biopsychosocial factors that interfere in the rehabilitation of burn.pdf

7/21/2019 Biopsychosocial Factors that Interfere in the Rehabilitation of Burn.pdf

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Rev. Latino-Am. Enfermagem Review rticle2011 May-Jun;19(3):622-30www.eerp.usp.br/rlae

Biopsychosocial Factors that In te rfe rein theReh abilitationofBurnVictims Integrative Literature Review

Natalia GonalyesMaria Elena Echevarria-GuaniloFernanda de Loureiro de CarvalhoAdriana Inocenti MiassoLidia Aparecida Rossi

This study aimed to identify the biopsychosocial factors that influence the rehabilitation of burnvictims, through an integrative literature review, from January 1987 to January 2007. Articleswere searched in databases Scielo, Pubmed and Lilacs, resulting in 982 articles, of which 45were selected, afterthe analysis and categorization processes. Most studies were descriptive andqualitative. The most frequently associated factors to the rehabilitation process were: mentalhealth state beforethe accident, coping strategies and family support, besides the severity o ftheburnand the total body surface area burned. Thequality ofthe selected studies, most classifiedas evidence levelVI , shows the scarce production of strong evidences in this knowledge area,which needs more investment, considering the important implications of the sequelae of burns inthe social rintgration of these people.

Descriptors: Rehabilitation; Burns; Social Support.

' Nursing undergraduate student . Escola deEn fe rmagem de Ribeirao Preto, Universidadede SaoPaulo,WHOCol laborat ing Cent re for NursingResearch Development , SP, Brazi l . Scholarship holder of the Scienti f ic In i t iat ion Program at the Conselho Nacional de Desenvo lv imentoCientif ico eTecnoigico (CNPq). E-mai i : natai iasjbv@ hotmai i .com .

^RN, Ph.D. in Nursing. Adjunct Professor, Faculdadede Enfermagem, Universidade FederaldePelotas,RS,Brazi l . E-ma il: bbpino@ hotmail.conn.^ Psyc hologist, Doctora l Stude nt, Escola deEn fe rmagem de Ribeirao Preto, Universidade de SoPaulo,WHOCol laborat ing Cent re fo r Nursing

Research Development , SP,Brazi l . E-nnail: fer. [email protected] .br. RN, Ph.D.in Nursing. Professor, Escoia deEn fe rmagem de Ribeirao Preto, Universidade de SoPaulo,WHOCol iaborat ing Cent re fo r Nursing

Research Development , SP,Brazi l . E-mai l : [email protected].= RN, Ph.D. in Nursing. Full Professor, Escola de En fe rmagem de Ribeirao Preto, Universidade de SoPauio, WHOCol laborat ing Cent re fo r

Nursing Research Development , SP,Brazi l . E-mai l : r [email protected].

Corresponding Author:Lidia Aparecida RossiUniversidadede SaoPaulo. Escolade EnfermagemdeRibeirao PretoDepartamentodeEnfermagem Gerale Esp ecializadaAv. dosBandeirantes, 3900Bairro: Monte Alegre


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6 3Fatores biopsicossociais que interferem na reabilitao de vtimas dequeimaduras: reviso integrativa da literaturaEste estudo teve como objetivo identificar os fatores biopsicossociais que influenciama reabilitao de vtimas de queimadura, por meio de revisao integrativa de literatura,no perodo de Janeiro de 1987 a Janeiro de 2007. A partir da busca dos artigos asbases de dados SciELO, PubMed e LILACS, obtiveram -se 982 a rtigos, dos quais 45 fora mselecionados. A maior parte dos estudos era do tipo descritivo e qualitativo. Os fatoresmais frequentemente associados ao processo de reabilitao foram: estado de sademental previo ao acidente, estrategias de enfrentamento e apoio da famil ia, alm dagravidade da queimadura e da superficie corporal queimada. A qualidade dos estudos,na maioria classificados com nivel de evidencia VI, chama a ateno para a escassaproduao de evidencias fortes nessa rea do conhecimento, necessitando maioresinvestimentos, considerando-se as importantes implicaes das sequelas da queimadurana reintegrao social dessas pessoas.Descritores: Reabilitao; Queimaduras; Apoio Social.

Factores biopsicosociales que interfieren en la rehabilitacin devctimas de quemaduras: revisin integradora de la literaturaEste estudio tuvo como objetivo identificar los factores biopsicosociales que influyen enla rehabilitacin de vctimas de quemaduras, por medio de una revisin integradora dela literatura, en el perodo de enero de 1.987 a enero de 2.007. A partir de la bsquedade los artculos en las bases de datos Scielo, Pubmed y Lilacs, se obtuvieron 982artculos, de los cuales 45 fueron seleccionados. La mayor parte de los estudios era deltipo descriptivo y cualitativo. Los factores ms frecuentemente asociados al procesode rehabilitacin fueron: estado de salud mental previo al accidente, estrategias deenfrentamiento y apoyo de la familia, adems de la gravedad de la quemadura y dela superficie corporal quemada. La calidad de los estudios, en la mayora clasificadoscon nivel de evidencia VI, llaman la atencin para la escasa produccin de evidenciasfuertes en esta rea del conocimiento, que necesita mayores inversiones, considerandolas importantes implicaciones de las secuelas de la quemadura en la reintegracin socialde esas personas.Descriptores: Rehabilitacin; Quemaduras; Apoyo Social.

IntroductionThousands of people suffer the physical,

psychological and social consequences a burn causes,which can continue over t ime or be pe rma nent .

The biological factors the burn affects need to betreate d and managed w ith a view to the burn vic tim sadaptation after discharge from hospital. It shouldnot be forgotten, however, that we l ive in a dynamicand sociable environment, where we infiuence and areinfiuenced by other people s behavior.

intel lectual, sensory, physical, psychological andsocial health levels, should offer tools to re-enablethem to gain independence and reassume their role insociety . H ealth professionals play a fund am enta l rolein support ing burn v ict ims adaptat ion ^ , keeping inmind their maximum exist ing capaci ty, instead of justfocusing on the disabil i ty. The interdiscipl inary teamshould work with the principles of the rehabil i tationphilosophy, which are independence, integration,


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624 Rev. Latino-Am . Enfermagem2 11 May-Jun;19(3):622-30.Literature shows that the total body surface area

(TBSA) burned, age, gender, ethnic origin, burn depth,injury site and pain can predispose to bad physical,social and psychological rehabilitation and worseningof the general health condition'^-^'. The burn, mainly inexposed body parts, provokes decreased self-esteemand turbulent emotions. Burns victims feel exposed dueto the skin injury, which exposes them to pathogens,deformations, fiuid loss and risk of death, as well asdue to the feeling of powerlessness and guilt for theaccident"-^'. The following have been described asfeelings associated with burn trauma: anguish, stress,fear, anxiety, which can hamper coping with the situation,that is, rehabilitation'- ^'.

After hospital discharge, survivors of severe burnsstart to experience a chronic condition that demandspermanent care, mainly skin care. This study aimedto identify, through an integrative literature review,biopsychosocial factors interfering in the rehabilitationof burns victims.Theoretical methodological framework

The integrative literature review is an importantmethod for evidence-based practice, as it permitsanalyzing various studies with different (quantitativeand qualitative) methods in the same research, as wellas to join trials and theoretical studies, constructing anew conception on a given topic. Nursing professionalsfrequently use this method, as it is strongly related withevidence-based practice, and mainly with patient careimprovements'" ' . Evidence can be ranked, dependingon the methodological approach used in the studies'"'.In this review, the following evidence level ranking wasused: I - evidence from systematic review or meta-analysis of all randomized controlled clinical trials orderiving from clinical guidelines based on systematicreview of randomized controlled clinical trials; II-evidences deriving from at least one well-designedrandomized con trolled clinicalt r ia l ;I II - evidence obtainedfrom well-designed clinical trials without randomization;IV - evidence from well-designed cohort and case-control studies; V - evidence from a systematic reviewof descriptive and qualitative research; VI - evidencefrom a single descriptive or qualitative study; VII -evidence based on authoritative opinions and/or expertcommittee reports' '^'.

The development of this integrative review involvedthe following phases: 1. establishment of guidingquestion; 2. selection of articles and inclusion criteria; 3.

Review; 5. interpre tations of Results and ; 6. presentationof Integrative Review'"'.

With a view to answering the guiding question:"What biopsychosocial factors interfere in therehabil i tation process of burns victims?", a search wascarried out in Pubmed, LILACS and Scielo, betweenOctober 2007 and January 2008. The fol lowingcontrol led descriptors were defined: rehabil i tation,burns, culture and social support, as well as the non-control led descriptors: psychological, biopsychosocialrehabil i tation and social. The search l imits were:humans, adults and publication period from 1987to 2007. Also, the inclusion criteria were: completestudies related to rehabil i tation themes in thebiological, psychological and sociocultural spheres,and papers in English, Portuguese and Spanish.

In PubMed, 905 papers were located, 79 of whichwere selected. For Scielo, the descriptors were definedas "key words" and "abstract", resulting in 54 papers,10 of which were selected. In LILACS, 23 papers werelocated, four of which were included. After analyzingthe full texts of all articles under analysis, in view ofinclusion criteria and repetitions, 48 papers wereexcluded. In the final sample, 45 articles were obtained.One ofthe researchers selected the papers and receivedconfirmation from two others.

To rank and facilitate analysis of the papers, aninstrument was adapted from l i terature'^^"', which tworesearchers experienced in this typ e of review and in thetheme area assessed for content adequacy.

The analysis of the study designs included in thisintegrative review was based on concepts presented inliterature"^-'' ', which classifies them as studies with aquantitative approach (experime ntal, quasi-experimentaland non-experimental design), qualitative approach(ethnographic, phenomenology, grounded theory, casestudy, biography, narrative analysis, history, meta-synthesis) and reviews (integrative, systematic and

The analysis process attempted to identify thebiopsychosocial factors associated with the rehabilitationprocess, resulting in the iden tification of three categories:1- Factors related with social and emotional support,2- Psychological factors and 3- Factors associated withburn trauma and severity.Results

The final sample included 45 papers (four from


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Gonalves N, Echevarrla-GuaniloME,CarvalhoFL,MiassoAI,RossiLA. 625experimental andqualitative); threeaslevelVII (expertopinion); and one as level V (systematic review).Numbers were used to refer to the papers included inthis review: 3 and 4; 6 to 12 and 20 to 55.

Next, the three identified categories arepresented.Factors related with social ndemotional s upport

The factors associated with this group wereidentified in 20 papers, 18 of which were classifiedasevidence levelVI.

According to two studies with a correlation design(evidence level VI , emotional support is associatedwith better rehabilitation and quality of life' ^^'but, atthe same time, one study mentions that living alone is

related with better integration in domestic and socialactivities,as burns victims would perform their activitiesindependently'^^'.Psychoiogicai factors

These factors were foundin 22papersandorganizedin three sub-categories: factors related with mentalhealth condition and individual characteristics beforetheaccident; related with treatment experience and withpost-trauma adaptation mechanisms. Factors relatedwith mental health conditionand individual characteristicsbefore the accident include aspects related to negativeexperiences before the accident, drugs abuse, organicbrain syndromes, psychological development, copingstrategiesand self-esteem (Figure2 .

vide nce LevelE-VI

E-VII

Team supp'; connm ufamily'^ ';

Ort'


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626 Rev. Latino-A m. E nfermagem 2011 M ay-Jun;19(3):622-30.Evidence Level

E VE V I

VII

Factors related with post trauma adaptation mechanismsDepression' 'Post-traumatic stress'^' ''^'anguish''^^' ';psychological vulnerability and feelings of threat' '; anxiety ^'^ ; dissatisfactionwith body image' ^; depres so '^^*Post-traumatic stress''^'

Figure 4 - Distribution of papers according to evidence level and factors related with post-trauma adaptationmechanisms

Factors related with burn trauma and severityRegarding the factors related with the burn trauma and severity, 31 papers were identified, shown in Figure 5.

Evidence LevelE VE V i

VII

Factors related with burn trauma and severityBurn location' 'Burned body surface'^^^as :-); burns on hands''', on feet'^ , in the face^'*' '; burn iocation'); burn severity'^4.6.11.20.22.24.42). gcars'^ ; facial disfigurement(46); limb amputation' '; time after injury'* ,in toleranc e to cold'^s', to heat'-5='; tosun light' '^', itchin g'^', numbness'^^', disfigurement' ''^ ', sleeping problems'^^', care depe ndence'**'; pain'^'-^'-^''^';weakness' '^ ' ' ,number of burns in different body parts'^', decreased physical mobility'^-^'**', need for graft'' and type of bu rn'Hand burns *'; scars *';pain' *'

Figure 5 - Distribution of papers according to evidence level and factors associated with burns trauma and severity

As for the factors associated with the burn traumaand severity, greater TBSA burned was associated withworse adaptation after hospital discharge in different

DiscussionIt is known that the rehabilitation process of burn

patients is complex, needs a multidisciplinary team,with a holistic care focus, and should aim to enhanceadaptation, including physical, psychological andsocial recovery. Therefore, knowledge is needed aboutthe different (internal and external) factors that caninfluence these people's reha bilitation. TBSA burned wasappointed as a sign of worse adjustment and quality oflife in some des criptive studies in this review (level VI)'=

' as , the larger the TBSA burned, the greater difficultieswill be to perform domestic chores, body care, mobility,social integration and, mainly, return to work. Burnseverity was also appointed as a factor that hampersrehabilitation and functional recovery, as it can lead tocontractures, numbness and itching skin' ' ' ' ' '^ ' .

In this review, besides burn severity and TBSAburned, mental health status before the accident(psychiatric pre-morbidities, mood disorders, chemicaladdiction), ineffective coping strategies and family

the rehabilitation process. It should be highlightedthat greater extent of TBSA burned is associated withlonger hospitalization and greater visibility of injuries. Arecently published review found similar results, despitedistinct inclusion criteria'^^'.

One of the factors that hampers the rehabilitationprocess is related w ith the patien ts' stress coping abilitiesand the strategies they use, which can be related withseveral other emotional, psychological or psychiatricdisorders (low self-esteem, depression, trait anxiety,personality disorder, among others). As identified in arecent stu dy ' ' , not included in this review, the pre-burnmental health condition can interfere in the rehabilitationprocess, as it can lead to worse psychosocial a djus tme ntandc nalso infiuence improv eme ntsinphysical function s.That research, which included 64 burn patients, foundthat 24 had depression and post-traumatic stress after12 months of fol low-up, 20 of whom had a previouspsychiatric history. It was also verified that most patientshad severe depression before the injury, while only twoparticipants did not experience any previous episode ofpsychiatric diso rde r' '. In this review , studies showedthat depression was more present in patients after theburn and that greater TBSA burned and hand and faceburn visibility can increase the chance of developing


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Gonalves N, Echevarria-GuaniloME,Carvalho FL, MiassoAI,Rossi LA. 627another study calls attention to the fact that even burnvictims without previous mental health diagnoses weremore vulnerable than the general popu lation, which canbe a factor that contributed to the accident'^^'.

As identified in the results, previous negativeexperiences and patients' personality are predisposingfactors regarding emotional conditioninth elongte rm.Theprevious Identification of these problems delays possiblecomplications during hospitalization and rehabilitation,besides helping care planning' ' '. Personality can alsoinfluence the appearance of post-traumatic stress andis related with individual coping'^'. It can delay returnto work' ' and this return, when hampered or absent,can lead to cases of post-traumatic stress'^'. Post-traumatic stress can be defined as an anxiety disorder,characterized by the occurrence of a traumatic event theperson experienced or witnessed, manifesting intensefeelings of fear, impotence or h or ro r' '. The burn is atrauma tizing event since, as reported, i t exposes victimsto pathogens, due to the loss of skin integrity, as wellas to perceptions, feelings and psychological reactionsrelated to the fact of being burned, which victims arenot always ready to cope wi th. The appearance of post-traumatic stress in burn patients is the main psychiatricillness. Health professionals should pay attention toidentify i ts signs and symptom s, demanding com petence,sensitivity and specialization to deal with this situation.

Besides affecting the victim, the burn affects theentire family, which should also receive attention andbe included in care planning, with a view to a betterreturn to activities for all members and to achieve betteroutcomes, m ainly in terms of quality oflife.Social supportfrom relatives, friends and significant persons wasanother important factor found in this review. In a studyinvolving relatives of burn victims, it was observed thatthey try to help the victim through stimuli and support,such as l istening, calming down and talking , so that theperson does not feel inferior; through the demonstrationof feelings of love and happiness'^'. The fam ily also takescharge of responsibilities, involving healthy membersas well as care delivery for the relative with a healthproblem, until complete recovery is achieved. Familymembers experience the disease and its consequencestogether, entailing weakness and vulnerability, due tothe disease itself as well as the financial conditions itentails'^ '. Support sources are maintained as a resultof interpersonal relationships, culture or belief. For thepatient, family members and the team, a significantrelation' 5' and the establishm ent of a strong bond are

Another important support source found in thereviewed studies includes friends, community and healthprofessionals. Relatives consider the social network,friends, community people and even health professionalsas very important for patients with chronic conditions.The main contributions this support source offers areproximity, care delivery and financial help


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628 Rev. Latino-Am. Enfermagem2 11May-Jun;19(3);622-30.mental health condition before the accident (psychiatricpre-morbidities, mood disorders, chemical addiction),ineffective coping strategies and family support (lackof support from relatives or friends), besides the burnseverity (extreme ages, TBSA burned and full thicknessburns). Patients with problems related to one or moreof these factors should receive appropriate follow-up.Knowledge on these factors can support interventionplanning to facilitate the rehabilitation process, as wellas further studies to test interventions or care models inthe rehabilitation phase.

The quality of the identified research calls attentionto the scarce production of strong evidence in thisknowledge area, demanding further research, as burnsmainly affect men of productive age and their sequelaeentail important implications for these people's return towork and social rintgration.Psychosocial rehabilitation trials are recommendedwith a view to testing interventions in multicenterstudies, so as to expand the sample size, and producingreliable scientific evidence to improve care quality forburn victims.References1. World Health Qrganization (WHO). A WHO Plan forBurn Prevention and Care, [acesso em: 12 setembro2008]. Disponvel em: http:/ /whql ibdoc.who.int/publications/2008/9789241596299_eng.pdf.2. Riggar TF, Maki DR. Handbook of RehabilitationCounseling. New York: Spring Publishing; 2004. 377 p.3. Tanttula K, Vuola J, Asko-Seljavaara S. Return toemployment after burn. Burns. 1997;23(4):341-4.4.K imm oT, Jyrki V, SirpaAS.Health status after recoveryfrom burn in jury. Burns. 1998;24(4):293-8.5. Yu BH, Dimsdale JE. Posttraumatic stress disorder inpatients with burn injuries. J Burn Care Rehabil. 1999;20(5) :426-33 .6. Dyster-Aas J, Kildal M, Willebrand M. Return towork and health-related quality of life after burninjury. J Rehabil Med. 2007 January;39(l):49-55. doi:10.2340/16501977-0005.7. Rossi LA. O processo de cuidar da pessoa quesofreu queimaduras: significado cultural atribuido porfamil iares. Rev Esc Enferm USP. 2001;35(4):336-45.8. Silva MF, Silva MJP. A auto-estima de pacientesambulatoriais com queimaduras. Rev Baiana Enferm.2002;17(3) :75-84 .9. Scherer ZAP, Luis MAV. Percepes e significados

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39 . Esselman PC, Ptacek JT, Kowalske K, Cromes GF,deLateur BJ, Engrav LH. Community integration afterburn injuries. J Burn Care Rehabii. 2001;22(3):221-7.40. Thombs BD, Bresnick MG, Magyar-Russell G.Depression in survivors of burn injury: a systematicreview. Gen Hosp Psychiatry. 2006;28(6):494-502. doi:10.1016/j.genhosppsych.2006.08.0104 1. Questad KA, Patterson DR, Boltwood MD, HeimbachDM , Dutcher KA, de Lateur BJ, et al. Relating mentalhealth and physical function at discharge to rehabilitationstatus at three months post-burn. J Burn Care Rehabii.1988 ;9 ( l ) :87 -9 .42. Bowden ML, Thomson PD, Prasad JK. Factorsinfiuencing return to employment after a burn injury.Arch Phys Med Rehabii. 1989;70(10):772-4.43. Cobb N, Maxwell G, Silverstein P. The relationshipof patient stress to burn injury. J Burn Care Rehabii.1991;12(4) :334-8 .44. Peota C. Survivor support. Minn Med.2 0 0 4 ; 8 7 ( 3 ) : 3 0 - l .45. Blumenfield M, Shoeps M. Reintegrating the healedburned adult into society: psychological problems andsolutions. Clin Pias Surg. 1992;19(3):599-605.46. Fukunishi I, Sasaki K, Chishima Y, Anze M, SaijoM. Emotional disturbances in trauma patients duringthe rehabil i tation phase: studies of posttraumaticstress disorder and alexithymia. Gen Hosp Psychiatry.1996;18(2) :121-7 .47. Blalock SJ, Bunker BJ, DeVellis RF. Psychologicaldistress among survivors of burn injury: the role ofoutcome expectations and perceptions of importance. JBurn Care Rehabii. 1994;15(5):421-7.48. Fauerbach JA, Heinberg LJ, Lawrence JW, MunsterAM, Palombo DA, Richter D, et al. Effect of early bodyimage dissatisfaction on subsequent psychological andphysical adjustment after disfiguring injury. PsychosomMed. 2000;62(4) :576-82.49.W illebrand M,W ikehultB,EkseliusL. Social desirabili ty,psychological symptoms, and perceived health in burninjured patients. J Nerv Ment Dis. 2005;193(12):820-4.doi: 10.1097/01.nmd.0000188976.84146.c350. Patterson DR, Questad KA, Boltwood MD, CoveyMH, de Lateur BJ, Dutcher KA, et al. Patient self-reportsthree m onths after sustaining a major burn. J Burn CareRehabi i . 1987;8(4):274-9.51. Helm PA, Walker SC. Return to work after burnin jury. J Burn Care Rehabii . 1 99 2; 13 ( l ) :5 3-7 .52. Druery M, Brown TL, Mller M. Long term functionaloutcomes and quality of life following severe burnin jury. Burns. 2005;31(6):692-5. doi : 10.1016/j .


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