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CHAPTER26 Occupational and physiotherapy
Scarring
Alongside the occupational therapists, physiotherapists will assist in the
management of scarring. See the Occupational therapy section.
Aid functional independence
The ultimate aim of physiotherapy intervention is to return the patient to as
near normal function as possible. This will involve rehabilitation of mobility,
range of motion, strength/ endurance, social re- integration, and functional
independence as soon as possible to enable patients to regain their former
life. Amultidisciplinary approach (including family and friends) to this is essential throughout their recovery to ensure consistency.
Psychological support
Alongside the rest of the team the burns physiotherapist is in an ideal position to develop a rapport with the patient and to identify/ address their
psychosocial needs. The use of agreed/ achievable goal setting as a motivational tool during their rehabilitation can support their psychological recovery. Amultidisciplinary approach (including family and friends) to this is
essential throughout their recovery to ensure consistency.
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Reference
1. British Burns Association. Standards of physiotherapy and occupational therapy practice in the
management of burn injured adults and children. London:British Burns Association 2017.
REFERENCE
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Chapter27
225
Outcome measures
forburns
Introduction to outcome measures for burns 226
Further reading 230
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CHAPTER27 Outcome measures forburns
Introduction tooutcome measures
forburns
Advances in burn care have markedly reduced mortality rates in the acute
phase. As patients survive longer, a variety of measures of outcomes beyond mortality, such as function and quality of life, have been developed.
Such standardized outcome measures allow treatments to be compared
and are useful in monitoring response to therapy. They also allow comparison of outcomes between centres. Certain outcome measures are aggregated into scales while others are considered separately. This chapter
does not include all published measures but lists only those validated or
most commonly used for burns patients.
Classication
There are various ways of classifying burns outcome measures (BOMs).
BOMs are used to evaluate short- and long- term (see Table 27.1) outcomes. Some measures may apply to more than one time- point.
Apart from the obvious physical eects (Table 27.2), the incidence of
psychosocial morbidity such as post- traumatic stress disorder (PTSD), depression, social isolation, and perceived low- quality of life in burn survivors
is high. Several measures exist to ascertain the degree of such morbidity
in burns patients (Table 27.3). Some scales measure more than one domain, eg. the SF- 36 assesses biological, psychological, and social functioning.
There are also measures developed specically for children as their experience is unique and distinct from adult survivors (Table 27.4). Some scales
measure outcomes in limbs (Table 27.5) and others outcomes are usually
regarded on their own (Table 27.6).
Table27.1 Examples ofoutcome measures relevant todierent
time- points
Short- term Mortality, length of stay (LOS), determinants of the
Long- term Functional scores:eg. exercise tolerance and grip strength,
hypermetabolic state, biochemical, and physiological markers for
morbidity assessment
functional independence measure, functional assessment
for burns
Quality of life scales:eg. short form 36 (SF- 36), Vineland
Adaptive Behaviour Scales Survey Form (VABS-SF)
Scar Assessment scales:Vancouver, Seattle and Hamilton Scar
Scales, Patient and Observer Scar Assessment Scale
Psychosocial outcome scales:eg. Coping with Burns
Questionnaire, Satisfaction With Appearance Scale, Burn Specic
Health Scale, Burn Specic Pain Anxiety Scale, Health Outcomes
Burn Questionnaire
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INTRODUCTION TOOUTCOME MEASURES FORBURNS
Table27.2 Biological/ physical outcome measures
Outcome measure(s) Explanation and features
Determinants of burn
injury hypermetabolic
response:(heart rate,
core temperature;
organ function; body
composition (lean muscle
mass, bone mineral
content by dual image
X- ray absorptiometry),
resting energy
expenditure (Harris
Bennedict formula),
stable isotope tracers )
Vancouver Scar Scale
(VSS)
Seattle Scar Scale (SSS) Uses the scar surface, thickness, border height, and
Hamilton Scar Scale
(HSS)
Patient and Observer
Scar Assessment Scale
(POSAS)
Functional Independence
Measure (FIM)
Functional Assessment
for Burns (FAB)
Burn patients are hypermetabolic up to 2years
post- injury. This state diminishes lean body mass,
weakens muscles, and is associated with poor immune
function and wound healing. It is characterized by
increased energy expenditure, raised temperature,
and increased protein, fat and glycogen breakdown.
β- blockers, oxandrolone, growth hormone and insulin
are all modulators of the hypermetabolic response.
These outcome measures can be used to monitor
return to normal metabolic state and also as research
tools
Aims to standardize assessments of scar height,
pigmentation, vascularity, and pliability between
assessors. This scale is widely used but is not
considered reliable unless used by at least three
assessors. Amodied VSS also assesses pain and
pruritus. Dermatospectrometry, chromametry,
durometry, planimetry, and histologic micrometry can
all be used to provide objective readings of aspects
of the VSS.
pigmentation dierences between scar and adjacent
normal skin to describe the general appearance of
a scar. May be more appropriate for patients with
widespread burns whereas the VSS selects a scar of
4cm2 or less. It is unreliable for comparing cosmetic
outcomes. Amodication is the Matching Assessment
of Scars and Photograph (MASP) tool which uses
a gridded body map to help relocate the scar at
subsequent assessment. Itch can also be assessed
using the Questionnaire For Pruritus Assessment
Assesses scar height, vascularity, pigmentation, and
irregularity from photographs
Although this scale measures the same parameters
as the VSS, SSS, and HSS, it has the advantage of
including a patient- rated component. Some authors
suggest this may be the best tool
The FIM was not developed specically for burns
patients but can be used mainly to predict the need
for rehabilitation, and therefore may be more useful
as a discharge planning tool
Assesses patients’ ability to independently feed, wash,
dress, transfer, walk, climb stairs, and use toilets.
The FAB is similar to the FIM but does not assess
communication, continence, psychosocial interaction,
and cognition. Also, the FAB measures a patient’s
ability to complete 100% of an acti vity whereas the
FIM assesses components of activities
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CHAPTER27 Outcome measures forburns
Table27.3 Psychosocial outcome measures
Outcome measure(s) Explanation and features
Burn Specic Health
Scale (BSHS)
Satisfaction With
appearance Scale
(SWAP)
Coping With Burns
Questionnaire
(CWBQ)
SF- 36 A36- item measure of quality of life not developed
Burn- Specic Pain
Anxiety Scale (BSPAS)
Beck Depression
Inventory (BDI) and
Hospital Anxiety and
Depression Scale
(HADS)
Impact of Events Scale
(IES)
The BSHS is a comprehensive 114- item constructed
by combining burn- specic questions with the Sickness
Impact Prole, Index of Activities of Daily Living,
and the General Well- being Schedule. It is used to
measure the quality of life of burn survivors. Several
variations of the BSHS have been formulated. The most
commonly used is the BSHS- Brief, which has proven to
be eective in dierent countries
A14- item questionnaire developed and validated to
assess the subjective appraisal and social- behavioural
components of body image in burns survivors. Six of
the items were adapted from the BSHS
A33- item measure of coping mechanisms after
burns and associated trauma. Patients are assessed
on emotional support, problem solving, avoidance,
adjustment, self- control, and instrumental action. As
patients are asked to think back to the time they were
discharged, there may be a degree of recall bias
specically for burns patients but validated. Measures
global reintegration and socialization under eight equally
weighted domains:general health and perceptions of,
vitality, physical function, pain, physical role function,
emotional role function, social role function, and mental
health
A useful marker for patients who might be at risk
of diminished function post- discharge. Ave- item
abbreviated version has also been validated for burns
patients. It is, however, validated only for in- patients
Both the 21- item BDI- II and 14- item HADS have been
used as measures of depression in burns patients. The
BDI- II assesses both physical and emotional symptoms
of depression while the HADS was developed as a
screening tool for anxiety and depression. Caution
should be practised when interpreting the results
of these scales as some authors have noted that
disturbances in some items from the scale such as sleep,
libido and appetite could be due to the physical injury
itself
The original 15- item IES patient- reported scale rates
patients’ experiences of two cardinal features of
PTSD:intrusion and avoidance. Other measures that
have been used to assess frequency and severity of
PTSD stigmata in burns patients include the Davidson
Trauma Scale
(Continued)
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INTRODUCTION TOOUTCOME MEASURES FORBURNS
Table27.3 (Contd.)
Outcome measure(s) Explanation and features
Impact of Event- Scale
(IES)
Perceived
Stigmatisation
Questionnaire (PSQ)
Social Comforts
Questionnaire (SCQ)
The original 15- item score comprises two subscales
assessing intrusion and avoidance symptoms. Arevision
(IES- R) was designed to include hyperarousal symptoms.
Both the original and revised versions are self- report
instruments for symptoms of PTSD. The IES- R is a good
screening tool for PTSD and can identify patients with
subsyndromal PTSD 1year after burn injury
This scale measures the frequency of various behaviours
from other people which stigmatize burn survivors.
These behaviours include staring, avoidance, confusion,
rudeness, bullying, and pressurizing burn survivors to
alter their appearance. It has been validated for use in
both adult and paediatric burn survivors
This scale was developed concurrently with the PSQ.
It aims to measure perceived social isolation and the
invasion of privacy
Table27.4 Paediatric- specic burn outcome measures
Outcome measure(s) Explanation and features
VABS- SF These scales are designed to measure children’s
Health Outcomes Burn
Questionnaire (HOBQ)
typical performance with regards to communication,
daily living skills, socialization, and motor skills and
NOT their ability
A quality- of- life measure for children. Versions exist
for children 5years and younger and from 6 to
18years. Assesses parents’ opinions on the child’s
play, language, gross and ne motor skills, family,
behaviour, pain and itching, appearance, satisfaction,
and concerns
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Table27.5 Limb outcome measures
Outcome measure(s) Explanation and features
Lower limb The single leg stance, tandem walk, and timed up-
Upper limb These include the Michigan Hand Outcomes
and- go tests are validated for burns patients, as is the
BSHS- B. Other lower limb function measures such
as the Lower Limb Functional Index have not been
validated for burns
Questionnaire an abbreviated 11- item version
of the Disability of the Arm Shoulder and Hand
(quickDASH) symptom scale are validated for use in
burns patients
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CHAPTER27 Outcome measures forburns
Table27.6 Single variable outcome measures
Outcome measure(s) Explanation and features
Mortality rate Number of deaths per unit time. Most valuable for
Pain Can be measured using several tools such as the visual
Length of stay Indicates burns- associated morbidity and cost of
Range of movement
(ROM)
Wound infection Can be diagnosed by biopsy, culture, tissue histology
Exercise tolerance, grip
strength
Return to work An indirect indicator of a patient’s ability to reintegrate
measuring acute phase outcomes
analogue scale, McGill Pain Questionnaire and the Brief
Pain Inventory (BPI). The BPI is a comprehensive tool
but has not been widely adopted by burns carers
treatment. May be more accurate if measured
retrospectively accounting for mistimed discharge, eg.
patient is readmitted within days of discharge
A marker for joint mobility. Goniometry and linear
measurements are validated measures for ROM
and other subjective stigmata of infection (pain,
redness, odour, and systemic symptoms)
These assess return to pre- injury activity level by
measuring muscle strength and for exercise tolerance,
aerobic capacity. Strength can be measured using free
weights or dynamometry. An exercise tolerance test
using the modied Bruce protocol is often used to
measure aerobic capacity
into society
Further reading
Pereira C, Murphy K, Herndon D. Outcome measures in burn care. Is mortality dead? Burns.
2004;30(8):761–71.
https://www.britishburnassociation.org/downloads/BBA_Outcomes_Doc_2nd_Edition.pdf
Falder S, Browne Aa, Eedgar D, Staples Ee, Fong J, Rrea S, Wood F. Core outcomes for adult burn
survivors: a clinical overview. Burns. 2009;35(5):618–41.
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Chapter28
231
Burns scar management
Common types of burn scars and interventions 232
Further reading 234
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