of Pages 13
ScienceDirect
Review
Article history: Objective: To systematically review the delivery and effectiveness of rehabilitation for burn
Accepted 13 October 2017 survivors in low and middle income countries (LMIC).
Available online xxx Methods: We systematically searched the literature through 11 electronic databases and the
reference lists of relevant studies. Studies were suitable for inclusion if they were primary
research with a focus on burns rehabilitation in LMIC settings describing either service
Keywords:
delivery or treatment effectiveness. No time, design or other limitations were applied, except
Burns
English language.
Injury
Results: Of 226 studies identified, 17 were included in the final review, including 7 from
Rehabilitation
India. The results were summarised in a narrative synthesis as the studies had substantial
Treatment
heterogeneity and small sample sizes, with many relying on retrospective data from non-
Low-income countries
representative samples with no control groups. Most studies (12) described service
Middle-income countries
delivery and 5 examined the effectiveness of different types of rehabilitation. Multiple
studies stressed the need for rehabilitation and multidisciplinary teams for burns
management.
Conclusions: The published research on burns rehabilitation is very limited and little is known
about current practices in LMIC settings. In order to inform policy and service delivery, the
effectiveness, feasibility and sustainability of current services needs to be investigated.
© 2017 Elsevier Ltd and ISBI. All rights reserved.
Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... ... .... .... .... .... .... ... .... .... .... .... . 00
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... ... .... .... .... .... .... ... .... .... .... .... . 00
2.1. Search strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... ... .... .... .... .... .... ... .... .... .... .... . 00
2.2. Inclusion criteria, data extraction and quality appraisal ... ... .... .... .... .... .... ... .... .... .... .... . 00
* Corresponding author at: Level 5, 1 King street, Newtown 2042, Sydney, Australia.
E-mail address: jjagnoor@georgeinstitute.org.au (J. Jagnoor).
https://doi.org/10.1016/j.burns.2017.10.007
0305-4179/© 2017 Elsevier Ltd and ISBI. All rights reserved.
Please cite this article in press as: J. Jagnoor, et al., Rehabilitation practices for burn survivors in low and middle income countries: A
literature review, Burns (2017), https://doi.org/10.1016/j.burns.2017.10.007
JBUR 5394 No. of Pages 13
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... ... .... .... .... .... .... .... ... .... 00
3.1. Descriptive studies of burns rehabilitation services . . . . . . . . . . . . .... ... .... .... .... .... .... .... ... .... 00
3.2. Studies evaluating effectiveness of burns rehabilitation services . .... ... .... .... .... .... .... .... ... .... 00
3.2.1. Impact of rehabilitation on functional outcomes . . . . . . . .... ... .... .... .... .... .... .... ... .... 00
3.2.2. Burns scar rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . .... ... .... .... .... .... .... .... ... .... 00
3.2.3. Psychological rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . .... ... .... .... .... .... .... .... ... .... 00
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... ... .... .... .... .... .... .... ... .... 00
4.1. Strengths and limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... ... .... .... .... .... .... .... ... .... 00
5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... ... .... .... .... .... .... .... ... .... 00
Conflict of interest statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... ... .... .... .... .... .... .... ... .... 00
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... ... .... .... .... .... .... .... ... .... 00
Please cite this article in press as: J. Jagnoor, et al., Rehabilitation practices for burn survivors in low and middle income countries: A
literature review, Burns (2017), https://doi.org/10.1016/j.burns.2017.10.007
JBUR 5394 No. of Pages 13
Table 1 – Search terms used to identify relevant studies. 2.2. Inclusion criteria, data extraction and quality
appraisal
Population
1 Developing countr* or LMIC
2 Communit* or home* Studies were suitable for inclusion if they were primary
research from LMIC settings, describing service delivery or
Exposure evaluating the effectiveness of burns rehabilitation services.
3 Fire* or burn* or flame* No publication date period or other limitations were applied,
4 Rehab* or treatment
except English language. LMICs were defined as those
published by the Australian Governments Department of
Outcomes
5 Injur* or damage* or trauma* or Foreign Affairs in 2015 [20].
wound* Study selection and data abstraction were carried out using
6 Death or mortality or fatal* or die* or a standard data abstraction form (Table 2) by one author (CL).
decease* or morbidity The study selection process is summarised in a flow diagram
(Fig. 1).
Combining search
1 and 2 and 3 and 4 and (5 or 6)
Fig. 1 – PRISMA flow diagram of the number of records identified, included and excluded in the study.
Please cite this article in press as: J. Jagnoor, et al., Rehabilitation practices for burn survivors in low and middle income countries: A
literature review, Burns (2017), https://doi.org/10.1016/j.burns.2017.10.007
4
Table 2 – Standardised data extraction table summarising studies included in the review.
Study Country Aim/focus Study type Participants Intervention Outcome Limitations Comment
Burns due to Sri Lanka To describe the epi- Retrospective, descrip- n= 46 Rehabilitation interven- Attendance to the follow- Retrospective data. Patients constitute cohort
acid assaults demiology, mecha- tive tion not detailed. up rehabilitation clinic Small sample size. of patients with worst
in Sri Lanka nism, complica- A retrospective review Participants rehabilitative was observed only in 18 compliance in rehabilita-
[21]. tions, management of patient records from a team included occupa- (39%) patients. tion process because they
challenges, and re- Burns and Reconstruc- tional and physio thera- do not attend the follow-
lated psychosocial tive Surgical Unit over pists for mobilizing and up clinic regularly. Rea-
factors associated an 18 month period. splinting; psychologists sons not clear, but may be
with acid assaults. Evaluated variables in- and counsellors. the perceived persisting
cluded, amongst other threat of a recurrent inci-
things, compliance with dent, or scarring and al-
rehabilitation. tered appearance imply a
stigma, preventing leaving
home.
A comparison Iran Compare two burn Comparison n= 30 Routine burn physiother- Significant difference Small sample size. Emphasis on need of
Study Country Aim/focus Study type Participants Intervention Outcome Limitations Comment
Paediatric India Relationship be- Retrospective, descrip- n =459 Rehabilitation interven-
A total of 13.7% of burnt The need for reha- Authors discuss need for a
rehabilitation tween age, aetiol- tive Case records tion not clear. children needed function- bilitation was as- support to carers and the
in a ogy, percentage A retrospective review of 459 children al rehabilitation; children
Rehabilitation in this con- sessed, however the cost of rehabilitation is
developing body surface area of patient records from a who were ad- from poorer socioeco-
text includes functional, tools used are not prohibitive.
country — burnt, social and paediatric burns facility mitted during cosmetic and psychoso-
nomic strata of society are well established.
India in economic status of over a 10 year period. 10 year period not able to get compre-
cial aspects, however was
relation to individual and ne- (1992–2002) not explicitly stated as the
hensive rehabilitation due
aetiology, cessity for intervention. to the financial con-
consequences rehabilitation. straints; patients came
and outcome from peripheral areas of
in a group of the state. Higher educa-
459 burnt tion results in rehabilita-
children tion; psychosocial
[22,46]. rehabilitation was not re-
ported as a need in the
5
(continued on next page)
6
Table 2 (continued)
Study Country Aim/focus Study type Participants Intervention Outcome Limitations Comment
A Brazil Assess presence of Quantitative, cross-sec- n= 63 Participants received Scores for depression and Small sample size. Comparison between
quantitative, depression and level tional physical and psychologi- body image in the study No comparison teenagers and young
cross- of self-esteem in Three instruments for cal rehabilitation for an participants were reported group. adults with and without a
sectional teenage and young assessing depression/ average of 124.74 months to be better in those who Routinely collected history of burn injury
study of adult burn victims low self-esteem admin- (SD 63.67) from a multi- were able to go back to data has limitation would be useful.
depression receiving follow-up istered to teenagers/ disciplinary team, tested school or work. in terms of quality
and self- (physical and psy- young adults undergo- using Beck’s Depression and completeness.
esteem in chological rehabili- ing burn rehabilitation. Inventory (BDI) & Rosen-
teenage and tation) care for their burg’s Self Esteem Scale
young adult injuries. (RSE).
burn victims Determine whether
in the location of the
rehabilitation burn (hand or head)
[24]. or current work
condition is a factor
Study Country Aim/focus Study type Participants Intervention Outcome Limitations Comment
Embracing India Explore and discover Qualitative, descriptive n =22 Parents provided rehabili- Parent’s demonstrated Data collected only Suggests: health care pro-
survival: a the process of par- Semi-structured inter- 22 family tative care at home to burn perseverance in meeting from family mem- viders need to be sensitive
grounded enting children in views (25), diaries and members of injured child. burn-injured child’s needs bers and not from about parents’ needs. Use
theory study India with burn in- observations used for 12 burn-in- at home. Burn-injured burns survivors and of genograms and eco-
of parenting jury at home and data collection. jured children child was not seen as a health care pro- maps to identify those
children who develop a conceptu- burden. viders; small sample who can help the parents
have al model to inform size. with home rehabilitation.
sustained interventions.
burns [29].
Burn India Paper discusses cer- Case study n =2 Multidisciplinary ap- Case 1: complete recovery Descriptive subjec-Suggests: inclusion of lei-
rehabilitation: tain examples of Description of protocols proach: chest physiother- from burns injury; voca- tive outcomes sure into burns rehabili-
a challenge, successful rehabili- for burns admissions to apy, splinting, range-of- tional rehabilitation reported. tation using multi-
our effort [26]. tation strategies for one medical centre. motion exercises, posi- helped the survivor to get disciplinary approach.
burns. 2 case studies included tioning, psychological back to education and Holistic approach to burns
to illustrate protocol therapy, pressure gar- work; social re-integration management. Social
function. ments, massage, activity- Case 2: return to home group activities for net-
7
8
Study Country Aim/focus Study type Participants Intervention Outcome Limitations Comment
hypertrophic scar man-
agement. Intervention
group additionally re-
ceived 3 sessions of 30min
massage therapy each
week for 4 weeks.
Speech and India To educate burns Descriptive review N/A N/A SLPs could help in the Suggests: active involve-
swallowing care team on inclu- Practical guidelines treatment of dysphagia, ment of SLPs in acute and
rehabilitation sion of Speech and provided for use by cognitive-linguistic defi- long term management of
following burn Language Patholo- medical facilities. cits, dysphonia, multisen- burns.
injury: role of gists (SLPs) sory coma stimulation
speech program, and develop-
pathologists mental milestones of the
in burnt child.
multidisciplinary team [32].
Impact of India To study impact of Pre-post design n =35 (20 men Assessment of depression Psychotherapy helped re- No comparison The results highlight the
rehabilitation interven-
no meta-analyses were performed.
interventions received by
prehensive rehabilitation
clinical interventions)
two groups; interven-
Comparison between
addition to standard
in Mainland
China [34].
Functional
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literature review, Burns (2017), https://doi.org/10.1016/j.burns.2017.10.007
JBUR 5394 No. of Pages 13
development and training, an absence of guidelines, and Patients were allocated into either a control group (n=15) who
insufficient government funding. received standard medical care, or to an intervention group
A case study of two paediatric burns patients who received (n=15) who received standard medical care with additional
surgeryinTaiwan[27] reportsonthefeasibilityandutilityoftele- intensive physiotherapy consultations. There was a signifi-
medicine for rehabilitation in an island setting, where access to cant difference (p<0.01) in burn contractures between both
rehabilitation services is a limited. The study evaluated range of groups, with one patient (6%) experiencing burn contractures
motion in the limbs of both patients up to 10 months post- in intervention group and 11 patients (73%) experiencing
surgery, but no other objective measures were taken. Both contractures in the control group.
patients and surgeons reported to be satisfied with videocon- One clinical trial from China [34] evaluated functional
ferencing as a method of follow-up consultation. A second case outcomes (self-care and quality of life) of 55 severe burns
study from India [26] provides a detailed description of the burns patients with and without rehabilitation. Patients were
treatment and rehabilitation protocol at one urban hospital. allocated into either a control group (n=25) who received
Case studies of two women, aged 30 and 35 years, who were standard medical care, or to an intervention group (n=30) who
treated at the hospital for accidental burn injuries sustained at received comprehensive rehabilitation including occupational
home, are presented to illustrate hospital procedures. The therapy, physiotherapy, and patient and family education.
article reports rehabilitation services to be negligible or non- Patient allocation was not random but based on convenience
existent. It states that private burn facilities are scarce and to access rehabilitation services. A wide range of outcome
unaffordable for most patients, while government facilities are measures were collected at 3 months post intervention,
frequently over-capacity and under-resourced, causing the including self-care performance (Modified Barthel Index
discharge of patients prior to treatment completion. [MBI]), QOL (World Health Organization Quality of Life-BREF),
A cross-sectional study from Brazil [24] of 63 teenagers and pain and itchiness (Visual Analogue Scale [VAS]) and mental
young adults receiving psychological and physical rehabilita- health (Self-Rating Depression Scale [SDS] and Self-Rating
tion for burn injuries, found low levels or an absence of Anxiety Scale). When comparing the intervention and control
depression (average Beck’s Depression Inventory (BDI) groups, the intervention group achieved significantly better
score=7.6, reflecting slight depression) and/or issues with low outcomes in MBI (p<0.001), VAS (p=0.009), physical health
self-esteem (average score on the Rosenberg Self-Esteem Scale (p=0.002), psychological health (p=0.021), and social relation-
(RSE)=8.4, reflecting an adequate degree of self-esteem). The ships dimensions of QOL (p<0.001). No confidence intervals
study suggests that multidisciplinary rehabilitation programs- were reported for p values.
may be effective for ensuring better psychosocial outcomes for
burns patients. This study was limited due to its small sample 3.2.2. Burns scar rehabilitation
size, use of convenience sampling to select the study popula- One study from Korea [36] evaluated a scar management
tion, lack of control group, and lack of information on individual program, reporting measures of skin status, depression, and
burn severity and associated mental health outcomes. There- burn-specific health among 26 burns survivors. Participants
fore, study outcomes should be interpreted with caution. were allocated into either a control group (n=13) who received
Two qualitative studies were included, which explored the standard medical care, or to an intervention group (n=13) who
rehabilitation care process for burns patients and their carers. received the scar management program over a three month
A study from Iran [30] used 28 semi-structured interviews to period. There were no significant changes in burn scars,
understand perceptions of patients and carers following self- subjective skin status, or depression between the control and
immolation, identifying the need for integrated rehabilitation intervention groups. Participants within the intervention
care. The second study from India [29] used 22 semi-structured group observed a reduced burn scar depth over the study
interviews to investigate parental involvement in the rehabili- period, although this change was not significant. A second
tation care process for children with burn injury. Parents were randomised controlled trial from Korea [33] evaluated the
found to identify and mobilise resources for their child’s effect of massage therapy performed by a skilled therapist on
treatment, manage wounds and perform other tasks associat- hypertrophic burn scars. This study had a large sample size
ed with rehabilitation in the home, and minimise their child’s (n=146), with 76 participants allocated to an intervention
exposure to stigma within the community. The authors group who received massage therapy in addition to standard
identified a lack of support for parents from health care medical care. The study found significant improvements in
professionals and other extended family members. scar pain (95%CI: 0.69–2.02; p<0.001), scar thickness (95%CI:
One Indian study [31] reviewed different approaches by 0.03–0.09; p=0.02) and scar melanin (95%CI: 12.1–21.3; p=0.02)
rehabilitation practitioners to improve the design of axillary between the control and intervention groups following
splinting devices to increase patient adherence. Structural massage therapy.
physical barriers, such as narrow corridors, were reported to
create difficulties for patients wearing the devices. 3.2.3. Psychological rehabilitation
One study from India [37] assessed the impact of psychological
3.2. Studies evaluating effectiveness of burns rehabilitation on 35 burns patients. This study evaluated the
rehabilitation services effectiveness of supportive psychotherapy for burns patients
using a pre-post-test design, examining depression as the
3.2.1. Impact of rehabilitation on functional outcomes outcome. Results showed that multiple (15–20), short, face-to-
One study from Iran [35] compared the outcomes of two burn face and tele-psychotherapy sessions led to a significant
rehabilitation treatment protocols among 30 burn patients. decrease in depressive symptoms and improved self-image
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JBUR 5394 No. of Pages 13
among both males (95%CI: 0.44–1.16, p<0.001) and females the use of local resources (human, financial, material) where
(95%CI: 0.4–1.33, p=0.001). possible to increase the likelihood of service sustainability.
Randomised controlled trials evaluating community-based
mental health rehabilitation programs in LMICs have shown
4. Discussion significant improvement in disability levels [43,44]. Whilst
isolated vertical programmes for community rehabilitation
This review identified a lack of accessible and sustainable are not sustainable, developing skills among community
burns rehabilitation services within LMICs. Scarce resources, health workers in rehabilitation, for all cause disability
competing health priorities and limited access for rural including traumatic brain injury, spinal injuries, hip fracture,
populations to healthcare facilities were identified as barriers stroke and other communicable and non-communicable
to providing appropriate long-term burns rehabilitation. Due conditions is likely to have far reaching impact. Previous
to the small number of studies identified for this review, it was studies have identified numerous benefits of eHealth appli-
not possible to comment on the effectiveness of existing burns cations in LMIC settings, such as the use of teleconferencing
rehabilitation interventions in this context. and videoconferencing for diagnosis and follow-up. Outcomes
Multiple studies included in this review identified areas include improved remote patient monitoring, reduced travel
requiring improvement within existing burns rehabilitation and waiting times for patients, improved diagnostic accuracy
services. Burns rehabilitation services offered through private and clinical efficiency [45].
sectors were reported to be costly, while government services
were reported to be over-capacity and under resourced. This 4.1. Strengths and limitations
issue is not unique to burns rehabilitation, with primary public
health facilities from a number of LMICs reported to be less This review emphasizes the limited research available on
responsive to patients and often lacking in supplies [38]. A lack rehabilitation options for burns survivors in LMICs. All studies
of appropriately qualified staff and limited professional included in this review emphasised the need for burns
development opportunities for clinicians were identified as rehabilitation services, highlighting some common barriers
barriers to making appropriate services available. This is to their operation. The majority of research work in LMICs on
particularly concerning as greater numbers of qualified the rehabilitation of burns has occurred in the last decade and
physicians from LMICs migrate to HICs, while training capacity therefore, all studies included in this review report on recent
within LMICs remains low [39]. data.
Multiple studies identified the need for a multidisciplinary Overall, the quality of the studies was poor. Limitations
approach to burns rehabilitation in LMICs, ideally including included small sample sizes [21,24,35,36], the use of retrospec-
elements of physiotherapy, occupational therapy, psycholog- tive data [21,22], non-representative participation [23], and an
ical therapy and patient and family education. It was absence of control group [24]. Due to the methodological
acknowledged that the likelihood of providing access to all variations between studies, direct comparisons between
services in a resource poor setting is low. Multidisciplinary outcomes were not possible. Definitions of rehabilitation
care has been shown to be an effective approach to improving varied across the studies and few studies reported clear,
functional outcomes in the areas of COPD, stroke and palliative validated outcomes. As many studies recruited participants
care however, its integration into standard medical practice from specific medical institutes or hospitals, the general-
presents many challenges, even in HICs [40]. isability of study outcomes is questionable. It is likely that
Successful rehabilitation requires components of health, there are many effective services currently being provided in
education, livelihood and social welfare [41]. It is well LMICs that are undocumented and have not yet been
established that there is an over-representation of psychiatric evaluated for effectiveness.
and psychological disorders in people with burns, with
estimates varying between 20% and 75% among adult patients,
which may develop during the continuum of care [42]. The 5. Conclusion
focus of most burn rehabilitation research has been on health
— primarily physical health. Our search found only two studies The limited published research on known burns rehabilita-
[34,37] specifically describing these components with the tion practices in low- and middle-income countries high-
addition of empowerment, but individual components were lights a number of barriers to the provision of high quality,
not evaluated. accessible and sustainable rehabilitation services. Although
Long travel distances to health facilities and associated a number of studies reported on various treatment practices
travel costs were both identified as barriers to accessing long- trialled with small numbers of patients, many of which were
term burns rehabilitation services. Recent years have seen a shown to improve patient outcomes, interventions varied
rise in the utilisation and success of community based and evidence on effectiveness is unclear. Few studies
rehabilitation services and eHealth applications. The World provided suggestions on how to incorporate these treatment
Health Organisation initiated the Community-Based Rehabili- options into health service protocols, or into the broader
tation (CBR) strategy in 1978 [41], which aimed to achieve a health system. As only a small number of studies were
multi-sectoral ‘bottom-up’ approach to providing long-term identified through this review, further research is required to
care in community settings. Practical aspects of the strategy investigate undocumented burn rehabilitation services,
include enabling communities to develop and implement evaluating their effectiveness, feasibility, sustainability
services to ensure they respond to local needs, and promotes and potential for upscale.
Please cite this article in press as: J. Jagnoor, et al., Rehabilitation practices for burn survivors in low and middle income countries: A
literature review, Burns (2017), https://doi.org/10.1016/j.burns.2017.10.007