Serious Burns: Rehabilitation and Management using Remedial Massage.
Burns are classified from I to IV according to severity. First degree burns involve the epidermis; second degree burns involve the superficial or partial dermis; third degree burns involve the complete dermis; and fourth degree burns involve bones and joints (see Figure 1). (1)
Rehabilitation begins as early as possible in hospital settings, with physiotherapists and occupational therapists. Appropriate analgesia is required. Early respiration training, oedema prophylaxis and scar therapy (e.g. compression garments) form the foundation of rehabilitation. More than half of all severe burn patients require psychological support (2)
Goals of physical treatment include: (3)
* early mobilisation
* prevention of joint contractures by early range of motion exercises, splinting/positioning, postural management
* promoting functional independence gait training, activities of daily living
* patient and family education about the importance of mobilisation and of splinting and positioning
Guidelines were developed by the Allied Health Interest Group of the Australian and New Zealand Burns Association to establish an effective standard for occupational therapy and physiotherapy in the care of burns patients. (4) More recent versions include the NSW Agency for Clinical Innovation's Physiotherapy and Occupational Therapy Clinical Practice Guidelines'. (5)
The role of remedial massage therapy in burns rehabilitation
Remedial massage therapists can be called on to assist with rehabilitation after the patient has returned home. They can continue working to prevent joint contractures, assist in the breakdown of scar tissue, and promote health and wellbeing.
In this article I would like to share my experience of treating a female patient who sustained third degree burns to over 80% of her body in a terrible accident with methylated spirits approximately 7 years ago. She had already been a client of mine for one year before the accident and was well known to the staff at the clinic. The news of her accident came as a shock to us all.
After the patient had been in hospital for several months I was asked if I could help with massage. Before the first appointment I searched for every shred of information on the subject that might be helpful, but there was very little that was any use to me with this case. I was advised that I was not limited in the number of treatments I could give and that I should submit regular reports for insurance purposes.
When the patient presented for the first time it was approximately 7-8 months after the accident and almost 50% of the burns were still too tender to touch. There was also an area with dressing over a deep wound. Fortunately her face was completely uninjured. In his referral letter to me the specialist highlighted the need to work in the creases of joints at the elbows and behind the knees as the first priority. Having suffered third degree burns to my own right arm as a child I recognised the importance of knowing the restrictions scars can cause. It is important to point out that room temperature was critical in the early stages, as the patient's sensitivity to hot and cold was extreme, so a neutral 23[degrees]C seemed ideal. Emotional factors, extreme tiredness and the tendency to pick up infections easily hampered treatment. I set about each treatment with a focus only on what I could achieve in that session, and often bringing about an improved level of comfort was all that was possible. In a case like this improvement is very slow and incremental. I rotated areas of focus and employed various techniques on the different types of scarring. There were large areas where only mesh compression bandaging was used, subsequently leaving an imprint over shiny contracture scars. One such area was a large square covering approximately 30% of the back. I use stretch moves over these wide areas with forearm, or opposing stretch moves transversely with the palms of my hands to work against the contracture that was present. These scars seemed to be the most sensitive to irritation from heat, clothing and contact with chemicals, including residue from laundry detergent, because of the large area they covered. They were also the cause of most of the itching and discomfort in the first three years. There were many times when I couldn't touch this area after the patient had been scratching vigorously.
The patient had extensive areas of keloid and hypertrophic scars, the largest being around her shoulders. The thickest of the keloid scars were surgically removed after three years and even now are still pink in places. These have caused her the greatest degree of itching over time. The pulling sensation from these scars trouble her so I work to stretch these areas with thumb strokes. On a few of the smaller scars I have been able to break down some of the scar tissue with cross friction. Over time I have noticed that any amount of friction around these scars is beneficial in reducing the pinkness. I tend to do this mainly towards the end of treatments.
In the last couple of years I have been gradually able to increase pressure, frequently asking the patient for feedback. I have to balance this with the fact that she gets fatigued very quickly. Improvement is very slow and incremental: certainly many areas tighten up if she is unable to make her appointment for a few weeks. I believe that there are further gains to be made and that it is eminently possible to maintain all those that has been achieved so far. My original instructions were to keep the treatments aimed at the scars but as the patient has expressed an increasing interest in exercise I have been able to take a more holistic approach by working on the muscle groups that will stretch the areas of greatest contracture. This encourages her to want to get out and move more, which is very positive.
Other areas I pay attention to include her extremities. The patient's feet were largely untouched, presumably because of protection by her shoes, but the back of her heels have thick scarring on the inferior part of the Achilies tendons. Ankle flexion is evident both by observation and palpation of the range of motion. For a long time she found it rather difficult to wear shoes or sandals; in fact she often presented with bleeding scars. She overcame this problem simply with very well padded walking shoes. I work these scars with deep longitudinal thumb strokes, both locally on the scars and continuing up the tendons, and flexing the foot several times as I go. I use a little transverse friction as well and generally achieve a small degree of improvement.
On her hands the scarring was different to that on her forearms, as this skin was exposed. The serious burns were only on the backs of each hand, where she had skin grafts extending along the top of each finger. This left them with a dark colour compared to the forearms, where pressure bandaging was applied. Her sense of touch remained intact but over the last three years early arthritic signs have occurred, which hampers treatment. I massage her hands thoroughly, taking particular care when they are painful.
I would like to talk a little about the emotional side of treating somebody with this level of injury and distress. When I worked with this patient previously she had very healthy, glowing skin, free from any sun damage. (I had been treating her regularly for some time for various aches and pains mostly relating to her work.) One thing she always had was a terrific British sense of humour and she had struck me as being a strong independent person. Needless to say, these would be much needed attributes to face the unexpected challenge ahead. I was very surprised to be asked to treat her. It was very daunting, but above all, an incredible honour. When she presented for the first time she was in amazing spirits and the humour kicked in. We had what was perhaps the longest pre-treatment discussion I had ever had with a patient. I had time available and she wanting to discuss her immediate priorities.
I sensed that she was feeling me out to see if I was ready to treat her. When I re-entered the room after she changed, it was a heartbreaking moment to see such damage, and she came straight out with, 'I made a fine old job of it, didn't I?' This began an exchange of banter during which I chimed in, 'Well you missed this bit here, didn't you?' This was the point where I began to 'climb the mountain' break down my task into small parts and only concern myself with what I could do. I called on what my first massage teacher, Bill Van Riksort, told me in 1992, 'trust your training', and thereafter I never doubted myself, or that I could really help and play an integral role in her recovery.
It is important for any massage therapist to be confident in their ability to be an effective practitioner, to show this confidence and willingness to help, while at the same time being totally honest when conveying what it is you think is achievable. I like to bear in mind that if a patient is in a really bad way then they are more than happy if any improvement occurs. If a significant improvement occurs that is a terrific outcome. I hope this article provides an interesting insight into this rare and unique case should anything similar ever come its readers' way.
Vincent has twenty five years' remedial massage experience in clinical practice, mobile service and sports events. Vincent T Nash. Dip RM. He can be contacted via Email: email@example.com
(1.) Spanholtz TA, Theodorou P, Amini P, Spilker G. Severe burn injuries: acute and long-term treatment. Deutshes Arzteblatt International. 2009; 106(38): 607-613
(2.) Dyster-Aas J, Willebrand M, Wikehult B, Gerdin B, Ekselius L. Major depression and posttraumatic stress disorder symptoms following severe burn injury in relation to lifetime psychiatric morbidity. J Trauma. 2008;64:1349-1356
(3.) Kuzma D, Malie P. Rehabilitation of the Burn Patient. Presentation at the Clinical Connections Conference, April 14,2014. UPMC Rehabilitation Institute.
(4.) Simons M, King S, Edgar D. Occupational therapy and physiotherapy for the patient, with burns: Management and guidelines. Journal of Burn Care and Rehabilitation, 2003,24(5): 323-335
(5.) A,CI Statewide Burn Injury Service. Physiotherapy and Occupational Therapy Clinical Practice Guidelines. Chatswood: Agency for Clinical Innovation; 2014.
Vincent T Nash | Dip RM
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|Author:||Nash, Vincent T.|
|Publication:||Journal of the Australian Traditional-Medicine Society|
|Date:||Sep 22, 2018|
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