A systematic review protocol on the effectiveness of therapeutic exercises utilised by physiotherapists to improve function in patients with burns
Mudawarima et al. Systematic Reviews
A systematic review protocol on the effectiveness of therapeutic exercises utilised by physiotherapists to improve function in patients with burns
Tapfuma Mudawarima 0 1
Matthew Chiwaridzo 2
Jennifer Jelsma 0
Karen Grimmer 3
Faith Chengetayi Muchemwa 2
0 School of Health and Rehabilitation Sciences, Faculty of Health Sciences , Observatory , University of Cape Town , Cape Town , South Africa
1 Rehabilitation Department, Harare Central Hospital , P.O Box ST 14, Southerton, Harare , Zimbabwe
2 University of Zimbabwe, College of Health Sciences , P.O Box A178, Avondale, Harare , Zimbabwe
3 Stellenbosch University , Cape Town , South Africa
Background: Therapeutic exercises play a crucial role in the management of burn injuries. The broad objective of this review is to systematically evaluate the effectiveness, safety and applicability to low-income countries of therapeutic exercises utilised by physiotherapists to improve function in patients with burns. Population = adults and children/adolescents with burns of any aspect of their bodies. Interventions = any aerobic and/or strength exercises delivered as part of a rehabilitation programme by anyone (e.g. physiotherapists, occupational therapists, nurses, doctors, community workers and patients themselves). Comparators = any comparator. Outcomes = any measure of outcome (e.g. quality of life, pain, muscle strength, range of movement, fear or quality of movement). Settings = any setting in any country. Methods/design: A systematic review will be conducted by two blinded independent reviewers who will search articles on PubMed, CiNAHL, Cochrane library, Medline, Pedro, OTseeker, EMBASE, PsychINFO and EBSCOhost using predefined criteria. Studies of human participants of any age suffering from burns will be eligible, and there will be no restrictions on total body surface area. Only randomised controlled trials will be considered for this review, and the methodological quality of studies meeting the selection criteria will be evaluated using the Cochrane Collaboration tool for assessing risk of bias. The PRISMA reporting standards will be used to write the review. A narrative analysis of the findings will be done, but if pooling is possible, meta-analysis will be considered. Discussion: Burns may have a long-lasting impact on both psychological and physical functioning and thus it is important to identify and evaluate the effects of current and past aerobic and strength exercises on patients with burns. By identifying the characteristics of effective exercise programmes, guidelines can be suggested for developing intervention programmes aimed at improving the function of patients with burns. The safety and precautions of exercise regimes and the optimal frequency, duration, time and intensity will also be examined to inform further intervention. Systematic review registration: PROSPERO CDR42016048370.
Strength exercises; Aerobic exercises; Function; Burns; Muscle strength; Physiotherapy
Burn injury is a frequent cause of hospital admission in
low-income countries [
] and often leads to secondary
complications such as disfigurement, contractures and scar
tissue formation [
1, 2, 4
]. Physiotherapy has an important
role to play in preventing these impairments and in
maintaining and improving functioning and participation in the
acute, chronic and rehabilitation phases [
resourceconstrained contexts, in which access to appropriate
therapy may be limited, it is particularly important to identify
which rehabilitation and physiotherapy interventions are
the most effective in restoration of function.
Therapeutic exercises can be described as bodily
movement prescribed to correct an impairment, improve
musculoskeletal function or maintain a state of
]. They have been defined as a range of physical
activities that focuses on restoring and maintaining
strength, endurance, flexibility, stability and balance [
The main goal of therapeutic exercises is to return the
injured patient to a fully functioning pain-free state [
]. Therapeutic exercises may include strengthening,
endurance, flexibility, balance and coordination exercises
Exercise is beneficial, not only for patients with burns
but also for healthy patients [
]. The beneficial effects
of exercise are improved cardiovascular health,
maintaining a healthy weight, improving bone weight,
improvement in self-confidence and social skills [
Exercise prescription might be beneficial for patients
with burns as they are at an increased risk of bed
immobility due to heavy sedation from pain medication,
constant wound dressing and bandaging. These factors
result in an increase for the demand to exercise due to
altered biomechanics, body posture and gait.
The focus of this review is the effectiveness of
therapeutic exercises in reducing impairments and functional
limitations related to burn injuries. In patients with
burns, the damaged tissues may give rise to severe pain
]. Moreover, pain is one of the most common
] related to therapeutic procedures of
restoring function [
] during rehabilitation. Particularly,
in children, not only are burns painful, but they also
cause distress and anxiety to both the child and the
]. Pain leads to non-compliance, and patients are
at high risk of complications of immobility and bed rest.
Anecdotal evidence shows that due to lack of resources
in low-income countries less effective treatment is done
and patients spend more days in the hospital [
Potential complications for increased immobility and high
admission days include musculoskeletal (decreased muscle
strength, decreased endurance, contractures and
osteoporosis) and cardiovascular (decreased heart rate,
decreased cardiac reserve, orthostatic hypotension and
venous thromboembolism) [
A search of the Cochrane Review database using
keywords “Burns” and “Rehabilitation” or “Physiotherapy/
Physical Therapy” or exercise returned one review on the
effects of stretch on contractures in people with, or at risk
of, contractures [
]. It concluded that stretch on its own
was not effective in preventing contractures. There have
been studies done on the effect of exercise, but the two
] systematic reviews could be found in the
Cochrane database, the Prospero database or PEDro
respectively which examined the effect of exercise did not
target exercise prescription for burn patients. There is
evidence that exercise might reduce the impact of secondary
complications of burns , such as muscle weakness and
decreased anaerobic capacity, and be as effective as
splinting in retaining range of motion of the shoulder after
axillary burns [
] and there is thus a need for guidelines,
especially those that can be implemented in low-income
Most of the interventions were developed for first
world countries [
2, 10, 11
] but may not be applicable to
Africa where most of the countries have resource
constraints with regard to health care provision. Examples
of this include lack of specialised staff, lack of state of
the art equipment and lack of dedicated burn units in
medical facilities. Nevertheless, there is also need to
implement evidence-based practice in the management of
patients with burns in these settings, where ironically,
burn injuries are more common [
Exercise prescription should be age specific and
individualised to meet the different needs of individuals with
different level of fitness. It has been shown that exercises
might be beneficial for patients suffering from burns
], but there is lack of guidelines on exercise
prescription for these patients.
Burns may have a long-lasting impact on both
psychological and physical functioning and thus it is important
to identify and evaluate the effects of current and past
aerobic and strength exercises on patients with burns.
By identifying the characteristics of effective exercise
programmes, guidelines can be suggested for developing
intervention programmes aimed at improving the
physical functioning and, possibly, the health-related quality
of life (HRQoL) of patients with burns. The safety and
precautions of exercise regimes and the optimal
frequency, duration, time and intensity will also inform
The broad objective of this review is to systematically
evaluate the effectiveness, safety and applicability to
low-income countries of therapeutic exercises utilised
by physiotherapists to improve function in patients
Key review question
1. What is the efficacy of aerobic and/or strength
exercises for individuals with burns, and overall
improvement of any measure of outcome?
P = adults and children/adolescents with burns of
aspect of their bodies
I = any aerobic and/or strength exercises delivered as
part of a rehabilitation programme by anyone (e.g.
physiotherapists, occupational therapists, nurses,
doctors, community workers and patients themselves)
C = any comparator
O = any measure of outcome related to physical and
psychological functioning (e.g. health-related quality
of life, pain, muscle strength, range of movement,
fear or quality of movement)
S = any setting in any country
Secondary review questions
2. What precautions and contraindications need to be
taken into account during aerobic and strength
exercises to individuals with burns?
3. Are the interventions applicable to physiotherapy
delivered in any location in a low-income setting?
This will take into consideration issues such as equipment required, staff training, cost, culture and community supports.
The literature identified from the search findings for
the key review question will be further reviewed to
answer the secondary review questions. Papers will be
investigated for additional intervention material:
For secondary review question 1: articles which
describe any attempt to monitor progress for adverse
events such as fatigue (measured in any way);
excessive pain (measured in any way); or describes a
stopping rule (where treatment does not proceed
because of safety to the patient, or high likelihood of
adverse events occurring from the intervention)
For secondary review question 2: any article that describes patient samples and interventions relevant to developing countries
This systematic review will be written in accordance with
the Preferred Reporting Items for Systematic reviews and
Meta-Analysis-Protocol (PRISMA-P) guidelines attached
as Additional file 1 and has been registered on
PROSPERO database (Ref: CDR42016048370).
In selecting studies, we will apply the following criteria:
Studies of human participants of any age suffering from
burns will be eligible, and there will be no restriction
on total body surface area (TBSA) affected or duration
of intervention to cater for both long- and short-term
outcomes in terms of exercise prescription [
males and females will be considered for the review
even though exercise tolerance may differ [
studies will be excluded due to their different
anatomical structure hence difficulty in exercise prescription.
Examples of how studies will be summarised are pro
vided in Table 1.
Studies with patients suffering from other
comorbidities will be excluded from the study as they
might not be able to complete the intervention or their
safety might be at risk during standard care procedures
]. Studies with patients with (1) other
neurological conditions and (2) patients unable to
comprehend instructions either who are on mechanical
ventilators or with decreased level of consciousness will
also be excluded. Studies with children who are unable
to comprehend instructions and those that are too
young or suffering from cognitive disorders will be
excluded from this study. Studies on the management of
respiratory complications due to inhalational injuries
and acute respiratory distress syndrome (ARDS)
constitute specialised care and will be beyond the scope of
this review. Similarly, studies on the management of
psychological effects will not be included in this review,
although the impact on HRQoL will be examined.
Although burns may also affect the patient and caregivers
psychologically, leading to emotional trauma especially
where infants or children are involved [
2, 20, 21
management of these conditions is beyond the scope of
this review. Studies on the use of virtual reality 
and behavioural therapy to manage pain have been
studied but will not be included in this review as we
are focusing on improving function through therapeutic
Exercise 2 2
Home (home programme)
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muscle bulk OR muscle size OR lean muscle strength
Aerobic exercises Endurance exercises
Included study designs
Only randomised control trials (RCTs) that investigate the effects of exposure to any form of therapeutic exercise will be considered for the review.
Interventions and comparators
Exercises will include any form of exposure to
strengthening (resistance) or aerobic (endurance) exercises. RCTs
will only be considered if validated outcome measures
were measured at least two time points including baseline,
follow-up and on completion of the exercise programme.
Length of follow-up was not prescribed due to the
variability in TBSA. The intervention may be
supervised/unsupervised, patient specific in combination or not in
combination with standard of care commencing at any
period of time either in a hospital setting or outpatient
setting. Participants will be compared with another
control group or they can act as their own control. Taking
cognisance that all ages and TBSA are being considered, it
is necessary to limit the study only to RCTs.
Strength exercise outcome measures might include
isometric, isokinetic or isotonic which can either be evaluated
through dynamometry, manual muscle testing (MMT) or 3
repetition maximum (3RM). Lean body mass (LBM) could
be measured radiographically. Aerobic exercises can be
measured by change in heart rate using heart rate monitors
and change in lung capacity using VO2 maximal out.
Secondary outcomes can be measured through functional
activities could include walking and stair climbing which can
be used in a low income and are easily applicable in a
clinical setting or outpatient department.
Table 2 exemplifies the Participants Interventions
Comparison Outcomes (PICO) table.
We will only consider full text articles published in English.
A comprehensive search will be conducted at the
University of Cape Town library during the period of July 2017
to August 2017. All accessible bibliographic databases of
published research reports will be assessed. All databases
will be searched from 1990 to date. The electronic
databases will include PubMed, CiNAHL, Cochrane library,
Medline, Pedro and OT seeker, EMBASE, PSYCH INFO
and EBSCOhost. Manual searches of reference lists of
included articles will be employed.
The terms in the title (“physiotherapy” OR “physical
therapy” OR “rehabilitation” OR Occupational therapy)
AND (“burns” OR “burns patient” OR “patient with
burns”) AND (“exercises” OR “therapeutic exercises”).
Outline in Table 3 is an example of how literature will
be searched in CINAHL.
Search results will be merged using reference
management software (Covidence) which is data management
software. The electronic searches will also be saved to the
researcher’s PUBMED account. The principal researcher
will create a shared DROPBOX folder to facilitate
collaboration among reviewers and to save the online versions
of the articles and electronic search strategy. Summaries
of all the searches are to be printed and are to be used as
physical backup for the screened articles.
Selection and data collection of studies
Two reviewers Matthew Chiwaridzo (MC) and Tapfuma
Mudawarima (TM), both physiotherapists, will
independently search the databases and screen the titles and
abstracts for eligibility. Title and abstracts will be
examined to remove irrelevant reports and full text of
potentially relevant reports will be obtained; multiple reports
of the same study will be linked to minimise bias of
duplicate publication. The two reviewers will assess full
text reports for compliance with the eligibility criteria,
and correspondence will be done with authors to clarify
study eligibility, where necessary.
In case of disagreement, arbitration by a third reviewer
Jennifer Jelsma (JJ) will be carried out. Full text which
meets the eligibility criterion will be assessed for risk of
bias and data analysis/synthesis independently by TM.
The reviewers will also manually search the references
for articles to include in the data extraction.
Outcomes and prioritisation
For this review, outcome measures for strength exercises
will include manual muscle testing (MMT) and lean
body mass (LBM) or increase in muscle bulk and for
aerobic exercises will include VO2max and HR.
Secondary outcomes will include sit to stand, gait, stair
climbing and HRQoL measured by the burn-specific
health scale or generic HRQoL scales. Patient reported
outcomes will be prioritised in the discussion.
Assessment of risk bias (or “quality”) individual studies
The Cochrane Collaboration tool for assessing the risk
of bias [
] in experimental studies will be used to
assess the methodological quality of the included studies.
The PRISMA reporting standards will be used to guide
the review report (http://www.prisma-statement.org/
Best evidence synthesis
A narrative synthesis of the findings from the included
studies will be provided due to the likely heterogeneity of
the intervention and outcome measures. The Template
for Intervention Description and Replication (TIDieR)
checklist will be used to describe components of the
exercise interventions which are reported in each included
]. The exercise interventions will be described in
subgroups of outcome measures of strength, aerobic and
functional measures, and data within individual studies
such as patient’s population and interventions will be
described in a narrative summary. Information on adherence
to exercises, compliance monitoring, resources used and
costs incurred in the delivery and receipt of services will
be extracted, if available. If pooling is possible from the
intervention data (as a whole, or in subsets of the included
studies), meta-analyses will be considered. Revman
software will be used for this [
As far as we are aware, this will be the first review of
experimental evidence related to aerobic exercises and
strength training delivered in any setting, for patients of
any age, suffering from burns to any part of the body.
This review will provide an answer to the question of
efficacy for this type of intervention for burn patients.
Subsequent analysis of intervention information
reported in the included literature will provide previously
unavailable information on the elements of the
interventions, whether specific elements are related to evidence
of significant benefit, and whether best practice can be
determined for the delivery of aerobic exercises and
strength training for patients with burns. Specific
information on safety measures that have been put in place
to prevent adverse events during aerobic exercises and
strength training for patients with burns will be
highlighted. Where information is available on this
intervention that is relevant to burn patients in low-income
countries, the authors will compile evidence-informed
guidance for the safe delivery of aerobic exercises and
strength training in these settings.
Additional file 1: PRISMA-P 2015 Checklist. (DOCX 34 kb)
3RM: 3 repetition maximum; ARDS: Acute respiratory distress syndrome;
CSP: Chartered Society of Physiotherapy; MMT: Manual muscle testing;
PICO: Participants Interventions Comparison Outcomes; PRISMA-P: Preferred
Reporting Items of Systematic review and Meta-Analysis-Protocol;
RCTs: Randomised controlled trials; RoM: Range of motion; TBSA: Total body
The systematic review is part of the principal investigator’s PhD work at the
University of Cape Town. There was no external funding for the protocol;
however, much appreciation goes to the Faculty of Health Sciences Library
for its support.
Availability of data and materials
TM and JJ conceptualised the idea of writing the systematic review protocol.
TM prepared the manuscript. FCM, JJ, KG and MC edited the protocol. All
authors read and approved the final manuscript.
Ethics approval and consent to participate
Consent for publication
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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