Thermal burns & chiropractic: A case study

Journal of the American Chiropractic Association, May 1999 by Hendricks, Chris L, Larkin-Thier, Susan M

Chiropractors are typically consulted to care for patients who have suffered musculoskeletal injuries. The following case is complex in that there was traumatic tissue destruction with neurological compromise-in addition to the musculoskeletal component. Although the patient received months of medical pain care, she still experienced debilitating pain and discomfort, as well as slow healing of the cutaneous tissues.

Skin and Burns

The skin is one of the most important components of the human body. Its primary function is to serve as a protective envelope for all the underlying tissues. A secondary function is to serve as an organ of excretion, regulating the body temperature through evaporation and radiation.'

There are three layers of skin, the epidermis, dermis, and subcutaneous layer. The epidermis, the outermost layer, contains durable cells with nerve endings and pigment granules. The dermis, the middle layer, is made up of dense connective tissue, which gives the skin its strength and elasticity. The dermis layer also contains sweat glands, sebaceous glands, and hair follicles. The deepest layer is the subcutaneous layer, made up of fatty tissue. Its thickness depends on the body region, sex of the person, obesity, and other issues.'

The three classifications of burns are as follows:

Thermal burns, due to heat

Chemical burns, due to acids and alkalis

Electrical burns, due to electrical current passing through the body.2

Despite the many technological advances made in the diagnosis of burn depth; most commonly, however, burn depth is determined based on the clinical judgement of the burn surgeon.3

Thermal burns cause approximately 9,000 deaths annually in the United States. Clinical presentation of direct thermal injury is dependent on the degree of damage, a direct function of the intensity and duration of exposure to skin. First-degree burns are painful, red, swollen, and they blanch with pressure. The most common causes are ultra-violet radiation, scalding, low-intensity exposure to steam, or contact with a hot object. Second-degree burns create painful red blisters or broken epidermis, exposing a weeping edematous surface. They are most often caused by sca ds or brief exposure to a flame. Third-degree burns usually result from prolonged contact with steam, hot objects, or flames. They create ulceration, tissue necrosis, and are often painless because nerve tissue in the area has been destroyed.4

Many complications occur during the healing phase of burns. Infection remains the major cause of morbidity and mortality. Measures to reduce the risk of wound infection and subsequent sepsis include early excision, where possible, and the use of topical antimicrobial creams, such as Silver Sulphadiazine.s Mechanisms of re-epithelialization, reattachment (skin grafting) and remodeling may result in skin prone to blistering, dryness, itching, contact dermatitis, photosensitivity, and hypertrophic changes in the relatively early course of healing.6

Noxious pain and thermal stimuli are carried by small myelinated fibers (delta) and unmyelinated fibers (G fibers). The diameter of these fibers differs greatly. Therefore, the speed with which stimuli travel varies, creating a consequence known as "double pain." The stimulus carried by the delta fibers is faster and causes a sharp pain that rises to a crescendo. This is the fast pain or first pain. The second pain, or slow pain, is poorly localized and particularly unpleasant.7

Burn-related pain is often severe and intermittently excruciating for months after the initial injury as a result of the multiple interventions necessary. While procedure-induced pain is untreated, general pain management is usually integrated into the overall patient care plan. In the case presented here, thermoreceptors had responded to noxious thermal stimuli, lowering their thresholds. Therefore, the thermoreceptors were responsive to relatively mild stimuli.8

When this patient presented for chiropractic management of her back and leg pain, the choice of an effective, yet non-invasive technique was necessary. Activator Methods (AM)* adjusting technique was selected because it is a standardized system of chiropractic analysis and low-force spinal adjusting technique. The Activator instrument was developed, and is currently used, to increase control of speed, force and direction of adjustive thrusts and reduce physical stress on clinicians. The modern Activator adjusting instrument is the product of many modifications and makes use of a hammeranvil effect to produce safe, reliable, and controlled force to osseous misaligned or subluxated structures.10

Case Report

Ms. K, a 61-year-old white female, sustained second- and third-degree burns over eight percent of her body. The burns came about when a hot steamer fell on her while she was attempting to remove wall paper in January, 1996. The patient sustained burns on the lower back, buttocks, and posterior lower extremities. (See Photo 1) She was treated by her private medical physician for four days, then referred to Trinity Medical Center Burn