Original Recibido: 22/08/2024 │
Aceptado: 20/11/2024
Effect
of strength work on muscles affected by hypodermic B burns in the shoulder
girdle
Efecto
del trabajo de fuerza en músculos afectados por quemaduras hipodérmicas B en la
cintura escapular
Juan Nicolás Soriano Justiz; Assistant Professor. University
of Medical Sciences of Granma. Cuba. [sorianojuannicolas@gmail.com]
Juan
Nicolás Soriano Díaz; Assistant Professor. University of Medical Sciences of Granma. Cuba. [juannicolassorianodiaz@gmail.com]
Roberto Frías Banqueris; Part-Time Professor. Clinical Surgical Teaching
Hospital “Celia Sánchez Manduley”. Plastic Surgery and Caumatology Service. Cuba. [rfbanqueris@gmail.com]
Alexis Rafael Macías Chávez; Full Professor.
University of Granma. Cuba. [amaciasch@gmail.com]
Abstract
The use of therapeutic physical exercise in
the treatment and integral rehabilitation of the burned patient is a resource
of outstanding value to get the capacity of movement back as part of the health
care of this entity. The present study aims at identifying the influence of a
system of physical exercises in the improvement of the strength of muscles
affected by hypodermic B burns in the shoulder girdle. This proposal is
determined from the study of a sample of 10 people with hypodermic B burns in
the shoulder girdle, 6 women and 4 men, with an average age of 39.4 years (23
minimum and 59 maximum), the data collected in the medical records and the
results of the initial and final explorations of the osteomyoarticular system
were analyzed. The DeLorme-Watkins Method was applied with the intention of
determining the evolution of muscle strength. At the end of the intervention, higher
results were recorded in each of the elements subjected to evaluation. The
system of therapeutic exercises created supports shorter recovery times of the burned
patient's strength.
Keywords:
Burns; Physical
therapy modalities; Burned patient; Therapeutic physical exercise; Muscle str Resumen:
El empleo del ejercicio
físico terapéutico en el tratamiento y la rehabilitación integral del paciente
quemado es un recurso de extraordinario valor para lograr la recuperación del
movimiento como parte de la atención de salud a esta entidad. El presente
estudio tiene como objetivo identificar como influye un sistema de ejercicios
físicos en la mejoría de la fuerza de los músculos afectados por quemaduras de
hipodérmicas B en la cintura escapular. Esta propuesta se determina a través de
una muestra de 10 personas con quemaduras hipodérmicas B en la cintura
escapular: (6 mujeres y 4 hombres), un promedio de edad de 39.4 años (23 mínimo
y 59 máximo), se analizaron los datos recogidos en las historias clínicas y los
resultados de las exploraciones del sistema osteomioarticular iniciales y
finales. Se aplicó el Método de DeLorme-Watkins con la intención de determinar
la evolución de la fuerza muscular. Al final de la intervención se lograron
registros superiores en cada uno de los elementos sometidos a evaluación. El
sistema de ejercicios terapéuticos creados respalda mejores plazos de
recuperación de la fuerza del paciente quemado.
Palabras clave: Quemaduras; Modalidades de Fisioterapia; Paciente
quemado; Ejercicio físico terapéutico; Fuerza muscular.ength.
Introduction.
Burns occupy a particular
place within the surgical injuries and diseases, which is due to the fact that,
along with the local injury, general disorders that can affect all organ
systems and functional cycles occur. This occurence definitely determines the
evolution of the process entailed to the general and often prolonged treatment
in which local and general therapeutic exercises have equal importance;
although in the different phases of the therapeutic evolution one or the other
may predominate, the serious disorders make every burn become an important
disease that today is still marked by a high level of mortality.
In the words of Xhardez
(2018), the burn is “the effect of an aggression on the skin and underlying
tissues according to two processes: Destructive, causing tissue necrosis and
susceptibility to infection and Evolutionary, the severity may appear after
several hours.”
In the opinion of Dupin
(2020), major burned patients have many consequences, both physically and
psychologically, since burns lead to a loss of autonomy, and often to a
restriction of the movements that the patients can make. In this sense, it is
necessary for the professionals involved in the rehabilitation scheme of these
patients to know the elements related to the recovery of the functional state
of the muscles involved in it.
With regard to
rehabilitation interventions for burned patients, several authors suggest that
the preparatory phases of the exercises should have a duration of 5 to 10
minutes of warm-up (Eid, 2020; Grisbrook, 2017; Salmerón et al., 2019). Schouten et.al. 2019), in such sense are in
agreement with the results proposed by the American College of Sports Medicine
(ACSM, 2000), which recommends this duration because it facilitates the
transition from resting periods to activity, increases blood flow, raises body
temperature and favors the metabolic rate and activation of the energy source
supply system. (Betancourt, 2017), (Soriano, Macías and Banqueris, 2023).
Likewise, studies have
revealed the efficacy of muscle strength training programs in burned patients
through isokinetic exercise, recommending a duration of between 8 and 12 weeks.
Within this period of time, neural adaptations associated with improvements in
motor learning, intramuscular synchronization, intermuscular coordination,
increased nerve impulses transmitted to motor units and muscle function are
generated (Jiang, 2017).
It is worth highlighting
that in the use of the term “rehabilitation”, the idea is to restore to the
highest possible level the physical, psychological and social adaptation
functioning of people with special educational needs. It includes putting all
possible means in place to reduce the impact of conditions that are disabling
and enable the affected person to reach an optimal level of social integration.
(Crespo, et.al, 2022).
Therefore when developing a
rehabilitation program for burned patients, the therapist must always take into
account the patient's general level of fitness, the type of injury or disease,
the recovery phase after the injury and, most importantly, the desired
functional outcomes, the best way being through the intervention of a
multidisciplinary team, where each professional works to enable the patient to
relearn how to reintegrate into their daily life (Crespo, et.al, 2022).
These findings are
associated with interventions through eight-week training programs that produce
an increase in dynamic strength without producing significant changes in muscle
fiber, since during the first weeks of training neural adaptations originate
that would allow changes in muscle protein and longer training sessions produce
muscle hypertrophy (Soriano, Macias and Fonseca, 2023). It is worth mentioning
that the duration variable among physical exercise programs focused on
increasing muscle strength differs among authors due to the diversity in sample
size, total body surface area affected, length of hospital stay, age, strength
training approach and burn etiology (Leao and Duarte, 2022).
As a consequence of the elements
analyzed above, the aim of this article is to identify the influence of a
system of physical exercises on the improvement of the strength of muscles
affected by hypodermic B burns in the shoulder girdle.
Population and sample.
A
pre-experimental study of minimal control, of correlational type, was carried
out for a period of 90 days (January to April 2024), and it was conceived to
implement 45 minutes of treatment twice a week. The universe was composed of
patients with hypodermic burns B in the region of the scapular waist, admitted
to the Plastic Surgery and Caumatology Service of the Clinical Surgical
Teaching Hospital “Celia Sánchez Manduley” of Manzanillo, Granma and then
followed by external consultation for the rehabilitation treatment. The sample comprised
10 patients (6 women and 4 men) with an average of 39.4 years old (23 minimum
and 59 maximum) with hypodermic B burns in the region of the shoulder girdle,
with affectation in the normal movement patterns of the joints affected by the
lesions. All voluntary participants were asked for
informed consent after being notified about the characteristics of the
research, objectives, possible benefits, risks and alternative treatments in
case of exclusion from the study and their right to participate or not and to
withdraw their consent at any time without being exposed to limitations in
their rehabilitation process.
Burned patients with lesions
in other body areas, dermal complications of the lesions and with the need for
future surgical events were excluded. The data collected in the medical records
and the results of the initial and final explorations of the osteomyoarticular
system were analyzed to evaluate the evolution of muscle strength using the
DeLorme-Watkins Method (Leao and Duarte, 2022), applying increasing direct
loads for muscle potentiation and verified by the progressive increase of expired
weights.
In order to use the
different modalities of proposed exercises that improve the functional state of
the muscles of each patient studied, especially those that reveal a more
effective result, it is important for the therapist to be aware of the main
movements affected by the injuries and muscles to which the interventions are
directed taking into account the severity of the same in the affected limbs and
the characteristics of the muscular planes most damaged by the injuries in the
areas included in the study in favor of a long-term follow-up of the
functional, psychological and physical state, which is important for the daily
life of this patient. For this purpose, easily performed exercises are
provided, which will make it better for the therapist to direct the work with the patient.
For
the development of muscular strength, simple exercises with and without
implements are applied, which can be combined depending on the stage of
treatment. The exercises without implements are performed by means of isometric
contractions with the fundamental objectives of obtaining muscular activity
when joint displacement is impossible, mobilizing the muscular elements that
modify the muscular tone, stimulating the mechanic-receptor system of the joint
cavity, thus delaying muscular atrophy. The actions performed with implements
are shown in table 1, and are described theoretically and graphically to
understand the performance methodology.
Table 1
Exercises with implements
(canes weighing ½ -1, 2 and 2.5 kilograms) for increasing shoulder girdle
muscle strength in burned patients.
|
Exercises with varied weight cane |
||
|
No |
Theoretical description |
Graphic description |
|
1 |
Supine, raise arms outstretched to the
floor. |
|
|
2 |
Standing, raise your arms up to bring them
above your head. |
|
|
3 |
Supine, perform wide circles varying the
distance of the hands on the cane. |
|
|
4 |
While standing, slide the baton along your
back, lowering your arms at the same time without releasing it. |
|
|
5 |
While standing, slide the baton behind your
back while bending your arms. |
|
|
6 |
Standing, alternately extend your arms to
one side and the other. |
|
|
7 |
Standing, the baton is held with one hand,
perform circular movement with one hand, alternating the movement. |
|
|
8 |
Standing, with the cane held in one hand,
make wide circles with it. |
|
|
9 |
Standing, perform number 8's with the tip of
the cane held with both hands. |
|
|
10 |
Standing, extend and bend the elbows to
describe circles behind the head. |
|
These
exercises should be performed in intervals of time remaining a time of
contraction by another of rest that will double the time of work. Those
exercises may also be dosed by repetitions starting with 3 or 4 and gradually
increasing between 1 and 2 to reach a number of 10 maximum. This type of
exercise will be performed on both sides of the body, with emphasis on muscle
groups damaged by injuries, with the aim of increasing the tone and strength,
allowing you to perform more complex exercises. Its effectiveness should be in
correspondence with the increase of tone and strength in areas subjected to
immobilization that present risks of muscular atrophy and will be worked from
different positions, but the most feasible are the sitting and standing
positions, to enhance the patient's control of his body scheme, since assuming
other positions results in unnecessary energy spending and loss of time in the
treatments.
In
relation to the intensities that fluctuate between 50% to 70% of the strength,
it should be noted that the American College of Sports Medicine (2000)
similarly recommends that programs focused on muscular strength should start
from 60% of the maximum resistance and for beginners from 50% (Tinajero, 2019).
Exercises with implements (½,1, 2 and 2.5 kilogram weight stick) allow a more
complex physical activity that makes possible the future performance of certain
exercises with more rigor and correction allowing to control and materialize in
space certain figures of the articular game.
The
research work complied with the ethical aspects of beneficence and justice,
respecting the confidentiality of the patients who, through an informed
consent, authorized and confirmed their participation before the intervention.
The ethical aspects are related to maintaining confidentiality with the data
information and photographs obtained in the study and the anonymity of the
patient.
Analysis of the results.
It
is a proven fact that the physiotherapeutic practice confirms that physical
exercise achieves changes that counteract the effects of inactivity and muscle
atrophy, which are directly related to the loss of muscle strength caused by
burn injury. This kind of practice was very remarkable as shown in Figure 1,
after the implementation of the physiotherapeutic procedures for the
development of muscle strength an increase in the weights overcome by the
patient was observed, which denotes a greater potentiation of muscle strength
in the area damaged by burn injuries.
The
degree of injury caused by a burn in the shoulder region leads to loss of
elasticity in muscles and loss of movement of the anatomical structure. On the
other hand, contractures often appear due to this lack of mobility during the
recovery process, which lead many patients to report restrictions in their
activities of daily living due to limitation of movement and permanent pain. Yet,
in the present study it was shown that the degree of severity in the functional
status of the shoulder girdle muscles could be reduced by including strength
exercises in early rehabilitation interventions in burned patients.
Furthermore,
the influence on the state of muscle strength within the rehabilitation of burned
patients allows during the first weeks of treatment to originate neural
adaptations that make possible changes in muscle protein, demonstrating that
treatments of longer duration produce muscle hypertrophy, by working on
strength exercises from the initial stages of the rehabilitation process of the
burned patient an increase in their values is presented, which indicates a very
significant improvement.
The
behavior of the injured muscles and their evolution during the treatment shows
criteria of functionability applied according to the possibilities of each one
of the patients. In general, an increase in strength is observed in the group
average. However, during the first 45 days of the application of the strength
exercise program, a small increase in muscle strength is observed with respect
to the first measurement, since the group has an average of 5.8 kg, which
determines that the muscles can perform movements overcoming weights greater
than the initial state, a higher category in terms of the rehabilitation
indexes described by different authors. (Costa, 2022).
As
shown in Figure 1, the averaged group is expressed in an initial increase from
3.1 to 7.5 kg, which translates as improvement, as well as the standard
deviation parameters which decreases from 0.99443 to 0.82327, which expresses
the decrease of the standard error mean from 0.31447 to 0.26034, confirming the
effectiveness during the process. The above is explained in the following
graph, which shows the evolution of the values of muscle strength in the
patients sampled (Figure 1).
Figure 1
Muscle strength status
before and after the performance of strength exercises using the
Delorme-Watkins Method in burned patients.
At
the end of the intervention process after 90 days of treatment, the group
showed quantitatively superior changes with respect to the first measurement,
since 50% of the sample presents qualification in terms of the functional
behavior of the muscular state that can already perform movements with maximum
resistance completing the articular arc, observable in 5 patients. It is
observed in 3 patients the evolution of strength when assessing that they can
overcome 80% higher than the initial weight, representing 30% of the simple. In
2 patients, representing 20% of the group, it is observed that they can
overcome weights but do not exceed 50% of the value of the initial weight
measured. These figures remained stable throughout the process because they are
influenced by the severity of injuries, associated diseases and the incidence
of variables outside the research; however, it is considered in general terms
as a positive influence of the treatment applied.
Figure 2 shows the results
obtained, initial and final, after applying the Delorme-Watkins Method, which
made it possible to corroborate the positive effect of the exercises applied in
terms of the recovery of the functional state of the muscles.
Considering the data
analyzed between one stage and the other, the results expressed in an increase
in the cross-correlations are listed, allowing a final coefficient of the
effects above the upper confidence line. In the end, an increase in values is
obtained, indicating a very significant improvement (Figure 2).
Figure 2
Cross-correlations.
Confidence coefficient significance analysis (N = 10)
The current development
achieved in the field of aesthetic rehabilitation has originated a growing
interest in the physiological properties of the osteomyoarticular system as a
main element of the comprehensive rehabilitation process of the burned patient,
mainly the use of non-invasive techniques such as therapeutic exercise programs
that support the results in the social reintegration of this patient. Burns are
among the leading causes of disability, adjusted life years lost in low- and
middle-income countries, the World Health Organization (WHO, 2018) refers that:
“Burns
are a public health problem worldwide and cause about 180,000 deaths per year,
in addition, this injury is one of the main causes of morbidity with various
factors in the evolution of the pathology as morphophysiological changes,
prolonged hospitalization and disability, having great impact on the social
role of the person”.
Therefore,
the rehabilitation of this health entity has to be based on an integral
approach taking into account the incidence of each of the specialties related
to the burned patient, who is in the focus of attention, and the specialist in
therapeutic physical activity, family members and medical staff have roles that
distinguish them in each moment of intervention.This type of approach allows to
contextualize the process as a comprehensive whole in the biopsychosocial
sphere, where the exercises cease to be a complement to become a means of the
rehabilitation process and their correct determination is of special importance
for the correct orientation of the rehabilitation process.
In
the recovery of the functional state of the muscles in the burned patient, it
is necessary to take into account some considerations on physical exercise for
the success of the therapy, such as: pain relief, preservation of joint
function, which facilitates ambulation and independent activity, prevents
contractures, preserves muscle tone, raises the patient's self-esteem,
facilitates the good evolution of the injuries and improves the range of
movements and the ease of performing them. The above mentioned makes us reflect
on the knowledge that must be taken into account when trying to frame a
rehabilitation process from the perspective of therapeutic physical activity,
since the specialist must start from the way previous preventive treatments
have been carried out in order to focus with better directionality on the ways
of applying the different treatments to fulfill the objectives set for the
benefit of the comprehensive rehabilitation of these people (Soriano, Macías
and Martínez, 2023).
It
is important to point out that the aforementioned elements should not be
observed independently, but as a multidimensional system of therapeutic
exercises that achieve their effectiveness acting together and not separately,
since one gives way to the other simultaneously, the patient receiving greater
benefit with the systematic exercise regime, so it is necessary to take into
account certain requirements for its application such as: the exercises should
be performed without delay since the patient should not be expected to assume
antalgic positions that disfavor the correct muscular trophism and the correct
position of the joints that limit their arcs of movements and ease to perform
them; they must be individualized, since there are neither two patients nor two
burns alike, therefore customizing the exercises is very effective in the
treatment of this type of injury.
Taking
into account the types of burns and the individual characteristics of each
subject, the planning of the exercises becomes more effective and orderly,
dosed with a good dosage of each of the elements to be included in the
treatment, faster and more effective results will be observed in the complete
rehabilitation of these subjects. One of the principles of physical training
proven in the increase of the improvement of the most accelerated movements in
subjects submitted to the regimen of three weekly sessions is its systematic
essence. It is also progressive since the exercises should be progressive both
in the amount of structures related to the activity performed and in the
complexity accentuated in the rehabilitation process. Finally, it is also
dynamic since in the hands of the specialist in therapeutic physical activity
it reveals a means to accomplish the objectives set, the sessions should be
motivating and respond to the needs of these patients, providing them with a
weapon that makes it possible to create better styles of confrontations.
(Soriano and Macías, 2022).
An
analysis of the general evolution of the group shows that the application of a system
of physical exercises improves the strength status of the muscles affected by
hypodermic burns B in the shoulder girdle in all patients, which demonstrates
that most of the problems of motor function of burned patients is due to the
presence of a gradual muscle atrophy in the damaged areas mainly caused by
physical inactivity. The severity of the injuries and the positions against the
pain that these patients assume will cause more aggressive manifestations with
the course of time since elements such as age, loss of strength and
maneuverability of the muscles and tendencies of late application of treatments
are added, reinforcing the importance of the urgency of the therapeutic
physical activity required in these cases.
Conclusions
The results obtained through
the research allowed the knowledge that the therapeutic system used was
effective to improve the strength of the muscles affected by hypodermic burns B
in the shoulder girdle, experiencing a significantly higher increase in their
values after applying the selected exercises.
The importance of the basic
principles of Therapeutic Physical Culture as a simple and low-cost way of
intervention is demonstrated in terms of the benefits provided by the integral
treatment of burns.
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