F-37 Dermatological and burns rehabilitation

Stigma is associated with many disabilities, but it may be the predominant problem related to burns and other skin disorders. Scarring and contractures are probably a close second for people with burns, but only a few dermatological conditions, such as scleroderma, cause reduced joint movement. Many skin disorders are associated with other systemic pathologies, such as arthropathy associated with psoriasis, and the rehabilitation service must always consider associations between skin and system conditions. If both are present, consider both. Third, burns are always accidental and arise suddenly, so post-traumatic stress disorder is an unsurprising consequence of the event, though not necessarily related to the severity of the burn injury.

Competency in dermatological and burns rehabilitation.

The rehabilitation expert is “Able to assess the need for, advise on, and manage the rehabilitation of someone with burns or other disorders of the skin (all ages).” The indicative behaviours and associated knowledge and skill areas are given in a downloadable document listing some relevant references. An article summarising all aspects of dermatological rehabilitation is also available and adds much material to that presented here.

Introduction

It is ironic but true that skin conditions are the most easily seen body disorders, yet they have multiple invisible disabling consequences. A burn affects the skin and the psyche and may leave scars on both, but only those on the skin are visible. Dermatological conditions may alter a person’s appearance, most obviously when the face is affected; they may change the person’s self-image and the perception of the person by others, leading to stigmatisation, and they may have associated disabling conditions; not all these consequences are visible.

Thus, rehabilitation of people with skin conditions, including burns, draws on the whole range of rehabilitation knowledge and skills. As in all rehabilitation, the expert must consider all the hidden and associated components contributing to the person’s illness.

Burns are also associated with poverty and population density, with more burns seen in children from low-income families and densely populated areas. This will have a significant impact on rehabilitation because the patients will have few social or financial resources.

Last, relatively few studies have been conducted on the rehabilitation of people with burns or skin conditions; Lynn Gerber and colleagues found this in a scoping review on rehabilitation after burns, and I found relatively little when writing this.

Burns rehabilitation: contractures.

Contractures arise from scaring the burnt skin around joints and because the joints may not be moved much due to pain or other consequences of the original accident. Hennie Schouten and colleagues from a Dutch burns centre followed up on 173 patients with burns affecting 548 joints over two years. Three hundred and fifty-three joints had operations (skin grafts), and 195 did not. All the joints that did not have a skin graft had a full range of movement by nine months, and even at three weeks, only 40% had a reduced range of movement. In contrast, 20% of operated joints still had a limited range of movement at one year.

Jeremy Goverman and colleagues examined data from an American national database, including 1865 patients. One-third had at least one contracture when discharged from the hospital. Most contractures affected arm joints, and most were mild or moderate. The total extent of burns and grafting was associated with an increased risk of contracture.

Orlando Flores and colleagues systematically reviewed studies on added exercise after burns and found that additional exercise was associated with a lower rate of contracture operations after burns. However, evidence is limited, with a systematic review in 2016 finding little. A few small, randomised trials are available, such as one on different approaches to grafting, but they need to be larger to draw any conclusions.

Skin and stigma

What is stigma? Stigma originated in the sixteenth century from marks made on the skin by pricking or branding to indicate disgrace on the person. Goffman introduced it into healthcare in 1963 and defined it as an: “attribute that is deeply discrediting” and as something that reduces its bearer “from a whole and usual person to a tainted, discounted one.” [From Martin Andersen et al]

Martin Andersen and colleagues discuss the definition of stigma in detail, and the article is well worth reading. They conclude that “groups, not individuals, are the target of stigma, though it is individuals who may be the victims of it.” This follows from their succinct definition that stigma involves:

labelling,
negative stereotyping,
using the stigmatising feature to refer to the person (e.g. “he is a psoriatic”), and t
the other person being in a position of power over the subject.

Their definition results in the fact that stigma is usually applied to a group and only manifests at the level of the person. In other words, a person is stigmatised because they belong to a group of people with, for example, facial scars rather than for any specific personal characteristic. This reflects its origin as indicating a person disgraced without reference to their crime or social misdemeanour.

The feeling of stigmatisation is one part of the mental health or emotional consequences of burns, and I will consider them together.

Burns: psychological sequelae.

This part covers stigma, emotional distress, and post-traumatic stress disorder.

I have not found any studies or reviews investigating the frequency of stigma, anxiety, depression, or post-traumatic stress disorder in representative populations of people with burns or skin conditions. However, the numbers involved in observational and exploratory studies suggest that stigma is common.

Heidi Willemse and colleagues reviewed published literature on stigma and analysed data from a cohort study in the Netherlands and Belgium. They investigated relationships between perceived stigmatisation, fear of negative evaluation, body image dissatisfaction, and self-esteem. They illustrate a model with two distinct pathways; gender and total body area affected also had an influence.

Annahir Cariello and colleagues investigated the influence of social support on the relationship between stigma and mental health in individuals with burn injuries in 97 people attending a specialist burns outpatient clinic. They found that stigma was associated with depression and anxiety and that social support had a significant moderating effect on the relationship, with increased support protecting the person. This implies that rehabilitation should attempt to expand and strengthen a person’s social networks if they are weak.

In a study involving 483 people with burns, Gyeong-Ho Son and Sung-Man Bae found that post-traumatic stress disorder was not associated with the total body area affected. However, they did find that the extent to which pain interfered with their lives and the degree of perceived stigma both increased post-traumatic stress disorder symptoms. This suggests that increased attention to alleviating the interference secondary to pain may reduce stress.

Conclusion

Damage or disease of a person’s skin may be a direct threat to the person as physical trauma, such as a gunshot wound, or a disease, such as myocardial infarction. It is an assault on their social identity. If this is not recognised, their rehabilitation will be incomplete. The functional consequences of the physical and external apparent implications of burns and many skin conditions can be rehabilitated using the general processes outlined on this site. The damage or disease can be alleviated to an extent. The research is limited, but there are no unequivocally beneficial interventions. However, the approach outlined in the general theory of rehabilitation will be appropriate for this population.