|Year : 2013 | Volume
| Issue : 1 | Page : 35-39
Burn rehabilitation: A challenge, our effort
Shobha Chamania1, Ranjana Chouhan2, Alpana Awasthi2, Anant Sharma3, Pranita Sharma4, Shwetha Agarwal5
1 Department of General Surgery, Choithram Hospital and Research Center, Indore, Madhya Pradesh, India
2 Department of Clinical Psychology, Choithram Hospital and Research Center, Indore, Madhya Pradesh, India
3 Department of Occupational Therapist, Choithram Hospital and Research Center, Indore, Madhya Pradesh, India
4 Department of Physiotherapist, Choithram Hospital and Research Center, Indore, Madhya Pradesh, India
5 Registrar in Burns and Plastic Surgery, Choithram Hospital and Research Center, Indore, Madhya Pradesh, India
|Date of Web Publication||22-Nov-2013|
202, Saikripa Apartments, 60, Jaora Compound, Indore - 452 001, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: The rehabilitation of the burn patient is difficult, time consuming and yet an undeniably integral part of their management. The long-term effects of burns are wide ranging; from permanent scarring and debilitating contractures and deformities, to deep psychological trauma, which often results in fear of social exclusion, depression and suicidal ideation. Methods: The successful rehabilitation of the burn survivor requires the involvement of a multi-disciplinary team from the 1 st day in order to meet the patient's complex needs. Following this, the burns team ensures the continuation of rehabilitation of the patient before and after discharge of the patient from the hospital. Finally, the patient is encouraged to join social networking activities to help regain confidence. Objectives: A burns unit must utilize all the skills and resources it has available to it, in order to provide the burn survivor with the best possible outcome. However, in hospitals located in resource-limited areas across India, the professions and resources required for this task may not be readily available to support the burns patient. The team must be able to reflect on itself and consider how best to continue to improve the provision of burns rehabilitation in the future so as to further reduce morbidity and improve quality-of-life. Conclusion: Nothing short of a multidisciplinary burn team that is dedicated to securing the patient's physical, psychological, social and spiritual wellbeing is required to ensure that a burn victim can return to their families, their work and their society and lead a long and fulfilled life.
Keywords: Burn, physical psycho social independence, rehabilitation, survivor group
|How to cite this article:|
Chamania S, Chouhan R, Awasthi A, Sharma A, Sharma P, Agarwal S. Burn rehabilitation: A challenge, our effort. Indian J Burns 2013;21:35-9
|How to cite this URL:|
Chamania S, Chouhan R, Awasthi A, Sharma A, Sharma P, Agarwal S. Burn rehabilitation: A challenge, our effort. Indian J Burns [serial online] 2013 [cited 2019 Nov 20];21:35-9. Available from: http://www.ijburns.com/text.asp?2013/21/1/35/121879
| Introduction|| |
Burns are a major, global public health problem, resulting in an estimated 195,000 deaths annually. The majority of burns occur in low-and middle-income countries, with almost half occurring in the World Health Organization (WHO) South-East Asia Region. Women in the WHO South-East Asia Region have the highest rate of burns and account for 27% of global burn deaths and nearly 70% of burn deaths in the region. 
Burn victims face many difficult and complex challenges from the 1 st day of their ordeal and many of these challenges continue throughout their path to recovery. The impact of their injury continues in their struggle to reintegrate and return to be a productive member of the society. There are many physical, emotional, social and economic challenges facing the burn survivor. They need support, encouragement and perseverance throughout their rehabilitation in order that they can return to live independently, productively and happily within their community. Successfully rehabilitating a burns survivor requires commitment and a herculean effort from the burns team as well as the burns survivor.
Advances in the treatment and care of burn patients have contributed to a reduction in burn mortality rates in many high-income countries. Developments in burn care have also improved functional outcomes for a large number of burn victims. This progress, coupled with an increased emotional and practical support from burn survivor groups, has resulted in many burn survivors returning to lead full, meaningful lives despite their injuries. 
In the majority of low- and middle-income countries in South East Asia, the training of a burns team does not include education about the multi-disciplinary perspective of rehabilitation needed for a burns survivor. There is a lack of knowledge and awareness of the immediate action required and the need for long-term burn rehabilitation and care, in order to prevent permanent and crippling deformities among the survivors. This lack of training results in increased morbidity and development of preventable deformities in burn survivors. It is detriment to the health of many that rehabilitation capabilities, whether for burns or other disabling injuries, are among the least developed capabilities in the spectrum of trauma care.  Inequities are also evident in the availability of support networks. Whereas burn victims support groups play an active role in providing peer support and assisting in the recovery of burn victims in high-income countries, such groups are almost entirely absent in low-and middle-income countries.
In 2012, Interburns developed the first operational standards for burn services in Low and Middle Income Countries through an international consensus meeting in Kathmandu, Nepal. This meeting brought together global experts in burn care and prevention in order to develop these important guidelines on the staffing, knowledge, skills, equipment and facilities that burn units need to deliver good quality care to patients. The WHO has recognized the standards as "an important stepping stone toward improving the health systems to which the vast majority of the world's burn patients present for care, as well as an important contribution to the overall public health challenge of preventing burns world-wide." 
The standards highlight the importance of comprehensive rehabilitation as a vital component of effective burn care. To ensure the optimal results in a limited resource environment, attention must be paid not just to the physical, but also to the psychosocial aspects of rehabilitation; both aspects of rehabilitation must commence at the time of admission and need to continue after discharge from the acute hospital setting. In this article, we describe the efforts made in support of this critical standard at the Choithram Hospital and Research Centre Burns Unit, which is also a designated Interburns Training Center.
| Optimal Burn Rehabilitation|| |
In burn victims, wounds should be closed as early as possible. Nutritional requirements are high in these patients and must be provided adequately throughout their care. Physical therapy (chest physiotherapy, range of motion of major joints, ambulation and strengthening exercises) and occupational therapy (execution of activities of daily living, splinting and hand therapy) should be started on the day of admission and continued for 18-36 months.  A psychologist and a social worker are crucial members of the team in addressing the physical, emotional, social and vocational rehabilitation challenges of the burns survivor and their re-integration into society. ,,
The rehabilitation of burns patients is a continuum of active therapy starting from the day of admission. There should be no delineation between an "acute phase" and a "rehabilitation phase"  because that approach can promote the inequality of a secondary disjointed scar management and/or functional rehabilitation team. 
| Our Effort|| |
With this background, our center (which has about 250 admissions a year and approximately 700-800 follow-up visits of survivors) utilizes a rehabilitation protocol, which has been developed over a number of years. Rehabilitation starts from the day of the patients' admission. Together with the surgeon, therapists observe and periodically assess the wounds of the patients and form a baseline rehabilitation plan.
By observing the grafts and flaps in surgery, therapists provide splints for immobilization, support and to secure the functional independence of that particular joint. Chest physiotherapy is given at the bedside to reduce the incidence of chest complications. During dressings, the therapist performs a range of motion exercises and modification of splints. The therapist also guides the nursing staff and paramedics on the anti-deformity positioning and application of splints during rest/night so that the patient is under therapy constantly for the whole 24 h period.
A psychologist prepares the patient for surgery, dressing sessions and for rehabilitation; addressing issues such as depression, anxiety, mood disorders and other mental health issues. Many of the patients present with pre-morbid psychiatric conditions, such as depression and suicidal ideation. Therefore, the role of a psychologist and a psychiatrist is considered a crucial component of the patient's overall care.
As the wound heals, therapists encourage the patient to do regular massages and exercises and to wear splints and pressure garments. Throughout their rehabilitation, patients are encouraged to return to their activities of daily living. Reassessment of the patient is performed periodically to monitor the wound healing and scar management therapies. The assessment also includes behavioral and social integration, work/job assessment and play assessment. The assessment is designed so that it meets the patient's goals and also ensures the patient's independence. Modification of tools and daily utility devices within the workplace, home and other environments may be required at this stage.
Burns patients are given multi-disciplinary care in their acute stage and the importance of continued management post discharge is discussed and emphasized. However many patients fail to fully appreciate the importance of daily activity and become non-compliant. Occasionally due to reasons of low income, patients have to be discharged prematurely. In these circumstances, they are then asked to stay in the low cost rest houses within the hospital campus where they can still be available for daily therapy and change of dressing (when required), until they are fit to go home.
Patients are reviewed regularly; weekly for 4 weeks, monthly for 12-18 months and then quarterly for 3 years. In each follow-up visit, burn victims are made to list their problems and the team considers how to provide the required support. The evaluation is for problems such as:
- Functional: Contractures, deformity, scars, limited range of motion, lack of strength, poor endurance, loss of sensation/hypersensitivity (in case of nerve injury), amputations etc.
- Esthetic: Shape, size, color and pigmentation of scars.
- Psychosocial issues: Depression, anxiety, mood disorders, interpersonal/social acceptance and other mental health issues.
- Return to work/school.
These are examples of cases where optimal rehabilitation was successful.
| Case Story 1|| |
Mrs. DB, 35-year-old married female having two children allegedly sustained accidental burns while cooking on a stove. She sustained 45%TBSA burns. During her convalescence, it came to light that her injury was homicidal and she did not go back to her husband's home, but returned to live with her parents instead. She completely recovered from the injury and was encouraged to return to school. Upon completion of her schooling, she was unwilling to continue with further studies because of her facial disfigurement. However as she needed some means of income to support her children and herself her school teacher encouraged her to undertake an online computer learning course. Mrs. DB later set up tuition classes for computer skills for children and was a great success. She now travels and meets people and is confident and happy enough not to cover her face.
| Case Story 2|| |
Mrs. AC, 30-year-old female, mother of two very young children sustained burns at home due to a kerosene lamp. She was treated at our hospital, but was discharged untimely against medical advice and was subsequently lost to the hospital's follow-up service. Subsequently, her husband deserted her and she was left to fend for herself, in a crippled state with many contractures. One and a half years later, she arrived in the hospital and was offered surgeries for her contractures. A psychosocial worker was delegated to accompany her to her home to assess the feasibility of some work in order that she could sustain her family. The burn team members raised the funds needed to help her initiate this process.
| Planning A Rehabilitation Centre|| |
When a survivor ultimately settles down in his/her own social environment, it is a mutually gratifying experience for both the care givers as well as the burns survivor. Therefore, the yardstick of evaluating the patient survival rate of a burn center should also include successful rehabilitation. "A survey on the current status of burn Rehabilitation services in China" shares the same needs and concerns.  To improve our rehabilitation program, we have plans to commence afternoon sessions of creative leisure activities in the form of dance, music, arts and crafts, yoga, games, walks in the garden etc. which will help to provide some distraction to burn victims. All these activities are structured to provide monitored support by a multi-disciplinary team for improving outcomes in burn victims. We also plan to provide for all the rehabilitation needs of the patients in one building so that when they leave the hospital, they are well equipped with their training, information and other equipment for their holistic well-being.
There has been an initiative to organize a survivor's group meeting annually since 2009. Survivors are personally invited by telephone calls. Burn survivors come from as far as 400 km to the center. They are encouraged to engage in various creative and pleasant activities such as dance, musical chairs, etc. These activities focus on social integration, so that they can form new friends and later take the initiative in organizing similar meetings in their community. These meetings help in bridging the gap between survivors so that those who want to know how they may look/function/live in the future will gain further insight and answers to their concerns. Meeting the long-term burn survivors, especially the successful ones, helps these victims gain confidence in their future and they consider the older survivors as role models. The anxiety of parents of burnt children can also be eased by such networking. The survivors meeting aims to create a social gathering of similar people and help them compare the prognosis and functioning of those who followed the instructions given by the team (exercises, splints, massage, pressure garments) and those who did not. This motivates newer patients to follow the instructions. It also provides a platform to share experiences and give each other comfort in the course of their rehabilitation, which leads to improved patient understanding and co-operation.
The main challenge to this initiative of providing a socializing and networking opportunity to the patients is that their injuries have made most burns survivors introverted. They attend the functions with their face and body covered due to their lack of self-confidence and also because of their psycho-social environment [Figure 1]. It is reported that 65% of adults and 45% of ? children do not find the help that they need to cope with the everyday impact of their disfigurement.  They are however comfortable in interacting with the team that supported them through their ordeal. Some of the successful survivors who are excellent role models are encouraged to be a part of this group [Figure 2]. The burns survivors are happy and relaxed by the end of the day and that provides a positive boost to them and the team [Figure 1]. Burn camp experiences of other rehabilitation services at USA have also been quite similar. 
|Figure 1: Note the scarf around her neck scar. She is very happy at the end of the survivor's meeting|
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|Figure 2: A doctor from UK, a burn survivor, shared his story with the survivors group and told them that he wants to become a burn surgeon|
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Lack of funding is also main issues why burn rehabilitation is lagging behind in India. Other countries, which are working successfully in this sphere, have done so through funds specifically provided for this cause. 
Reviewing our progress, we consider that we could make improvements in many areas such as:
- When the patient is discharged, a mini survivor group can be established of at least 5 recently discharged patients. They could later join the survivor groups.
- Role models, who are independent from the burn care team, could be identified from the survivors in order to become leaders to develop the group further.
- Provision of vocation within hospital, such as supervisor, helper etc. commensurate with their skills, during long-term rehabilitation, for economic independence and to offset the expense of rehabilitation.
- Establishing a directory of survivors so that they can identify a survivor in their neighborhood for networking and sharing of experience.
- Raising funds specifically for rehabilitational care and activities for survivors.
| Conclusion|| |
Working with burn patients is not popular and is generally seen as unglamorous and dirty. However, there are a few organizations like the Acid Survivor Foundation, Bangladesh, which have displayed a real pride in what they are doing and realize the significance of their work. 
The fatalities within a burn unit can be disheartening to the burn care team. It is therefore important that the team be encouraged by their successes to continue to work effectively. When severely burnt victims are rehabilitated successfully, the team can be proud of their success and share a bond of satisfaction. Being a part of a team that achieves good outcomes in burn patients can also be very attractive for young individuals who wish to pursue a career in burns care. Burn patients require continuing care with sincere efforts for long periods of time and often requiring novel solutions utilizing a wide variety of resources. Vocational understanding is also an important factor that should be kept in mind while dealing with patients so that they can survive independently within society. Empowering the semiliterate females is one of the major challenges among the survivors.
In short the take home message is that a burn victim who survives the injury but ends up in many deformities because of lack of attention during the acute stage or due to his/her non compliance cannot be a successful burn survivor. His life ahead will be full of many challenges. We as the burn care givers must ensure that the rehabilitation must begin from the day one of injury and the joint efforts of the team must be focused to achieve what Spires and his team state :
"The ultimate rehabilitation goal is re-building self-esteem and independence in all spheres of an individual's life. Achievement of these will depend on the commitment of the injured individual and the entire health-care team."  We must shift our focus to early prevention of deformities rather than allowing the deformities to develop and later go ahead and reconstruct them.
| Acknowledgment|| |
We wish to express our special thanks to all the visitors from Interburns who have helped our team to develop the sensitivity and attitude toward their rehabilitation needs. We also wish to acknowledge the contribution of editing the manuscript by the visiting students from UK for their electives Gareth John Williams and Louise Tayler-Grint.
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[Figure 1], [Figure 2]