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 Table of Contents  
REVIEW ARTICLE
Year : 2021  |  Volume : 16  |  Issue : 2  |  Page : 388-392

Role of physiotherapeutic interventions in dagdha (burn) injuries


1 Department of Community Health Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (Meghe), Wardha, Maharashtra, India
2 Department of Neuro Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (Meghe), Wardha, Maharashtra, India

Date of Submission02-Jul-2020
Date of Decision10-Nov-2020
Date of Acceptance15-Feb-2021
Date of Web Publication18-Oct-2021

Correspondence Address:
Dr. Ashish Bele
Department of Community Health Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Medical Sciences (DU), Sawangi (Meghe), Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_246_20

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  Abstract 


Background: In developing countries with low income, one of the most common causes of hospitalization is Dagdha (burn) and it also contributes to secondary problems, such as disfigurement, contractures, and scar tissue development. On the basis of degree/depth of tissues involved the burn may be classified as superficial, superficial partial, and deep partial, deep. Physiotherapists and occupational therapists, as part of the specialist burn multidisciplinary team, have many overlapping expertise and positions in the treatment of burn injury victims by delivering drills and splintering. Methodology: The data were collected from the electronic databases, including PubMed, Web of Science, Cochrane Library, EMBASE, Google Scholar, ResearchGate, Springer publications, Statewide Burn Injury Service, McGraw-Hill publications, etc., This review included burn patients of all age groups and both genders. Results: This systematic review indicated that physiotherapeutic intervention played a vital role in the management of Dagdha (burn) injury not only to reduce pain and scar but restoring the musculoskeletal and cardiopulmonary functions and making patient functionally independent so that they can enjoy their rest of life independently. Conclusion: This systematic review study concluded that physiotherapy played an important role in the management of all types of Dagdha (Burn) injuries of all age groups.

Keywords: Dagdha (burn), injuries, intervention, physiotherapy


How to cite this article:
Bele A, Irshad M Q, Singh NC, Jethwani D, Shalaka D, Madhuri W. Role of physiotherapeutic interventions in dagdha (burn) injuries. J Datta Meghe Inst Med Sci Univ 2021;16:388-92

How to cite this URL:
Bele A, Irshad M Q, Singh NC, Jethwani D, Shalaka D, Madhuri W. Role of physiotherapeutic interventions in dagdha (burn) injuries. J Datta Meghe Inst Med Sci Univ [serial online] 2021 [cited 2021 Dec 9];16:388-92. Available from: http://www.journaldmims.com/text.asp?2021/16/2/388/328457




  Introduction Top


In developing countries with low income, one of the most common causes of hospitalization is Dagdha (burn) and it also contributes to secondary problems, such as disfigurement, contractures, and scar tissue development.[1],[2],[3],[4] Burn injuries have a unique and significant effect on one's skin and body.[5]

Dagdha (Burns) are common outpatient presentations in hospitals around the world. The largest amount of cases will wind up with hospitalization. Most burns are minor so treated with primary care. In most cases, burns heal without any complications, but complete healing in terms of cosmetic outcome is often dependent on appropriate care, especially within the 1st day after the burn. Burn levels differ widely across societies and exist in all age groups. A major proportion of burns occur in major disasters such as petroleum fires.[2]

Burns are preventable although in some cases it leads to major injuries and is serious. Every year >30,0000 people die from injuries due to fires alone.[2]

Out of these incidences, many people get permanently scarred of electric, chemicals burn are likely to be preventable, burn injuries are very often seen. All over the world, fire-related burns are responsible for 238,000 deaths in the year 2000 and burns are the eighth-most common cause of mortality. It was found that 95% of fatal fire burn injuries occur in underdeveloped and developed countries. In India, with a population of around 1 billion, 700,000 to 800,000 burn admissions are handled annually. Four million women worldwide suffer severe fire burns every year.[4]

On the basis of the degree/depth of tissues involved the burn may be classified as superficial, superficial partial, deep partial, and deep.[6]

The superficial burn (First Degree), [Figure 1] caused due to exposure to the sun, hot liquid (with less viscosity and short exposure). Only epidermis is involved. Appearance is pink-red in color, moist with no blisters, pain is moderate to severe, no scar, and healing time is usually 3–7 days.[6]
Figure 1: First degree of burn: Source: From Wikipedia, the free encyclopedia

Click here to view


Superficial partial-thickness burn (Second Degree) [Figure 2] caused due to hot liquids, chemical burn (with weak acids/alkali), and flash. Superficial epidermis (papillary) is usually involved. Appearance is with blisters, red moist, intact epidermal appendages, and blanches to pressure. Pain is severe, and there is minimal scar and healing time is 1–3 weeks.[6]
Figure 2: (a) Second degree of burn: Source: From Wikipedia, the free encyclopedia. (b) Showing second degree of burn: source: from Wikipedia, the free encyclopedia

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Deep partial-thickness burn (seeticular) [Figure 2]a. It involves the dermis. Appearance is dry, skin, non-white, and lack of all epidermal appendices. Pain is minimal with high-risk scarring and contractures and healing time is 3–6 weeks with scar.[6]

Depth/Full-thickness burn (Third Degree) [Figure 3] caused due to fire, magnetic, gas, explosion, and self-immolation. It included the maximum width of the skin and subcutaneous fat or lower. Appearance is leathery, clear, white, or red of thrombotic vessels. There was no pain in the zone of coagulation but painful at surrounding tissues with severe risk scarring and contractures and no healing by primary intention requires grafting of skin.[6]
Figure 3: Third degree of burn: Source: From Wikipedia, the free encyclopedia

Click here to view


The four type of burn (Fourth Degree) [Figure 4] caused by prolonged exposure to flame, electrical, chemical, blast, and self-immolation. It extends through skin, subcutaneous fat, and into underlying muscle and bone. Appearance is gray, burnt with a burn, dry. There was no pain in the zone of coagulation but painful at surrounding tissues with definite scars and contractures and requires excision.[6]
Figure 4: Showing fourth degree of burn: Source: From Wikipedia, the free encyclopedia

Click here to view


Burn size is measured as a percentage of the total body surface area (TBSA) affected by partial thickness or full-thickness burns. First-degree burns, which are only red in color and are not blistering, are not included in this estimate.[7] The bulk of burns (70%) compensate for <10% of TBSA.[8]

There are a number of methods used to determine the TBSA, including the Wallace rule of nines [Figure 5], the Lund and Browder chart, and estimates based on the size of a person's palm. The rule of the nines is easy to remember, but only accurate in people over the age of 16. More precise predictions can be produced using the Lund and Browder tables, taking into consideration the various proportions of body sections in adults and babies.[9]
Figure 5: Distribution by rule of nine: Source: From Wikipedia, the free encyclopedia

Click here to view


Problems resulting from immobilization can exacerbate a primary illness or accident which may potentially become more troublesome than a primary condition.

Chronic, disabled, and geriatric people are, particularly at risk. These people already have little or no physiological reserve function, and any additional difficulties caused by immobilization result in functional losses.[10]

Musculoskeletal risks include reduced muscle power and atrophy, diminished mobility, contracture, and osteoporosis. Cardiovascular complications include increased heart rate, decreased cardiac reserve, orthostatic hypotension, and venous thromboembolic.[10],[11]

Hypertrophic scarring results from the build-up of excess collagen fibers during wound healing and the reorientation of these fibers in nonuniform patterns. Keloid scarring arises from hypertrophic scarring in that it occurs past the limit of the original fracture. It is more common in people with pigmented skin than in whites.[12]

Physiotherapists and occupational therapists, as part of the specialist burn multidisciplinary team, have many overlapping expertise and positions in the treatment of burn injury victims by delivering drills and splintering.[5]

The goal of the physiotherapist is to prevent cardio-respiratory complications, to control edema, to maintain joint range of motion (ROM), to maintain strength, to prevent excessive scarring, and to prevent contracture.[6]

Comprehensive rehabilitation therapy is vital for patients with severe burn injuries.

Rehabilitation starts immediately after the individual is admitted to the hospital which can require surgical pacing, splintering, application of medical measures (e.g. hydrotherapy, paraffin, and electrical stimulation), and clinical activity.[11]

Therapeutic therapy plays a vital role in avoiding lasting impairments induced by burning skin contractures, which is a known complication. Physical therapies can involve constructive activity, passive ROM and relaxation, and strengthening. Collectively, these techniques help improve the elasticity of the healing tissue, help preserve maximum joint ROM and work, and may facilitate flexibility, relaxation, and ambulation. Without such procedures, natural healing will possibly result in scarring, skin contractures, and minimal ROM. Participation in such rehabilitation activities is therefore crucial to the long-term minimization of disability.[11],[13]

The transcutaneous electrical nerve stimulation (TENS) can be used in patients who suffer burns with positive results, are an alternative that can complete with analgesic medicaments, with the advantage of which have lacks side effects. The TENS offers to a useful alternative to diminish the pain in patients with burns of second superficial degree.[14]

The aim of this systemic review is to formulate appropriate physiotherapeutic intervention for burn injuries.


  Methodology Top


Data source

The data were collected from the electronic databases including PubMed, Web of Science, Cochrane Library, EMBASE, Google Scholar, ResearchGate, Springer publications, Statewide Burn Injury Service, McGraw-Hill publications, etc. This review included burn patients of all age groups and both genders.

Burn management

Burn management and scar management can be done under the following subheadings ~

  1. Edema management
  2. Pain Management
  3. Exercise
  4. Splint and positioning
  5. Compression clothes
  6. Silicone and scar softer goods
  7. Skincare
  8. Massage
  9. In reconstructive surgery: Skin grafting.


edema management

  1. Positioning: Height and splinting
  2. Compression: Bandaging and pressure garments
  3. Exercise: Active and passive
  4. Activities of daily livings participation
  5. Massage.


Exercises

  1. Includes ambulation, physical retraining, can ROM, motivation and aerobic exercise. Every type of physical activity may be a form of exercise[5]
  2. To improve ROM and strength of muscles, physical agents include hydrotherapy, electrical stimulation, etc.[11]
  3. Therapeutic exercises can be described as physical movements recommended to correct disability, enhance musculoskeletal function, or sustain a condition of well-being.[6] They have been identified as a series of physical activities that concentrate on preserving and sustaining energy, stamina, resilience, stability, and equilibrium[16],[17]
  4. Exercises help enhance physical wellbeing, preserve healthier weight increase bone weight, boost self-confidence, and develop social skills.[16],[17] Exercise counseling can be helpful to burn victims because they are at an elevated risk of bedridden due to extreme pain control sedation, continuous wound treatment, and bandaging. Such influences result in enhanced demand for exercise 'due to altered biomechanics, body position, and gait.[13]


Splinting and positioning

Aims

  1. Immobilize the graft of the skin after surgery
  2. To secure fragile objects, for example, exposed tendons
  3. Avoid the contracting of the skin and tendon
  4. To retain the joint function while the patient is unable to do so, for example, postoperative, intubated in the intensive care unit with ventilation and sedation, resting, and small children
  5. Avoid long-term deformity.


Pain management

Physical agents

Hydrotherapy, Paraffin Wax Bath, Ultrasound Therapy (low Pulsed Dose), Electrical stimulation, TENS).[11],[14]

Music therapy

This is supposed to target pain through the theory of gate control. This suggests that music is a distraction from noxious stimuli. Furthermore, anxiety associated with the rehabilitation of burns may increase the activation of the sympathetic nervous system. Music incorporates the three cognitive techniques employed in pain and anxiety recovery (imagery-imagining things that are associated with pain, self-statement, and focus diversion devices) to guide focus away from pain and shift it to another case.[17]

Virtual reality

Immersion of the patient in a virtual world has shown some beneficial effects on the control of procedural pain and is better than handheld gaming devices. However, the equipment is costly and bulky and is not always suitable for pediatric intervention. Pediatric intervention, using handheld gaming devices that provide increased reality, has been tested among 3–14-year-old. This has demonstrated slightly lower pain ratings than normal diversion and relief while experiencing dressing changes.[6] Interactive virtual reality (VR) is a modern type of visual diversion and has been described as an important adjunctive, nonpharmacological analgesic for post-burn physical therapy.[11]

Compression

The purpose of compression therapy is to keep scars developing flat and prevent increased scarring. It is believed that compression reduces the excess blood flow of scarring mediators. Compression may be done in a number of forms, for example, clear adjustable bandage, tubular elasticized garment, bandaging, and pressure dressing (customized or off shelf). Some form of relaxation system can also be used to assist the retention of skin-softening items. The level is advised to stay between 24 and 40 mmHg and to be replaced or changed periodically to sustain this level.[5],[12]

Silicone products

Medical grade silicone solutions are typically used to smooth raw, swollen, or thickened (hypertrophic) wounds. Silicone is available in the form of sheet, liquid, and putty. Ideally, silicone can be used in conjunction with friction garments and splints.[5],[12]

Skin care

Burning may impair the thermoregulation of the skin temporarily or permanently, as the skin loses its ability to sweat or heat up. It is, therefore, important to control the temperature of the environment. Sebaceous glands that produce oils that naturally moisturize the skin may be damaged and therefore the hydration of the skin needs to be replaced by a regular moisturizer. There is also a higher risk of developing skin cancer, as ultraviolet barrier function can also be damaged during burns. There is a chance of sunburn with access to sunlight. Regular sunscreen protection: Shoes, large brim caps, and minimum SPF 30+ sunscreen before the wounds are mature.[5]

Massage

Massage is used to split away from the coils of collagen that make up the wound. The goal is to soften and desensitize the skin, prevent adhesions and reduce pruritus, and to stretch the skin and scar tissue.[5],[12]

In reconstructive surgery

Preventing the need for reconstructive surgery is also the first target. This is achieved by cautious primary surgery and regeneration, including early debridement and grafting, preventing widespread skin grafts whenever practicable, early recovery, early mobilization, massage, relaxation, moisturizing creams, and ultrasound treatment (low pulse).[5],[12]


  Results Top


This systematic review indicated that physiotherapeutic intervention played an vital role in the management of Dagdha (burn) injury not only to reduce pain and scar but also restoring the musculoskeletal and cardiopulmonary functions and making patient functionally independent so that they can enjoy their rest of life independently.


  Discussion Top


This systemic review provided knowledge about the benefits and various modes of Physiotherapeutic interventions for burn injuries.

Dittmer DK et al. (1993) stated in their study that rehabilitation included therapeutic positioning, splinting, and use of physical agents (e.g., hydrotherapy, paraffin, ultrasound and electrical stimulation, and TENS), and therapeutic exercise.[10]

Therapeutic exercise plays an important role in preventing permanent impairments caused by burning scar contractures, which is a recognized complication.

Physical therapies can involve constructive activity, passive ROM and relaxation, and strengthening. Collectively, these manipulations help improve the elasticity of the healing muscle, help preserve maximum joint ROM and work and can facilitate stamina, relaxation, and ambulation. Without such procedures, the natural healing process can theoretically result in scarring, skin contractures, and minimal ROM Carrougher et al., 2009.[11],[13]

There are some advanced therapies including music therapy and VR which showed beneficial effect reduction in pain in burn patients.[6],[11]

Physiotherapy has been proved very effective in the management of burn injuries including edema, scar, weakened structures, contractures, and reconstructive surgeries.


  Conclusion Top


This systematic review study concluded that physiotherapy played an important role in the management of all types of Dagdha (Burn) injuries of all age groups.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Agbenorku P, Edusei A, Ankomah J. Epidemiological study of burns in Komfo Anokye Teaching Hospital, 2006-2009. Burns 2011;37:1259-64.  Back to cited text no. 1
    
2.
Parbhoo A, Louw QA, Grimmer-Somers K. A profile of hospital-admitted paediatric burns patients in South Africa. BMC Res Notes 2010;3:165.  Back to cited text no. 2
    
3.
Forjuoh SN. Burns in low- and middle-income countries: A review of available literature on descriptive epidemiology, risk factors, treatment, and prevention. Burns 2006;32:529-37.  Back to cited text no. 3
    
4.
Oladele AO, Olabanji JK. Burns in Nigeria: A review. Ann Burns Fire Disasters 2010;23:120-7.  Back to cited text no. 4
    
5.
Burn Physiotherapy and Occupational Therapy Guidelines. Statewide Burn Injury Service. 1st ed. Burn Physiotherapy and Occupational Therapy Guidelines; October, 2017.  Back to cited text no. 5
    
6.
Hale A, O'Donovan R, Diskin S, McEvoy S, Keohane C, Gormley G. Physiotherapy in burns, plastics and reconstructive surgery. Impairm Disab Short Course 2013;19:2-6.  Back to cited text no. 6
    
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Tintinalli JE. Emergency Medicine: A Comprehensive Study Guide (emergency Medicine (Tintinalli)). New York: McGraw-Hill Companies; 2010. p. 1374-86.  Back to cited text no. 7
    
8.
Herndon D, editor. Epidemiological, Demographic, and Outcome Characteristics of Burn Injury. Total Burn Care. Ch. 3. 4th ed. Edinburgh: Saunders; 2012. p. 23.  Back to cited text no. 8
    
9.
Granger J. An evidence-based approach to pediatric burns. Pediatr Emerg Med Pract 2009;6:251-6.  Back to cited text no. 9
    
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Dittmer DK, Teasell R. Complications of immobilization and bed rest. Part 1: Musculoskeletal and cardiovascular complications. Can Fam Physician 1993;39:1428-32, 1435-7.  Back to cited text no. 10
    
11.
Carrougher GJ, Hoffman HG, Nakamura D, Lezotte D, Soltani M, Leahy L, et al. The effect of virtual reality on pain and range of motion in adults with burn injuries. J Burn Care Res 2009;30:785-91.  Back to cited text no. 11
    
12.
Edgar D, Brereton M. ABC of burns. Rehabilitation after burn injury. BMJ 2004;329:7.  Back to cited text no. 12
    
13.
Mudawarima T, Chiwaridzo M, Jelsma J, Grimmer K, Muchemwa FC. A systematic review protocol on the effectiveness of therapeutic exercises utilised by physiotherapists to improve function in patients with burns. Syst Rev 2017;6:207.  Back to cited text no. 13
    
14.
Vasquez-Ortega EK, Garcia-Ramirez MC, Cruz-Ramirez MC, Vazquez-Morales LE. Electrotherapy as alternative management of pain in burns. Rev Sanid Milit Mex 2008;62:141-4.  Back to cited text no. 14
    
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Kottke FJ, Stillwell GK, Lehman JK. Handbook of Physical Medicine and Rehabilitation. W B Saunders; 1982.  Back to cited text no. 15
    
16.
Disseldorp LM, Nieuwenhuis MK, Van Baar ME, Mouton LJ. Physical fitness in people after burn injury: A systematic review. Arch Phys Med Rehabil 2011;92:1501-10.  Back to cited text no. 16
    
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Brink Y, Brooker H, Carstens E, Gissing CA, Langtree C. Effectiveness of resistance strength training in children and adolescents with ≥30% total body surface area: A systematic review. S Afr J Physiother 2016;72:1-8.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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