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Effects of a Skin Rehabilitation Nursing Program on Skin Status, Depression, and Burn-Specific Health in Burn Survivors
The objective of this study was to identify the effects of a skin rehabilitation nursing program (SRNP) on skin status, depression, and burn-specific health in Korean burn survivors. A pretest-posttest design with a nonequivalent control group was used to examine the effects of SRNP for 3 months in a group of 26 burn survivors. The SRNP group of 13 burn survivors received massage therapy 30 minutes three times a week for 3 months compared to a control group of 13 burn survivors receiving typical care. The SRNP group showed no significant changes in the burn scar, subjective skin status, depression, or burn-specific health. Burn survivors receiving SRNP had reduced burn scar depth after the intervention compared to the control group. The findings of this study demonstrate that SRNP for burn survivors may improve burn scars, and findings suggest that future studies with a larger sample should be conducted using SRNP as an intervention for burn survivors.
Hypertrophic scarring and psychosocial symptoms are principal problems for burn survivors after the acute stage has passed (Dyster-Aas, Willebrand, Wikehult, Gerdin, & Ekselius, 2008; Field et al., 2000). Full-thickness burns frequently form hypertrophic scars, which are characterized by elevation, redness, and rigidity (Bray et al., 2003). Consequently, scar management is an important aspect in the rehabilitation of burn survivors because scars cause deformity and loss of function (Edgar & Brereton, 2004).
Research suggests that perfusion is increased in hypertrophic scars when compared with nonhypertrophic scars, and perfusion indices are increased at 6–12 months after injury in burn survivors (Oliveira et al., 2005). Although estimates of depression rates among burn survivors differ from study to study, the prevalence rates of moderate-to-severe depression reported within the first month after a burn are at 54% (Wiechman et al., 2001) and 20% during acute care (Dyster-Aas et al., 2008).
Little attention has been devoted to helping burn survivors reduce the physiologic and psychosocial effects of burn scars. Massage therapy is defined as the manipulation of the skin and underlying tissues with varying degrees of hand pressure to reduce pain, produce relaxation, or improve circulation (Dochterman & Bulecheck, 2004). Early use of massage therapy is effective in decreasing scar vascularization. It also can minimize the adverse effects of hypertrophic scars, including soft-tissue contracture and irreversible disfigurement. Massage therapy aids in softening or remodeling scar tissue by freeing adhering fibrous bands, which makes scars more elastic (Serghiou et al., 2002).
Several studies have shown that massage therapy for burn survivors has positive effects on reducing postburn pruritus (Field et al., 2000; Roh, Cho, Oh, & Yoon, 2007), pain (Field et al.), and psychological symptoms (Field et al.; Roh et al.). A significant improvement in burn scar also has been reported in burn survivors after 3 months of massage therapy (Roh et al.), but, contrary to this result, massage therapy was found to have no significant effects on vascularity, pliability, or elevation of the hypertrophic scar (Patino, Novick, Merlo, & Benaim, 1999).
Physiologic variability also has contributed to difficulties encountered in measuring physiological changes that accurately reflect the effects of massage. Burn wound depth is a significant determinant of patient treatment success and morbidity. The Vancouver Scar Scale (VSS) has been used to evaluate changes in skin pigmentation, vascularity, pliability, and height of burn scars (Sullivan, Smith, Kermode, McIver, & Courtemanche, 1990). In one study, the interrater reliability in pediatric burn scar assessment was examined using a modified version of the VSS (the MVSS). All subtests were shown to have significant correlations except for the pigmentation subtest. Results indicated that only total scores of the MVSS should be used when determining burn-scar outcomes because individual subtest scores appear to have little reliability (Forbes-Duchart, Marshall, Strock, & Cooper, 2007). Consequently, subjective ratings are too variable to demonstrate overall scar formation and test the efficacy of interventions (Oliveira et al., 2005).
In several studies, the effects of massage therapy on burn scar have been measured using the VSS (Patino et al., 1999; Roh et al., 2007). There are limitations because visual inspections tend to overestimate the depth of the wound in general (Oliveira et al., 2005), but objective data may provide a good explanation of scar status if laboratory parameters can represent scar thickness and blood perfusion of the burn scar. Measuring vascular perfusion with a laser Doppler blood perfusion imager and scar thickness with ultrasonography rather than variable subjective scar ratings may be more reliable measures of scar response to massage therapy compared to the VSS.
The aim of this study was to assess the effects of a skin rehabilitation nursing program (SRNP) on skin status (self-report, blood perfusion, and scar thickness), depression, and burn-specific health in Korean burn survivors.
A pretest–posttest design using a nonequivalent control group with five measures (scar thickness, blood perfusion, subjective skin status, depression, and burn-specific health) was employed to test the effects of SRNP in Korean burn survivors.
Participants and Procedures
Twenty-six adult patients with burns were recruited from a university inpatient burn center in Seoul, Korea. The inclusion criteria were (a) 18 years or older, (b) diagnosis of partial- or full-thickness burn on forearm or hand, and (c) agreement to participate.
The study was approved by the institutional review board of the university hospital. All participants agreed to participate in the study and signed an informed consent form.
A research assistant who had been trained by the principal investigator and was blind to participants’ group assignment to the SRNP or control group collected data on subjective skin status, depression, and burn-specific health through in-person interviews at baseline and 3 months after the intervention. After obtaining the questionnaires, the researcher measured blood perfusion using a laser Doppler blood perfusion imager and scar thickness using ultrasonography. Measurements were taken at baseline and 3 months after the intervention.
After obtaining preintervention data, skin rehabilitation massage therapy (SRMT)—administered 30 minutes three times a week for 3 months—was given to participants in the experimental group. SRMT is defined as the manipulation of the skin and underlying tissues with light palm stroking, acupressure, and an occlusive dressing by a certified skin rehabilitation nurse and home care by the primary caregiver. The length and duration of the massage administered in this study were based on a report by Roh and colleagues (2007) that showed significant improvement in burn scars after SRMT. Participants in the control group received routine care without any form of massage for the burn scar.
Description of the SRNP
SRNP consists of SRMT and self-care education. Two certified skin rehabilitation nurses applied SRMT. The total number of SRMT sessions administered by the nurses was 36 for each patient. In addition, primary caregivers moisturized burn scars daily. Whenever participants visited the skin rehabilitation clinic for SRMT during the study period, the skin rehabilitation nurses reminded them and their families to moisturize daily. Self-care education was provided using a booklet developed by the research team.
Data on personal and burn characteristics, subjective and objective skin status, depression, and burn-specific health were recorded. All of the participants were assessed before and after the 3-month study period. All questionnaires were self-administered, and some patients received help in responding to the questionnaire.
Burn Scar Assessment
Blood perfusion to the burn scar was measured with a laser Doppler blood perfusion imager (Periscan PIM II®, Denmark) with skin and temperature probes to allow all measurements at the same temperature. Blood perfusion represents perfusion indices as volts, with high scores indicating increased perfusion.
Scar thickness was measured by one of the researchers using high-resolution ultrasonography (the 128 BW® system from Medison, Seoul, Korea). Measurement of ultrasonography is represented in centimeters, with high scores indicating thick burn scars. All data were interpreted by one of the researchers who has specialized in burn rehabilitation and scar measurements.
Subjective Skin Status
Subjective skin status was measured using the Patient Scar Assessment Scale (Draaijers et al., 2004). This scale assesses a burn survivor’s perspective on pain, pruritus, pigmentation, pliability, size, and dryness of the burn scar. It consists of 6 items; participants are asked to respond on a 10-point Likert-type scale. Scores range from 1 to 10, with high scores indicating poor skin status. The alpha coefficient for the present study was 0.80.
Depression was measured using the Korean Center for Epidemiologic Studies Depression Scale (CES-D; Cho & Kim, 1993). This scale gauges depressed mood, feelings of guilt and worthlessness, feelings of helplessness and hopelessness, psychomotor retardation, loss of appetite, and sleep disorders. It consists of 20 items; participants are asked to respond on a 4-point Likert-type scale (from 0 to 3). Scores range from 0 to 60, and higher scores indicate more depression. Alpha coefficients for the scale have been reported as 0.85–0.90 (Cho & Kim); the alpha coefficient for the present study was 0.96.
Burn-specific health was measured using the Korean Burn Specific Health Scale-Brief (BSHS-B-K; Son, Seo, Kim, Jang, & Noh, 2005). This scale gauges simple abilities, heat sensitivity, hand function, treatment regimens, work, body image, effect, interpersonal relationships, and sexuality. It consists of 40 items; participants are asked to respond on a 5-point Likert-type scale. Alpha coefficients for the scale have been reported as 0.96 (Son et al.).
Descriptive and t-test statistics were used with an SPSS program (V14.0 for Windows). Differences were considered significant at p < .05. Levine tests revealed equal variances on the major dependent variables.
Homogeneity of SRNP and Control Groups
Twenty-six burn survivors (13 in the SRNP group and 13 in the control group) participated in this study. The SRNP and control groups each consisted of 12 men (92.3%) and 1 woman (7.7%). The mean age (± SD) for the SRNP group was 37.7 years (± 13.67), and 41.62 years (± 9.73; t = -.843, p = .408) for the control group. The mean total body surface area (TBSA) covered by the burn in the SRNP group was 29.54% (± 16.44), and 21.15% in the control group (± 16.68; t = 1.291, p = .209). The mean number of postburn months for the SRNP group was 3.46 months (± 2.40), and for the control group 3.38 months (± 2.26; t = .084, p = .934). There were no statistically significant differences between the groups in terms of gender, age, postburn days, and TBSA involved in the burn. No significant between-group differences were found for scar thickness (t = .162, p = .873), blood perfusion (t = -.007, p = .994), subjective skin status (t = -.413, p = .684), depression (t = -1.180, p = .250), and burn-specific health at baseline (t = -.502, p = .621).
Effects on Burn Scar and Subjective Skin Status
Descriptive statistics on burn scar and subjective skin status are presented in Table 1. Thickness of the burn scar for the SRNP group increased slightly from a baseline value of 0.24 cm (± 0.15) to a posttreatment value of 0.27 cm (± 0.16). Comparison of the total scores of the thickness between the two groups showed no significant difference (t = -.501, p = .621). There was no significant difference in blood perfusion in the SRNP group compared to the control group (t = .026, p = .979). There also were no significant differences in subjective skin status between the two groups (t = -1.749, p = .093).
Effects on Depression and Burn-Specific Health
There also were no significant differences for depression (t = -.284, p = .779) or for burn-specific health (t = .380, p = .707) between the two groups (Table 2).
The SRNP group demonstrated no significant changes in the burn scar, subjective skin status, depression, and burn-specific health compared to the control group.
In terms of burn scar, scar thickness in the SRNP group was less thick than seen in the control group after 3 months, but the findings in this study did not indicate any significant change. This finding differs from studies in which patients in the massage group experienced no change in scar height from baseline to 3 months (Patino et al., 1999), or experienced significant improvement in burn scar after 3 months of massage therapy (Roh et al., 2007). These varying results may have occurred because of the subjective nature of the VSS and visual inspections that tend to overestimate the depth of deep-thickness burns. Although our results did not show statistically significant effects on burn scar, this study provided evidence that SRNP has a slight positive effect on scar thickness. This study may have benefitted from the use of reliable and objective burn-scar assessment tools such as ultrasonography.
Blood perfusion indices on hypertrophic scars increase at 6–12 months after burn injury compared to normal skin (Oliveria et al., 2005). In this study, the mean postburn days among participants was equal to about 4 months, and the follow-up study period was 3 months. Future study with a longer duration of treatment may reveal improvement in the effects of massage therapy at 6–12 months for burn survivors with high risk for hypertrophic scars.
In terms of depression, the findings in this study did not indicate any significant change after SRNP, although several studies have shown a decrease in depression after massage therapy (Field et al., 2000; Roh et al., 2007). Estimates of depression rates in burn survivors range from 20% to 54% (Dyster-Aas et al., 2008; Wiechman et al., 2001). Massage therapy helps patients feel cared for. Patients may be more ready to discuss and deal with difficult psychological issues after they are less anxious and have come to trust their care providers. This is the one way in which massage can serve as an important adjunct to manage depression (Vickers & Zollman, 1999). In a metaanalysis of massage therapy research, depression was reduced more than 73% compared to a control group (Moyer, Rounds, & Hannum, 2004). Future studies with randomized designs and massage standards are necessary to demonstrate the sustained effectiveness of massage therapy on depression.
No significant change in burn-specific health occurred in the SRNP group. It may be that burn-specific health is slower to respond to massage therapy and that an intervention of longer duration is necessary.
There are several possible explanations as to why there were no significant improvements in skin status, depression, and burn-specific health. These explanations include duration of treatment, type of massage administered, amount of pressure applied to the body, approach of the therapist, and apparatus used in treatment. These factors, along with scar care by family members and family monitoring of adherence to treatment protocol, should be considered for future studies.
Future research with a larger sample may result in significant improvements, especially for skin status. Insignificant findings in scar thickness, blood perfusion, depression, and burn-specific health were found in this study. SRNP was applied for 30 minutes three times a week for 3 months. It is possible that the duration of treatment was insufficient to produce any beneficial effects. Further studies could compare the duration, frequency, and timing of the procedure to determine more precise parameters for treatment.
The reported prevalence of hypertrophic scarring in burn patients is between 67% and 75% (Bombard et al., 2003). Despite the introduction of pressure therapy, early excision and grafting, and the use of dermal replacements, burn scarring is the main problem in burn rehabilitation. Our study introduced SRNP as a nursing intervention to improve the quality of burn rehabilitation. The positive aspects of this study are novel insight with regard to both physiologic and psychosocial variables being measured, and scar status assessment using objective assessment tools. These findings may be useful for rehabilitation and burn care nurses who want to develop strategies to improve skin status in burn survivors.
Positive changes in burn scar thickness may be valuable indicators of the effects of SRNP. Future research is needed to test the effects of SRNP using a longitudinal follow-up design with a larger number of burn survivors.
Deep partial- and full-thickness burns frequently result in hypertrophic scars, which are characterized by elevation, redness, and rigidity and may persist for several months. The use of skin rehabilitation massage therapy appears helpful in reducing thickness of burn scars, but it did not show any statistically significant physiologic and psychosocial effects.
This work was supported by a Korea Research Foundation Grant funded by the Korean government (MOEHRD, Basic Research Promotion Fund; KRF-2006-331-E00408).
About the Authors
Young Sook Roh, PhD RN, is an assistant professor at Red Cross College of Nursing in South Korea. Address correspondence to her at firstname.lastname@example.org.
Cheong Hoon Seo, MD, is an assistant professor at the Hangang Sacred Hospital, Hallym University in South Korea.
Ki Un Jang, PhD MD, is a professor at the Hangang Sacred Hospital, Hallym University in South Korea.
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