A Comparison of Three Different Physiotherapy Modalities Used in the ...

Original Article

A Comparison of Three Different Physiotherapy Modalities Used in the Physiotherapy of Burns Zübeyir Sarı, PT, PhD,* Mine Gülden Polat, PT, PhD,* Bahar Özgül, PT, MSc,* Onur Aydoğdu, PT,* Burcu Camcıoğlu, PT, MSc,* Ahmet Hakan Acar, MD,† Saadet Ufuk Yurdalan, PT, PhD*

The present study compared the effectiveness of matrix rhythm therapy, ultrasound treatment (UT), laser treatment (LT) used in the physiotherapy of burns. The study was conducted at the Wound and Burn Healing Center, Dr. Lütfi Kırdar Kartal Education and Research Hospital (Turkey) from June 2009 to January 2012. The case series comprised 39 individuals with second- and third-degree upper-limb burns, whose burn traumas ended approximately 1 to 3 months previously. Participants were separated into three groups: matrix rhythm treatment (MRT), UT and LT; each group was also applied a treatment p rotocol including whirlpool and exercise. Pain, range of motion (ROM), muscular strength, skin elasticity, and sensory functions were evaluated before and after the treatment. Pressure sense and passive ROM were higher in the MRT group than in the LT group (P < .05). Pain was lower in the LT group than in the UT group, and passive ROM was higher in the UT group than the in LT group (P < .05). Active ROM was found to increase in all treatment groups, whereas passive ROM increased only in the MRT and UT groups; pressure sense increased only in the MRT group, and pain decreased only in the LT group (P < .05). MRT was found to be more effective in the restoration of sensory functions than LT, whereas LT was more effective in reducing pain than UT. No significant difference was observed in terms of skin elasticity according to the results of three treatment modalities. It is suggested that further research with more cases should be conducted to examine the long-term effect of treatment modalities. (J Burn Care Res 2013;34:e290–e296)

Burn traumas are the second most common traumarelated cause of death after traffic accidents in both developed and developing countries.1 Survival rates after burn traumas have increased, indicating the importance of the rehabilitation process.2 Physical and psychological recovery in individuals surviving burns lasts for months and even years. However, physiotherapy evaluation methods and approaches applied after burns differ in many health centers. The approaches used during the rehabilitation process include electrotherapeutic modalities such as heat, sound and mechanical waves, light and electrical currents.3 Accepted for publication September 28, 2012 From the * Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Marmara University, Istanbul, Turkey; †Wound and Burn Healing Center, Dr. Lütfi Kırdar Kartal Education and Research Hospital, Istanbul, Turkey The authors declare no conflict of interest. Address correspondence to Zübeyir Sarı, PT, PhD, Marmara University, Health Sciences Faculty, Department of Physiotherapy and Rehabilitation, Istanbul, Turkey. Copyright © 2013 by the American Burn Association 1559-047X/2013 DOI: 10.1097/BCR.0b013e3182789041

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General physical symptoms of burns include pain,4,5 sensory disorders, irritation,5 loss of physical strength,4,5 and reduced joint mobility.4 Burns require complex and long-term rehabilitation because of the formation of scar tissues, contracture, amputation, neuropathy, heterotrophic ossification, and pain.2 Despite very good treatment, scar tissue is inevitable in all severe burns, except superficial dermal burns.1 Healing of a burn injury depends on the formation of scar tissue with the help of injured tissue collagen fibers.6 Although scar tissue cannot be completely removed, it can be minimized via various physiotherapy approaches.1 All of the physical problems resulting from a burn injury result in reduced daily functionality, limitation of physical roles, and pain.7 It is important to focus on alternative treatment methods that will shorten the healing period of the injury and enable the formation of a quality scar. Therapeutic ultrasound is a common treatment used in wound healing. It can be used in the inflammatory, proliferative, and remodeling phases of wound

Journal of Burn Care & Research Volume 34, Number 5

healing at 0.125 to 3 watt/cm2, 1 to 3 MHz. The basic feature of the ultrasound enabling tissue healing is its mechanical effect.8 Electric stimulation and laser treatment (LT) also facilitate and accelerate wound healing. LT is used in decubitus ulcers, open wounds, venous ulcers, graft ulcers, incisions, lacerations, and burns.8 LT accelerates biochemical reactions, fibroblast activity, collagen metabolism, neovascularization, and quality scar and wound formation.9,10 A new therapeutic and clinic modality, matrix rhythm treatment (MRT), which activates and rebalances specific physiological vibrations of skeletal muscles and nervous system was improved by Dr. Ulrich Georg Randoll.11 It is applied by an electrically powered oscillator (resonator) comprising an asymmetric (cam type) head whose mechanical oscillations are being supplemented by a magnetic sinusoidal phase synchronized field. These mechanical oscillations produce a visually detectable longitudinal motion in the musculature similar to that under muscle strain.11 There is no previous study in the literature on the alleged effects of this new treatment modality on burn injuries, such as cell regeneration and fast healing at a cellular level. Main purposes of physiotherapy are to increase the range of joint motion, develop the functions,6 increase local circulation and scar flexibility, enable muscle relaxation to increase mobility, increase hydration of scar tissue, and to reduce pain.3 Therefore, physiotherapy applications are of great significance in the rehabilitation of patients who have suffered burns.12 The present study compared the short-term effects of ultrasound treatment (UT), LT, and a new application, MRT modalities, which are used in the physiotherapy of burns patients.

METHODS The study was conducted at the Wound and Burn Healing Center, Dr. Lütfi Kırdar Kartal Education and Research Hospital (Istanbul, Turkey) between June 2009 and January 2012. Participants were chosen randomly from patients attending the Center, who were aged 18 to 65 years and had secondor third-degree upper-limb burns. Forty-five burn patients were randomly allocated to three groups via sealed-envelope technique: MRT,14 UT,14 or LT.11 Six patients who could not keep on the treatment owing to transportation problems or weather conditions, were excluded from the rest of the study (n = 39). All participants gave signed informed consent, and the present study was approved by the Local Ethics Committee at the Dr. Lütfi Kırdar Kartal Education and Research Hospital (4/26.03.09).

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Participants underwent physiotherapy after a minimum 1-month and maximum 3-month period after the burn trauma, and their treatment protocol began when the first evaluations were completed. All participants were assessed two times in pre- and post-15 sessions treatment via same protocol. Pain, range of motion (ROM), muscle strength, skin elasticity, pressure sense, and two-point discrimination sense were evaluated via visual analog scale, goniometer, myometer (J-Tech, Powertrack Commander II), durometer (Schmidt Control Instruments), Semmens-Weinstein Monofilaments (Touch-TestTM Sensory Evaluator Instructions) and Touch-TestTM discriminator (Touch-TestTM, North Coast Medical, Inc., CA). All participants were wearing burn garment. Joints including burn tissues are assessed with goniometer and are reported as “degree.” ROM of shoulder flexion, extension, abduction, internal and external rotation, elbow flexion, extension, pronation and supination, wrist flexion, extension, ulnar and radial deviation, thumb flexion, extension, abduction, adduction, 2 to 5 metacarphalangeals flexion, extension, proximally and distally interphalangeal flexion, extension, abduction, adduction are assessed because of including only upper extremity burn cases in the study. Average values of the measurements in the joints were calculated for burned injured extremity. Muscle strength of muscles of the body parts including burn tissue, were measured via myometer and recorded as newton. Measurement of muscle strength at pre- and posttreatment was performed as triplicate, and average value of three measurements was calculated. Skin elasticity was measured via durometer by determining three areas that were in the burned tissue of participants and was recorded as millimeter by calculating the average value of three measurements. Monofilament assessment was applied to 12 seperated areas; anterior–posterior and medial–lateral parts of arm, forearm and hand, and 10 seperated areas; and palmar–dorsal parts of fingers. The distribution of burned areas of the participants is shown in Tables 1, 2, and 3. The same treatment protocol was applied to all participants of three groups during 3 weeks of therapy of five sessions per week. The treatment protocol began with the whirlpool application, followed by either matrix rhythm, ultrasound or LT; all treatments concluded with a stretching and exercise regime. Whirlpool application is applied for 15 minutes to all participants. MTR was applied to the region of scar tissue and the surrounding tissues at a frequency range of 8 to 12 Hz. The application was conducted from proximal-to-distal and central-to-peripheral tissues for 15 to 45 minutes

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Table 1. Distribution of burned areas of the participants of MRT group Burn Area Subjects 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Age (yrs)

Right hand

Left hand

Right forearm

Left forearm

Right arm

Left arm

39 39 41 24 39 36 45 40 60 55 35 50 58 58

+ + − + − + + + − + + + + −

+ + + + − − − − + − − − − +

+ + − − − + + + − + + + + −

+ + − − − − − − + − − − − +

+ + − − + + − + − − − − − −

+ + − − − − − − + − − − − −

by physiotherapists qualified in MTR. Continuous ultrasonic waves of 1 MHz frequency and intensity of 1 W/cm2 were applied with a 5-cm diameter applicator for 5 minutes per session. LT was applied with a continuous 808-nm GaAlAs laser for 10 minutes at 960 joule. The region of scar tissue was separated into 10 equal areas, each of which received 1-minute continuous LT; care was taken to not apply the laser to open wounds or bony tissue. The treatment was completed with active assistive ROM and passive ROM, strengthening, stretching, and proprioceptive neuromuscular facilitation exercises in the period of 15 minutes for all joints of the burned area. Proprioceptive neuromuscular facilitation exercises were used to reduce the joint limitations.

SPSS 15.0 (SPSS Inc, Chicago, IL) was used for statistical analysis. Variables were determined as mean ± SD (X ± SD), frequency, and percentage. Statistical significance was determined to be P < .05. Wilcoxon and Kruskal–Wallis tests were used for intragroup and intergroup comparisons of pain, ROM, muscle force, elasticity, and sense evaluations. Significant intergroup data were compared in two groups via the Mann–Whitney U test with a Bonferroni correction method.

RESULTS Ten of 39 participants (25.6%) were women, whereas 29 cases (74.4%) were men, and the average overall

Table 2. Distribution of burned areas of the participants of UT group Burn Area Subjects 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Age (year) 36 58 26 56 16 16 21 50 44 25 25 41 41 36

Right hand

Left hand

Right forearm

Left forearm

Right arm

Left arm

− − + − − + − − + − + − + −

+ + − + + − + + − + − + − +

− − + − − + − − + − + − − −

+ − − − + − + − − + − + − +

− − − − − + − − + − − − − −

+ − − − + − − − − − − + − +


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Table 3. Distribution of burned areas of the participants of LT group Burn Area Subjects 1 2 3 4 5 6 7 8 9 10 11

Age (year) 51 36 50 16 16 25 25 49 30 30 24

Right hand

Left hand

Right forearm

Left forearm

Right arm

Left arm

+ − − + − − + − − + −

− + + − + + − + + − +

− − − − − − − − − − −

− − − − − − − − − − −

− − − − − − − − − − −

− − − − − − − − − − −−

age was 37.48 ± 13.29. Physical characteristics of participants are shown in Table 4. The case series included 12 individuals with second-degree burns (30.76%) and 27 cases with thirddegree burns (69.23%), and 30 cases had undergone grafting surgery. Sex, severity of burn, and grafting distributions of the cases are given in Table 5. Treatment groups were similar in terms of the first measurements of age, pain, pressure sense, two-point sensory discrimination, active and passive ROM, muscular strength, and skin elasticity evaluations (P > .05; Table 6). Kruskal–Wallis comparison of pre- and posttreatment data showed no statistically significant intergroup differences for active and ROM, two-point discrimination, muscular strength, and skin elasticity. (P > .05; Table 7). A statistically significant difference was found between pre- and posttreatment measurements of pain, pressure sense, and passive ROM (P < .05). The Mann–Whitney U test with a Bonferroni correction was used to determine the group to which these differences belong. No significant difference was observed between the pre- and posttreatment data for the MRT and UT groups (P > .017; Table 8). Pressure senses and passive ROM of the MRT group were significantly Table 4. Physical characteristics of participants

MRT group UT group LT group

Age (yr)

Body Weight (kg)

Body Height (cm)

44.21 ± 10.56

71.85 ± 15.31

168.14 ± 8.21

35.07 ± 14.00 32.00 ± 12.93

72.71 ± 17.73 66.18 ± 10.73

170.64 ± 9.98 170.90 ± 11.59

MRT, matrix rhythm treatment; LT, laser treatment; UT, ultrasound treatment.

higher than that of the LT group (P < .017). Passive ROM of the UT group was significantly higher than the LT group, and severity of pain in the LT group was significantly less than in the UT group (P < .017). The variations between pre- and posttreatment measurements of the MRT group were compared via Wilcoxon test, and statistically significant increases were found for pressure sense, active ROM, passive ROM, and muscle force (P < .05; Table 9). The UT group showed significant increases in active and passive ROM (P < .05; Table 9); The LT group showed a significant posttest decrease in pain evaluation, and a significant increase in active ROM (P < .05; Table 9).

DISCUSSION This study compared existing ultrasound and LTs with a new MTR in the physiotherapy of burns. Preand posttreatment data were evaluated via intragroup and intergroup comparisons. Pre- and posttreatment data were compared on terms of pain, pressure sense, discriminative sense, ROM, muscle force, and skin elasticity, and significant differences were found for pain, pressure sense, and passive ROM. Intergroup comparisons (MRT–UT; MRT–LT; and UT–LT) were made of these three significant parameters. Passive ROM in the MRT and UT groups increased significantly more than the LT group. However, no significant differences were observed between the changes in the MRT and UT groups. These results indicate that MRT and UT modalities have a similar effect on passive ROM. Similarly, there was a significant posttreatment increase in active and passive ROM in the MRT and UT groups; however, the LT group only showed a significant increase in terms of ROM. Loss of motion is one of the most common complaints after scar and contracture development in

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Table 5. Sex, severity of burn, and grafting distributions of the cases Sex

MRT group UT group LT group

Degree of burn

Grafting

Female

Male

2

3

Yes

No

4 4 2

10 10 9

2 7 3

12 7 8

13 11 6

1 3 5


burn patients.13 A previous study examined changes in ROM in burn patients during physiotherapy, comparing the effects of different exercise approaches rather than different treatment modalities.12 That study found that scar contractures were less likely to develop in the group that performed exercises simultaneously with electric stimulation, followed by stretching exercises, compared with patients following a standard physiotherapy program.12 However, in the present study, all the treatment groups performed the same exercise program, to determine the effectiveness of different treatment modalities. The increase in the passive ROM in the MRT group may result from the microstretching characteristic of the treatment on the scar tissue.14 There is insufficient evidence of the clinical effectiveness of therapeutic ultrasound, which is used for the treatment of pain and musculoskeletal injuries, to support soft-tissue healing. In another study of therapeutic ultrasound on ROM and pain in burn patients, no significant difference was found between placebo and therapeutic ultrasound.13 However, in the present study, the increase in movement in the UT group compared with the LT group was thought to result from one of the nonthermal effects of the ultrasound, namely its mechanical characteristic;8 this may result from the finding that it increases skin elasticity on soft tissue. On examination of the distributions of other parameters of pain and sense evaluations between which a significant difference was observed, the increase in the monofilament values evaluating the

pressure sense in the MRT group before and after the treatment was found to be higher than the LT group. The change between pre- and posttreatment pressure sense was significantly greater in the MRT group than in the LT group. The significant increase in the senses of the MRT group was determined to be parallel to the abovementioned result. Sensory impairment is a common result of burn injuries.15 Previous studies suggested an increase in the thresholds of pressure and two-point discrimination senses in the unburned extremity by considering it as the control region.16–19 Malenfant et al16 reported that the decrease in the threshold may result from peripheral mechanisms, as the loss of senses in the burned region affects the nerve endings of the scar tissue; the nerve fibers are damaged; and as the nerve fiber healing is not completed in the burned region. No previous study has examined the effects of physiotherapy modalities on sensory functions. The present study determined that the MRT has a positive effect on restoring sensory function. This may result from the suggestion that MRT rebalances the cellular microprocesses upon which cell regeneration and cellular healing depend.14 However, further studies should be conducted to determine the effect of MRT on sensory functionality in the physiotherapy in burns. Pain is another common complaint of burn patients undergoing physiotherapy.16 The visual analog scale used in the present study showed that pain was significantly lower in the LT group than in the UT group at the end of a 15-session treatment program. This

Table 6. Pretreatment evaluation

Age (yr) Pain Pressure sense Discrimination Active ROM Passive ROM Muscle strength Skin elasticity

MRT group

UT group

LT group

χ2

P

44.21 ± 10.56 4.77 ± 2.22 4.89 ± 7.42 10.44 ± 2.84 53.49 ± 29.80 71.78 ± 24.57 67.76 ± 25.15 17.50 ± 6.56

35.07 ± 14.00 3.07 ± 3.05 2.28 ± 7.94 9.84 ± 3.06 49.63 ± 13.42 65.15 ± 8.87 82.50 ± 31.19 23.09 ± 7.88

32.00 ± 12.93 2.67 ± 1.69 11.95 ± 32.37 9.20 ± 3.83 48.27 ± 14.92 69.93 ± 18.50 83.77 ± 27.00 18.77 ± 7.02

5.407 5.926 5.097 2.492 0.144 1.771 2.447 3.733

.067 .052 .780 .288 .931 .413 .294 .155



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Table 7. Pre- and posttreatment comparison of patient groups

Pain Pressure sense Discrimination Active ROM Passive ROM Muscle strength Skin elasticity

MRT group

UT group

LT group

χ2

P

−1.53 ± 2.62 −3.46 ± 6.08 −0.02 ± 1.42 13.18 ± 9.45 12.84 ± 8.62 10.02 ± 16.98 −0.99 ± 4.08

0.26 ± 1.40 0.08 ± 0.33 −0.32 ± 3.08 11.79 ± 11.34 8.75 ± 6.34 4.12 ± 23.41 1.52 ± 5.74

−1.75 ± 2.48 3.34 ± 7.37 −1.32 ± 1.98 10.65 ± 9.11 1.25 ± 3.10 27.54 ± 49.71 −0.48 ± 3.51

8.279 8.909 2.812 0.195 13.820 0.965 1.527

.016* .012* .245 .907 .001* .617 .466

MRT, matrix rhythm treatment; LT, laser treatment; UT, ultrasound treatment. *P