Burns and Burn Rehabilitation

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Description (Pendleton & Schultz-Krohn, 2006, p. 1059)

  • Burns can be thermal, chemical, or electrical in nature
  • Can be caused by flame, steam, hot liquids, hot surfaces, and radiation
  • Severity of injury depends on area of the body exposed, duration & intensity of exposure

*See Burn Wound Characteristic Chart handout for breakdown

Percent Total Body Surface Area Involved

  • Burns are classified as a percentage of the total body surface area involved: %TBSA
  • There are two methods for estimating %TBSA: the “rule of nines” and the Lund and Browder chart.
  • Rule of nines divides the body surface into areas comprising 9% (or multiples of 9%), with the perineum making up the final 1%.
  • Head & neck = 9%, each upper extremity is 9%, each lower extremity is 18%, and the front and back of the trunk are each 18%.

*The rule of nines only applies to adults because body properties vary with children.

  • Lund and Browder chart provides a more accurate estimate and is used in most burn centers.
  • This chart assigns a percentage of surface area to body segments with adjusted calculations for different age groups.
  • (See pg. 1063, figure 42-4 for the Lund & Browder chart).

Phases of Wound Healing

  • Inflammatory Phase
  • Lasts 3-10 days after onset.
  • Wound is painful, warm, and erythematous (red) and develops edema.
  • Proliferation Phase
  • Begins by the third day after the injury and lasts until wound heals.
  • Revascularization, reepithelialization, and contraction of the burn wound takes place.
  • Wound remains red and raised with rigid scars possible developing.
  • Maturation Phase
  • Begins by the third week after initial healing, may last 2 or more years after burn or reconstructive surgery.
  • Collagen remodeling takes place, redness fades, scar softens and flattens.
  • Tensile strength of scar increases but never recovers more than 80% of original tensile strength.

Scars

  • Hypertrophic scars: thick, rigid, red, and become apparent 6-8 weeks after wound closure. (Superficial burns that heal in less than 2 weeks do not usually form hypertrophic scars).
  • Keloid scars: excessive scar formation that may take up to 3 years to mature.

Initial Medical Management

  • With circumferential full-thickness burns, loss of burned skin elasticity and increased edema can cause compartment syndrome – a condition in which interstitial pressure becomes severe enough to compress blood vessels, tendons, or nerves resulting in secondary tissue damage.
  • Ischemia may be a result of compressed blood vessels, leading to tissue death to the areas of compromised circulation or the entire extremity.
  • Escharotomy(incision through necrotic burned tissue) can be performed to for pressure release, or an incision down through the muscle fascia may be needed for deeper wounds.
  • A smoke inhalation injury is a common secondary diagnosis with thermal injury and can increase mortality in burn patients.
  • Can happen when the face is burned or burn was caused by a fire in an enclosed space.
  • A tracheostomy can performed if ventilatory support is prolonged.

Wound Care and Infection Control:

Wound treatment may involve a combination of surgical and nonsurgical treatments.

  • Topical Antibiotics:
  • Decrease wound- relate infections and morbidity in burn wounds
  • Control microbial colonization, preventing development of invasive infections
  • Neomycin/polymixin B/bacitracin antibiotic ointments used for facial and superficial burns
  • Silver sulfadiazine (Silvadene cream) antibacterial commonly used over larger burns and held in place w/layers of gauze
  • Mupirocin (bactroban) agent used to treat wounds infected with methicillin-resistant Staphylococcus aureus (MRSA)
  • Biological Dressings:
  • Serve as temporary covering to sclose a wound, prevent contamination, reduce fluid loss and alleviate pain
  • Biological adressingsxenografts (porcine skin) and allografts (human cadaver skin)
  • Allografts generally used with full-thickness burns
  • Biosynthetic Products:
  • Closure of wounds with these dressings may lead to less pain, faster skin regrowth, and therefore less scarring
  • Used until the wound is healed over, usually in 10 to 14 days, then the dressing peels off
  • Biobrane a biosynthetic skin substitute wound dressing sheet
  • Hydrotherapy
  • Once patient’s condition is stable, hydrotherapy is performed at least once a day to remove loose debris
  • Provides thorough cleansing of the wound and the uninvolved areas
  • Consists of patient on a shower trolley in which washing and showering the wounds for 20-30 minutes
  • Non submersive showering method is preferred method of cleansing burn wounds to prevent cross-contamination of wounds between patients
  • Sepsis:
  • Wound cultures and biopsies are performed to monitor the wounds when there are signs of possible serious infection
  • Severe infection can result in sepsis, in which infection spreads from the original site through the blood stream, condition known as septicemia
  • Septicemia initiates a systemic response that affects blood flow to viatl organs
  • Antibiotic therapy is usually initiated
  • If host defenses continue to be overwhelmed, bacterial by products accumulate in blood stream, which is condition known as toxemia which eventually leads to septic shock
  • Septic shock, cardiovascular response that impedes blood flow to the organ systems, characterized by: ischemia, diminished urine output, tachycardia, hypotension, tachypnea, hypothermia, disorientation ad coma
  • Septic shock requires multisystem supportive measures for recovery
  • Surgical Intervention:
  • Surgical treatments for burns usually consist of removal of the nonviable burned tissue (called eschar), and placement of biological or synthetic skin grafts.
  • There are 3 types of grafts: a xenograft (processed pigskin), an allograft (processed human cadaver skin), and an autograft (permament surgical transplant of upper layers of person’s own skin).
  • Vacuum-Assisted Closure (VAC)
  • Aka negative pressure wound therapy, VAC is a treatment in which sealed dressing and controlled negative pressure are used to provide evacuation of wound fluid, stimulate growth of granulation tissue, and decrease bacterial colonization.
  • Nutrition
  • The metabolic rate of the burn victim greatly increases with increases in protein, vitamin, mineral and calorie needs.
  • Protein is especially important for wound healing and must be substantially provided.
  • Nutritional requirements are calculated on the basis of the %TBSA and the patient’s admission weight.

Associated Problems and Complications

  • Stress: Burn patients responses to stress are reliving the event, avoidance, and hypervigilance, these responses can continue long after the burn incident. PTSD is common comorbid condition in burn patients; they often have changes in mood, anxiety, sleep, conduct, learning, and attention problems.
  • Treatment for Stress: Pain assessment, paint management, psychiatric consultation, and crisis intervention. Treatment should include the patient’s family.
  • Pain: Can cause physiological and emotional effects on burn patients, pain assessment and pain management are important factors for better outcomes. Pain relief and pain control and reevaluation are essential for treatment.
  • Treatment for Pain: Pharmacological is the primary treatment, Opiates are the most common form of analgesic therapy for burn patients, as wounds heal the amount of pain medication will decrease. Nonpharmacological interventions include hypnotic, cognitive, behavioral, sensory treatment methods, use of TENS unit, relaxation techniques, breathing exercises, guided imagery, aromatherapy, music therapy, and teaching coping strategies.
  • Psychological Factors: Depression, withdrawal reaction caused by disfigurement, behavioral regression, grief, denial and isolation, anger, and anxiety over the ability to resume the individual roles before then burn incident. How an individual copes with the burn injury will influence their psychological status.
  • Treatment for Psychological Factors: Emotional support and education, development of coping mechanisms for the patients, and self-direction can help with a patients psychological adjustment.

Burn Rehabilitation

  • Goals of Rehab: Multidisciplinary team approach with the client and the clients family/support system being the most important members of the team. Aspects of rehab include providing verbal support, preparing client for self-care tasks, active motion reinforcement, and patient education. Communication and cooperation between all team members is important. Co-treatments promote independence in mobility and ADL’s.

3 Phases of Recovery

  • Acute-Care Phase: 1st 72 hrs. after injury, medical management is important for the patients survival and treatment is directed at restoring function. Goals of the acute phase include: provide cognitive reorientation and psychological support, reduce edema, prevent loss of joint and skin mobility, prevent loss of strength and activity tolerance, promote occupational performance such as independence with self-care skills and provide patient and caregiver education.
  • Surgical and Postoperative Phase: Excision, grafting, and immobilization period. Goals: preserving/enhancing performance skills and patterns while supporting surgical objectives, promote cognitive awareness, continue psychological support, protect/preserve graft and donor sites using splints and establish positioning techniques that support surgeons care orders, prevent muscular atrophy and loss of activity tolerance, increase self-care independence by teaching alternative techniques/use of adaptive equipment, educate patient/family on this phase of recovery.
  • Rehabilitation Phase: Begins as wound closure occurs, focus on maximal self-care, promoting physical and emotional independence, scare management to prevent deformity and contracture formation. Goals: Continue psychological support, improve joint mobility, reduce contractures using correct positioning, sustained passive stretching exercises and splinting, restore muscle strength, coordination, activity tolerance, initiate compression therapy and scar management program using vascular/custom support garments, provide instruction/opportunities to practice IADL’s, continue instruction in scar development, guide and implement post-discharge plan.
  • Occupational Therapy Evaluation: Evaluation is completed within the 24-48hrs. after hospital admission. Client and family are interviewed to establish rapport, obtain history of pervious occupational performance. Information can help the OT assess any changes in clients behavior and cognition functioning to help choose the appropriate interactive approach to encourage clients involvement in goal setting/rehab process.

The Acute Care Phase

  • Focuses on prevention positioning to
  • Reduce edema
  • Prevent deformity
  • Position of contracture is usually more comfortable for cx
  • Adduction and flexion of the UEs
  • Flexion of the hips & knees
  • Plantar flexion of the ankles
  • “Claw hand” with wrist and IP flexion, MP extension, and thumb adduction
  • Evaluation
  • Wound assessment
  • Positioning required based on edema and positions/posture cx demonstrates
  • Initial goal to reduce edema
  • Secondary goal, prevention of skin tightness
  • Interventions
  • Splinting to provide correct position and protect tissues
  • ADLs are usually limited in this phase
  • Choose ADLs which cx values
  • Provide AE if needed while promoting independence
  • Therapeutic Exercise & Activity Tolerance (as soon as approved by MD)
  • Ambulation and weight bearing (if cx has LE burns cx requires elastic wraps)
  • During sitting, (if LE burns are present) make sure LE are elevated (don’t allow them to dangle)
  • Exercises to “preserve ROM and functional strength, build up cardiovascular endurance, and decrease edema” (p. 1075)
  • Client Education

Surgical and Postoperative Phase

  • Following grafts and excisions the focus is on
  • Reducing edema
  • Immobilization of the affected area
  • Assist wound healing
  • Intervention
  • Splinting for immobilization (often uses bulky restrictive dressings)
  • Therapeutic Exercise & Activity Tolerance
  • Usually temporarily discontinued on involved extremities (should be continued on uninvolved extremities)
  • Gentle activity continued typically 3-5 days post-op & for amputations typically 5-7 days post-op (should have double elastic bandage wraps applied)
  • ADLs
  • Difficult due to position
  • Activities should be graded according to ability
  • Client Education pre-op and post-op for understanding of procedures, protocol, & precautions

Rehabilitation Phase: Inpatient

  • It begins when the client no longer needs intensive wound care, most of the wounds are closed or the client is moved to a rehab center. Patients are expected to have a more active role in establishing treatment goals, demonstrate more independence in their own care, and fully participate in therapy. During this phase, some techniques to increase ROM, strength, activity tolerance, higher level ADLs and IADLs are introduced. Intervention focuses on work, recreation, and self-skills necessary to return to normal routines and roles; including performance patterns and participation in occupation. Psychological adjustments are also addressed during this phase.

Reassessment and Intervention Goals:

  • OT evaluations, assessments, and treatments in this phase focus on performance skills active and passive goniometric measurement, muscular and cardiopulmonary endurance, performance of self-care, home management, skin integrity, presence of edema, and scar development.
  • Intervention techniques to counteract scar development include:
  • Skin conditioning and scar massage: To improve scar integrity and durability against minor trauma caused by pressure or shearing forces of garments, and decrease hyposensitivity. Lubrication, massage, and sunburn precautions are taught to the client before discharge.
  • Compression therapy: Should start as soon as most of the larger wounds are closed. The type of compression chosen and the degree of compression gradient applied depend on how much pressure and shear force the client’s skin can tolerate and it is upgraded as the integrity of the skin improves.
  • Therapeutic exercise and activities: Every session starts with moisturizing and massage of the skin; the stretching is performed to increase flexibility and stretching motion. ROM exercises are not individually performed, but combined to increase joint mobility in functional patters of movement. Strengthening activities include cuff weights, dumbbells, putty, hand manipulation boards, WEST II, BTE work stimulator, and Valpar Work Samples (page 1084).
  • Edema management: Elevation and progressive compression are recommended to treat edema.
  • ADLs and IADLs: Eating, dressing, grooming, bathing, and home management, are the ADLs and IADLs that should be emphasized during this phase. Adaptations can be provided to support independence. Splinting at this stage is used to limit or reverse disabling contracture formations, increase ROM, and distribute pressure over problem areas.
  • Client education: Education on wound healing, preserving independence, causes and effects of scar contractures, scar management techniques, and home management are important for the client and family to know during the predischarge phase.

Rehabilitation Phase: Outpatient

  • After discharge ROM, strength, activity tolerance, ADLs, IADLs, and skin status need to be reassessed to identify new problem areas. Driving evaluation and prevocational assessment are also evaluated. Inpatient rehab activities are still appropriate in outpatient. However the frequency and intensity of the activity need to be graded accordingly.
  • Scar Management
  • A primary objective of rehabilitation techniques is the prevention or treatment of hypertrophic scars and scar contractures.
  • Scar Maturation is when the scars become less vascular in color, with flatter and more pliable contours and smoother texture (usually 12 to 18 months).
  • A rating scale (scar pigment, vascularity, pliability, and height) or digital photography can be used to document changes in scar appearance.
  • Use of compression garments is indicated for all burn wounds that take longer than 2 weeks to heal. The OT is often responsible for the measurement, ordering, and fitting of compression garments.
  • Compression garments shouls be fitted no later than 3 weeks after wound healing. Should be worn 23 hours a day! Compression therapy should be used for 12 to 18 months or until scar maturation is complete.
  • To be effective, compression garments must exert equal pressure over the entire burn surface area. Flexible inserts or pressure-adapting conformers are needed to distribute pressure evenly over body contours and bony prominences.
  • Activities of Daily Living
  • Outpatient intervention plan should be directed at increasing independence with home care while also emphasizing resumption of past life roles and context. Scar contracture is often the primary cause of dysfunction.
  • Community Reentry
  • Returning to school or work become primary objectives during outpatient rehabilitation.
  • A community reentry program should be implemented before the client’s return to work or school. Correspondence can be sent to the community setting educating about burns, compression garments, splints, exercise, and skin care precautions.
  • Strength, activity tolerance, and flexibility, often identified as work tolerances, are obvious goals of burn rehabilitation.
  • With the compression garments, skin-conditioning (friction) and temperature (heat) education are important.
  • Psychological Adjustment
  • Clients may experience symptoms of post-traumatic stress disorder, nightmares, and appetite changes with weight gain or loss. They may become reclusive, disengaged, and depressed.
  • Counseling, support, training in pain management, relaxation techniques, and burn support groups are shown to be effective.
  • Discharge for Treatment
  • When clients have resumed their pre-injury activities, outpatient therapy may be discontinued. Follow-up care every 2 to 3 months for scar maturation and compression garment adjustments. Annual visits are recommended for children until full physical maturity is reached.

Burn-Related Complications

  • Heterotopic Ossification
  • Formation of bone in locations that normally do not contain bone tissue (around joints, joint capsules and ligaments).
  • AROM exercise of the joint should be carried out within pain-free range to maintain joint motion. Splinting and forceful passive stretching should be discontinued. Surgery may be needed.
  • Neuromuscular Complications
  • Peripheral neuropathic conditions occur with high-voltage electrical burns or burns greater than 20% TBSA.
  • Localized compression or stretch injuries to nerves occur from improper or prolonged positioning in bed or on the operating room table, tourniquet injury, and external edema.
  • Therapists should be attentive to developing symptoms of sensory or motor dysfunction.
  • Facial Disfigurement
  • Vision, speech, feeding, and dental hygiene can be adversely affected by oral and eye contractures. Facial disfigurement affects self-image and inhibits social reentry.
  • Elastic face mask can be worn. Provides uniform multidirectional compression during movement, but cosmetically and socially less acceptable.
  • Transparent, rigid facial orthosis is expensive and time consuming. Disadvantages include exerting primarily unilateral compression and not allowing perspiration to evaporate.
  • Computer-aided design and manufacturing systems have developed to efficiently and economically fabricate transparent face masks.
  • Client compliance is essential to effectiveness of treatment (wearing the mask, proper skin care, and facial massage and exercise 4 times a day).
  • OT can provide early education, ongoing encouragement, and continued support to ensure the client’s compliance with wearing a facial orthosis.

References