
* non-steroidal anti-inflammatory drugs (NSAIDs) have been used to help manage pain after surgery:
* non-steroidal anti-inflammatory drugs (NSAIDs) and regional blocks may also be 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
* local anaesthetic gels may be applied after surgery to large, raw areas, such as donor sites, before the dressing is applied


===== Dressings Changes and Wound Cleaning =====
===== Pain Associated with Dressing Changes and Wound Cleaning =====
Pain management during dressing changes and wound care is a significant consideration:<ref name=":2" />   
Pain management during dressing changes and wound care is a significant consideration:<ref name=":2" />   


* a general anaesthetic or deep intravenous sedation may be required while dressing large, deep burns, as they can take up to two hours to dress and may need to be debrided, or staples may need to be removed
* 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 - Entonox can be used for short procedures in addition to opioids to help reduce breakthrough pain and avoid long periods of sedation
* smaller dressings can be managed by administering analgesia (e.g. opioids, local anaesthetics) before starting the procedure
* using appropriate dressings (e.g., a synthetic temporary skin substitute) can help reduce the number of dressing changes required, which is particularly beneficial for pediatric patients
* 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


===== Rehabilitation (Physiotherapy, Occupational Therapy, Movement Therapy) =====
===== 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" />   
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" />   


* during the subacute and chronic phases, oral analgesics are commonly used to ensure patient can actively participate in treatment
* 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 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 ====
'''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>   
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.<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> 
* 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<ref name=":2" />
* moisturisers<ref name=":6" />
==== Persistent / Chronic Pain ====
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>
Treatments for persistent pain following a burn injury might include:<ref name=":2" />
* analgesics
* antidepressants
* anticonvulsants
* regional nerve block
* cognitive behavioural therapy
===== 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" />
# '''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)


==== 2. Resting Pain ====
'''Rehabilitation strategies to help with pain, post-burn pruritus and altered sensation include:'''<ref name=":6" />
This type of pain is usually low intensity but longer duration. Patients often describe their general state as 'low-grade persistent discomfort". This is often managed by using NSAIDs in combination with a low-dose opioid. This is managed by the physician or burns nurse. The patient is managed by regularly dosing the patient to prevent breakthrough pain. 


==== 3. Itching ====
* education, reassurance, distraction
As itching, or pruritus, is a common side effect of healing, it can be difficult to understand. But if the patient is reacting by scratching, they could cause damage to forming skin.  Treatment may involve a combination of antihistamines and NSAIDs. alternatively a cold compress could help the symptoms in a subacute phase. 
* splinting
* exercise
* massage
* sensory re-education / desensitisation


==== 4. Chronic Pain ====
'''Sleep normalisation''' also plays a role in pain management:
Chronic pain, in a burn injury, is often due to damaged or regenerating nerve fibres. The patient often suffers from hyperalgesia (Increased response to a painful stimulus) and allodynia (Painful response to a non-painful stimulus). This can often affects the patients sleeping and result in depressive symptoms and cause barriers to rehabilitation. There is a strong correlation with 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>


Treatment involves the following:<ref name=":2" />
* 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>


* Antidepressants
== Oedema Management for Individuals with Burn Injuries  ==
* Anticonvulsants
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.
* Regional nerve block
* Cognitive behavioural therapy  


==== Alternative Pain Management Techniques: ====
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.
Alternative pain management techniques entail:
# Psychological techniques can reduce fear and anxiety associated with activities or environments
## Relaxation
## Distraction<ref>Chu H, Brailey R, Clarke E, Sen SK. [https://www.sciencedirect.com/science/article/abs/pii/S030541792100019X Reducing pain through distraction therapy in small acute paediatric burns.] Burns. 2021 Nov 1;47(7):1635-8.</ref>
## Cognitive Behavioural Therapy
# Hypnosis can be used in the management of procedural pain and anxiety
# Virtual Reality can lower pain scores when undergoing 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>
## Immersing the patient in a virtual world
## Hand-held gaming devices
# Sleep Normalisation with a bedtime  routine
## To promote sleep
## Makes use of analgesics and night sedation
# Music therapy can target pain via the gate control theory<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>
## distraction from noxious stimuli
## Uses imagery<ref>Aghakhani N, Faraji N, Parizad N, Goli R, Alinejad V, Kazemzadeh J. [https://academic.oup.com/jbcr/article-abstract/43/3/756/6537123 Guided Imagery: An effective and practical complementary medicine method to alleviate pain severity and pain-related anxiety during dressing change in burn victims.] Journal of Burn Care & Research. 2022 May;43(3):756-.</ref>, self-statements and attention-diversion
== 2. Management of Oedema  ==
When oedema occurs in the acute phase of a burn wound, there are two commonly used options for management, these being elevation and compression.


===== Elevation =====
===== Elevation =====
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.   
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>  


If a patient is experiencing systemic inflammation, which can be common with large, severe burns, consider the following precautions:<ref name=":1" />  
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" />  


* 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.
* 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
* elevate all affected limbs
* Maintain feet in neutral
* maintain the feet at 90 degrees
* Maintain hips in a neutral position  
* maintain the hips in a neutral position
* Monitor constantly for pressure sores  
* monitor for pressure sores


===== Compression =====
===== Compression =====
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>.
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>
 
* 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>  
 
For more information on Coban wraps, please see: {{pdf|Coban - English.pdf|Burns and Plastic Surgery Occupational Therapy}}.


{{pdf|Coban - English.pdf|Burns and Plastic Surgery Occupational Therapy}}
== Scar Management for Individuals with Burn Injuries  ==
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>


== 3. Management of the Scar ==
* pain
Scarring is a common complication following a severe burn wound and affects approximately 70% of patients.<ref name=":3">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>
* 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 ====
'''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<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)]]
'''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: [https://www.posas.nl/about/ About POSAS]  
==== Management Options for Hypertrophic Scars ====
The following sections discuss approaches used to help manage hypertrophic scars, such as silicone, compression / pressure garment therapy (PGT) and massage. Other treatments include:


* Self image difficulties due to cosmetic changes 
* 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>
* Pain
* 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>
* Itchiness
* 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>
* Limited range of motion, particularly where they occur on or near  a joint
* moisturisers<ref name=":6">Whitaker IS, Shokrollahi K, Dickson WA. Burns. Oxford: OUP Oxford, 2019. </ref>


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.  
===== '''Silicone''' =====
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:


==== Scar Outcome Measures ====
* 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].


# '''Vancouver Burn Scar Scale (VBSS/VSS)'''  
===== '''Pressure Garment Therapy (PGT)''' =====
##<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)
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" />
## <u>Method</u>: [[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 ====
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" />
When working with Burns scars, there are three common options selected for the most effective treatment.


# '''Silicone'''
'''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:
# '''Pressure Garment Therapy (PGT)'''
# '''Massage'''


===== '''<u>1. Silicone</u>''' =====
* 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>
Silicone can be used in the form of a gel or sheeting. Using silicone in the treatment of hypertrophic scars is relatively new, beginning around 1981<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>. There is not much evidence to support the use of silicone to treat scars, but it does appear to common practice in many areas around the world. Often, practitioners prefer using the gel form as it has an easier application, more adaptable to different body parts and appears to have a higher patient compliance.<ref name=":4">Bloemen MC, van der Veer WM, Ulrich MM, van Zuijlen PP, Niessen FB, Middelkoop E. [https://www.sciencedirect.com/science/article/abs/pii/S0305417908002568 Prevention and curative management of hypertrophic scar formation.] Burns. 2009 Jun 1;35(4):463-75.</ref> 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" />  
* 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>


'''Physiological Effects of Silicone:'''  
'''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>


# Hydration Effect:
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.  
#* 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" /> simulate the physiological skin barrier and decrease transepidermal water loss<ref name=":0" />
# Increase in temperature:
#* A rise in temperature increases collagenase activity thus  increased scar breakdown.
# 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>''' =====
Pressure garment therapy is believed to help:<ref name=":1" />
There is no recent evidence supporting pressure garment therapy, but it is common practice among therapists in many areas of the world. It is a commonly used technique to reduce oedema and manage hypertrophic scars. <ref name=":1" />  It is generally advise to maintain a pressure of 15 mmHg. Pressure exceeding 40mmHg can cause complications.<ref>Engrav LH, Heimbach DM, Rivara FP, Moore ML, Wang J, Carrougher GJ, Costa B, Numhom S, Calderon J, Gibran NS. [https://www.sciencedirect.com/science/article/abs/pii/S0305417910001129 12-Year within-wound study of the effectiveness of custom pressure garment therapy.] burns. 2010 Nov 1;36(7):975-83.</ref><ref name=":3" /> . Once the wound has closed and the wound can tolerate pressure, usually approximately 14 days post graft, the patient is advised to wear the garment as much as possible, and to only remove it for around one hour per day.<ref name=":1" /><ref name=":3" /> <ref name=":4" />


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


# The increased pressure will decrease blood flow to hyper vascular scars.
{{#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'''
# Decrease collagen deposits
## Reduces thickness of scar
## Reduces red colouration of scar
## Decreases swelling
## Lessens pruritus
## Offers some protection of new skin/grafts
## Maintains normal body contours


Physiological effects:<ref name=":5">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> 
It is important to educate patients on how to look after their pressure garments.


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


'''Patient Adherence''' to Pressure Garment Therapy  
* 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].


Poor patient adherence to pressure garment therapy has been observed. This can be due to:<ref name=":5" />
===== '''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>  


* Physical limitations and discomfort caused by the garments,
* improved pliability and range of motion of the scar
* Additional garment care  requiredand h
* reduced pain and skin sensitivity
* High cost of the garment
* reduced post-burn pruritus
* Heat generated
* decreased anxiety
* Skin breakdown
* changes in scar characteristics and reduction in scar thickness
* Allergies


===== '''<u>3. Massage</u>''' =====
Recent research suggests:
Aims of scar massage:  


# Prevent adherence
* 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>
# Reduce redness
* there is low-to-moderate quality evidence that massage has "negligible or unclear effects for improving scar elasticity and vascularisation"<ref name=":25" />
# Reduce elevation of scar tissue
* 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
# Relieve pruritus  
** when used together, friction and oscillation can improve scar function
# Moisturise (Glassey 2004) 
** longer sessions of effleurage and petrissage can help with scar visibility and pain 
# Improve range of motion(Morien et al 2008)
** 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" />


'''Scar Massage Techniques'''<ref>Holey EA, Cook E. Evidence Based Therapeutic Massage: A Practical Guide for Therapists. Churchill Livingstone, Edinburgh, London, New York.</ref>  
'''Massage techniques and proposed effects:'''<ref name=":13" /><ref>Holey EA, Cook E. Evidence Based Therapeutic Massage: A Practical Guide for Therapists. Churchill Livingstone, Edinburgh, London, New York.</ref>  


# Retrograde massage
* '''retrograde massage'''
#* Aids venous return
** aids venous return
#* Increases lymphatic drainage
** increases lymphatic drainage
#* Mobilises fluid 
** mobilises fluid 
# Effleurage
* '''effleurage'''
#* Increase circulation
** increases circulation
# Kneading, Skin rolling and wringing
* '''kneading, skin rolling and wringing'''
#* Mobilises the scar and surrounding tissue
** mobilise the scar and surrounding tissue
# Frictions
** restore mobility to tissue interfaces
#* Loosen adhesions
** stretch and promote collagenous remodelling
* '''frictions'''
** loosen adhesions
   
   
{| class="wikitable"
{| class="wikitable"
| colspan="2" |Guidelines for Massage during 3 Stages of Healing:
| colspan="2" |Table 1. Guidelines for massage during the three stages of healing<ref name=":13" />
|-
|-
|Inflammatory Phase
|'''Inflammatory phase'''
|Gentle massage to decrease oedema and increase blood supply  (currently no high level evidence to support this)
|Gentle massage to decrease oedema and increase blood supply - please note there is no high-level evidence to support this
|-
|-
|Proliferative Phase
|'''Proliferative phase'''
|Massage that applies gentle stress to the healing scar is recommended  to ensure collagen is aligned correctly.
|Massage should be used to apply gentle stress to the healing scar
|-
|-
|Remodelling Phase
|'''Remodelling phase'''
|Massage should be progressed to include prolonged stretching to  minimise adhesions. This is proposed to aid in scar tissue breakdown
|Progress massage to include prolonged stretching to minimise adhesions
|}
|}
'''[Presentation: Suggestions for practice include: (Shin and Bordeaux, 2012, Morien et al, 2008)'''  
* Clean hands essential
* Use non irritating lubricant, free of any irritants  
* Modify practice according to patient stage of healing, sensitivity and pain levels.]


'''Contraindications''':<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>


* Open wound
'''Massage treatment considerations:'''
* Acute infection
 
* Bleeding
* there is insufficient evidence to determine protocols on the frequency or duration of treatment
* Open wound  
* clean hands are essential
* Graft failure  
* use a lubricant or lotion that is free of irritants  
* Intolerable discomfort  
* clinicians must adapt treatment based on the patient's stage of healing, sensitivity and pain levels
* Hypersensitivity to emollient  
 
'''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>
 
* open wound
* acute infection
* bleeding
* graft failure
* intolerable discomfort
* hypersensitivity to emollient
 
{{#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>


== 4. Reconstruction Post Burn Injury ==
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].
'''Burn injured patients are seriously impacted by reconstructive surgery.  Working as part of an MDT, allied health professionals aim to establish successful surgery with long term function and health. Acute burn surgical management entails timely wound excision and skin grafting. (Klein 2010). It typically takes 48 hours after injury to determine the depth of the burn and thus whether surgery is warranted. Evidence of necrotic tissue is the only exception that may justify early excision.  Reconstruction surgery facilitates the injured area to be cosmetically acceptable, extensible and sensate. (Glassey 2004).  Plastic surgeons may also have to replace or rebuild muscles, nerves, tendons and joints to establish everything is intact.'''


REPHRASE: 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.  
== 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>


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


* Achieve would closure
* there is debate over the optimal timing for early excision
* Prevent infection
* surgery aims to ensure there is no full-thickness necrotic tissue with debridement down to viable tissue
* Re-establish the function and properties of an intact skin
* Reduce the effect of burn scars causing joint contractures
* Reduce the extent of a cosmetically unacceptable scar


=== Skin Grafts ===
=== Skin Grafts ===
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. A graft can be split thickness, often from the thigh, which a specialised tool is used or full thickness, often from the groin, where a scalpel is used. The tissue can be used as is, known as a sheet graft, or it can be run through a machine which makes small holes in the skin (fenestrations) to increased the surface area, known as a meshed graft. Before the graft is laid in place, the would should be debrided and any necrotic tissue for foreign bodies should be removed. This will increase the chance of the graft adhering the the surface below or "taking". The donor site should heal within 10 -14 days, this would would be a superficial or a superficial partial thickness wound. The donor site is often more painful due to the exposure of the nerve endings.
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:<ref name=":20" />


There are five different types of grafts that can be used:
* there are issues with the viability or bacterial load of the wound bed
* the patient is not sufficiently medically stable


# Autograft which is the patients own skin  
'''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>
# Allograft which is comprised of donor skin  
# Heterograft or xenografts which is comprised of animal skin
# Cultured skin
# Artificial skin  


===== '''Pre-Graft Criteria''' =====
'''Split-thickness skin grafts (STSG)''':<ref name=":21" />


* Diagnosis of DEEP tissue loss
* most commonly used for wound coverage
* Patient is systemically fit for surgery
* include the epidermis and the upper layer of the dermis
* Patient has no coagulation abnormalities 
* 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)
* Sufficient donor sites available
* '''mesh grafts''' can increase the total surface area of the mesh, but can result in significant scarring<ref name=":20" />
* No infections
** 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" />


===== '''The Recipient Site''' =====
'''Full-thickness skin grafts (FTSG)''':<ref name=":21" />
'''The graft which will become a permanent covering of the injury should take within five days.  The best chance for graft survival is by ensuring it is vascularised.  To safeguard vascularisation, the graft should always be placed over healthy, bleeding tissue. (Glassey 2004)'''


REPHRASE: 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).  
* 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


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.  
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 Failure =====
===== Graft Failure =====
Graft failure means that the grafted tissue did not adhere to the surface below and become vascularised. The following could be reasons for this<ref name=":6" />:  
A graft should be stable within five days. It should be placed over bleeding, healthy tissue to ensure adequate vascularity.<ref name=":13" />
 
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.<ref name=":13" />
 
Skin grafts are more likely to fail if:<ref name=":20" />
 
* excision of the recipient site is insufficient
* there is shear stress
* there is wound infection
Other causes of graft failure include:<ref name=":13" />
 
* 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 =====
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" />


# Inadequate blood supply to wound bed
If you would like more information on skin substitutes, please see:
# Graft movement
# Collection of fluid beneath graft (e.g. haematoma)
# Infection (e.g. streptococcus)
# The grafts properties (e.g. vascularity of donor site)


{{#ev:youtube|er9YxF_C60A}}
* [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>


=== Skin Flaps ===
=== Skin Flaps ===
A skin flap will remain attached to it's blood supply<ref>Prohaska J, Cook C. [https://www.ncbi.nlm.nih.gov/books/NBK532874/#:~:text=Skin%20grafts%2C%20in%20contrast%20to,creates%20a%20second%20surgical%20site. Skin grafting]. 2018</ref> and is used in cases where the wound bed is avascular<ref name=":6">Glassey N. Physiotherapy for burns and plastic reconstruction of the hand. London: Whurr; 2004.</ref>.
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" />
 
Skin flaps might be used on areas such as:<ref name=":13" />
 
* 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>


Tissues which a skin graft will not take over include and which a skin flap will include<ref name=":6" />:
=== Reconstruction Surgery ===
<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" />


# Bone without periosteum
* anxiety
# Tendon without paratenon
* depression
# Cartilage without perichondrium
* pain
* itching
* altered pigmentation
* temperature intolerance
* decreased range of motion (from contractures)


{{#ev:youtube|T5LOCl0JYbY}}
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" />


== References ==
== References ==

Latest revision as of 11:28, 19 April 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]

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 techniques and proposed effects:[2][46]

  • retrograde massage
    • aids venous return
    • increases lymphatic drainage
    • mobilises fluid 
  • effleurage
    • increases circulation
  • kneading, skin rolling and wringing
    • mobilise the scar and surrounding tissue
    • restore mobility to tissue interfaces
    • stretch and promote collagenous remodelling
  • frictions
    • loosen adhesions
Table 1. Guidelines for massage during the three stages of healing[2]
Inflammatory phase Gentle massage to decrease oedema and increase blood supply - please note there is no high-level evidence to support this
Proliferative phase Massage should be used to apply gentle stress to the healing scar
Remodelling phase Progress massage to include prolonged stretching to minimise adhesions


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][47]

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

[48]

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.”[49] These burns require surgical intervention to remove devitalised tissue and to promote regeneration by providing the injured skin with a new source of epidermis.[49]

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.[50]

Early Excision[edit | edit source]

Early excision is considered the gold-standard treatment:[50]

  • 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:[50]

  • 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.[49][50] Autologous skin grafts can be split-thickness skin grafts (STSGs) or full-thickness skin grafts (FTSGs).[51]

Split-thickness skin grafts (STSG):[51]

  • 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[50]
    • 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[50]

For more information on STSGs, please see: Burn injury.[50]

Full-thickness skin grafts (FTSG):[51]

  • 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.

[52]

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:[50]

  • 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).[49][50]

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.

[53]

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.”[51]

Burn scars that develop after skin grafting and can lead to:[51]

  • 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.[54] Surgical scar revision can involve skin substitutes, laser therapy, flaps, biomaterials, etc.[51]

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 2.11 2.12 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. ↑ Holey EA, Cook E. Evidence Based Therapeutic Massage: A Practical Guide for Therapists. Churchill Livingstone, Edinburgh, London, New York.
  47. ↑ Shin TM, Bordeaux JS. The role of massage in scar management: a literature review. Dermatologic Surgery. 2012 Mar;38(3):414-23.
  48. ↑ 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]
  49. ↑ 49.0 49.1 49.2 49.3 49.4 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.
  50. ↑ 50.0 50.1 50.2 50.3 50.4 50.5 50.6 50.7 50.8 50.9 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.
  51. ↑ 51.0 51.1 51.2 51.3 51.4 51.5 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/
  52. ↑ MotionLit. Skin Graft Procedure - Flash Fire Injury. Available from: http://www.youtube.com/watch?v=er9YxF_C60A [last accessed 1/4/2024]
  53. ↑ 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]
  54. ↑ 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.
Retrieved from "https://www.physio-pedia.com/index.php?title=Burn_Injury_Management_Considerations_for_Rehabilitation_Professionals&oldid=353451"