Phases for Burn Recovery

Clinical Phases of Burn Intervention and Time-Oriented Decision Making

  • Intervention strategy is primarily organized around phases that dictate when specific actions are taken. Many examination questions are time-sensitive, focusing on "what to do next" based on the client's current status or the time elapsed since the injury.

  • There are three primary phases utilized in this curriculum:

    • Acute Phase
    • Surgical and Post-Operative (Post-Op) Phase
    • Rehabilitative Phase

  • Conflict in Academic Resources:

    • Different textbooks and resources do not always agree on phase definitions.
    • Some resources include an "Emergent Phase" (0−720-72 hours), which effectively shifts the Acute Phase to a later position in the timeline.
    • While the terminology varies, the clinical priorities remain consistent across sources: until wound closure, the emphasis is on preventing deformity; after wound closure, the focus shifts to function and maintenance.

The Acute Phase: First 7272 Hours Post-Injury

  • Primary Goal: Preventing deformity through anti-deformity positioning and orthotics.

  • Range of Motion (ROM):

    • Active Range of Motion (AROM) and Active Assisted Range of Motion (AAROM) are performed as much as possible, depending on physician-directed immobilization protocols.

  • Edema and Scar Management:

    • Interventions in this early phase are low-key.
    • Edema is primarily managed through elevation to reduce swelling.
    • Area is typically covered by bandages, limiting direct intervention.

  • Activities of Daily Living (ADLs) and Mobility:

    • Heavy weights or intensive therapeutic exercise (Therex) are inappropriate during the first three days post-major burn.
    • Focus resides on basic mobility and simple ADLs, such as sitting at the edge of the bed or walking to the bathroom, provided it is medically appropriate based on the burn location (e.g., upper body burns with intact lower body function).

The Surgical and Post-Op Phase: Skin Grafting and Immobilization

  • Primary Goal: Preventing deformity and ensuring the success of the skin graft.

  • Skin Grafting:

    • Involves harvesting skin from a donor site to cover the burned area.
    • This is the standard intervention for full-thickness burns.

  • Immobilization Timelines:

    • There is variance in documentation regarding immobilization periods.
    • General guidelines: 2−72-7 days for partial burns and 7−147-14 days for full-thickness burns.
    • The "middle ground" standard for study purposes is approximately 11 week (77 days).

  • Interventions:

    • Strict positioning of involved joints in anti-deformity postures to ensure graft adherence.
    • Therapeutic exercise (Therex) of non-involved joints to maintain strength and ROM.
    • Adapting ADLs to accommodate immobilization while maintaining as much function as possible.

The Rehabilitative Phase: Function and Long-Term Maintenance

  • Timeline: Begins at the point of wound closure. This phase can be extensive, lasting up to 22 years or more, as scars are not fully mature until that time.

  • Transition of Focus:

    • Shifts from strictly preventing deformity to regaining the prior level of function.
    • Emphasis includes maintenance of progress and reversing or preventing contractures.

  • The ASSESS Mnemonic for Rehabilitative Intervention:

    • A: ADLs (Transitioning from basic ADLs to Instrumental ADLs, work, social, and leisure tasks).
    • S: Scar Management (Lotion and massage).
    • S: Splinting (Focusing on overcoming contractures and range of motion losses using serial static or dynamic splints).
    • E: Edema (Compression garments).
    • S: Sensation (Desensitization for hypersensitivity).
    • S: Strength (Therapeutic exercise and strengthening as allowed).

Comprehensive Scar Management Protocols

  • Hypertrophic Scarring:

    • Without intervention, scar tissue can become thick, fibrous, inflexible, and raised (lumpy).
    • This can restrict range of motion and cause pain.

  • Lubrication and Massage:

    • Skin must stay hydrated to remain flexible.
    • Use water-based creams or lotions rather than oil-based products. (Mnemonic: Use water to put out a fire, not oil).
    • Massage should occur 3−43-4 times per day.

  • Massage Technique and Pressure:

    • Pressure must be firm enough for the skin to "blanch" (turning white when pressed).
    • Tools for massage include hands, vibrators, rollerballs, or icing.

  • Pressure Garments:

    • Constant pressure prevents raised scar surfaces.
    • Pressure should be applied for 2323 hours per day, with a 11 hour break for hygiene.
    • Recommended pressure range: 20−40 mmHg20-40\,mmHg.
    • Memory Trick: The 22 and 44 from the "2424-hour day" can help recall the 20−40 mmHg20-40\,mmHg range.
    • Customization: Silicone inserts or elastomers can be used under garments to fill body contours and ensure even pressure.

Sensation, Pain Relief, and Modalities

  • Hypersensitivity:

    • New skin areas can be extremely sensitive to texture, pressure, or temperature.

  • Desensitization Process:

    • Graded exposure to textures and pressures.
    • Hierarchy: Start with light/soft touch (e.g., cotton ball). Once tolerated, progress to harder/rougher materials, eventually reaching textures like sandpaper.

  • Therapeutic Modalities:

    • Heat is the preferred modality for pain relief and movement preparation.
    • Fluidotherapy: Effective for encouraging movement during heat application.
    • Paraffin Wax: Excellent for burns as it provides heat while simultaneously lubricating/hydrating the skin.
    • Hot Packs: Standard heat application.
    • Cold: Generally avoided. It decreases blood flow to healing tissue and the area is often already hypersensitive to temperature changes.

Clinical Complications: Heterotopic Ossification (HO)

  • Definition: The formation of bone in abnormal locations (soft tissue or joints where it should not exist).
  • Common Site: The elbow joint.
  • Key Clinical Sign: A "hard end-feel." Unlike the "tight" feeling of a scar or muscle contracture, HO presents as a full stop in movement (a "clunk") with no elasticity or "play" at the end of the range.
  • Management and Contraindications:
    • Do NOT perform forceful range of motion or intensive stretching.
    • Do NOT use dynamic or serial static splints.
    • Limit intervention to gentle Range of Motion (ROM) within the pain-free range.
    • Notify the physician immediately upon detecting a hard end-feel, as this is a surgical/medical issue.

Summary of Essential Knowledge

  • Early Phases (Acute/Surgical): Focused on anti-deformity positioning.
  • Late Phase (Rehab): Focused on function, ADLs, and scar/edema maintenance.
  • Critical Pressure/Time: 23 hours/day23\,hours/day at 20−40 mmHg20-40\,mmHg.
  • Wound Closure: The signal to transition from immobilization/deformity prevention to functional therapy.