BURN REHABILITATION

Burn Rehabilitation: Onset to Return to Independent Function
 April C. Cowan, OTD, OTR, CHT
 OCCT 6475: Musculoskeletal Rehabilitation
 February 10, 2025




Objectives

  • The student will be given the opportunity to:
    – Recognize the functional impact of thermal injuries
    – Describe common assessment tools
    – Describe treatment interventions
    – Explore application of assessments and interventions




What is a Burn Injury?

  • Heat exposure for a prolonged time damages the skin:
    – Thermal, electrical, radiation, and chemical

  • Destruction of the different layers of the skin and the structures within the skin:
    – Sweat glands, oil glands, and hair follicles

  • Depth of injury:
    – First, second, third, or fourth degree




How Do Burns Affect the Body?

  • Skin is the largest organ:
    – Regulates body temperature
    – Prevents fluid loss
    – Barrier to infection
    – Sensory reception




1st Degree Burn

  • Superficial

  • Flash burn/sunburn

  • Pain & tenderness

  • Redness

  • Heals in +7 days




2nd Degree Burn

  • Partial thickness:
    – Superficial or deep

  • Scalds or flames

  • Exquisitely tender

  • Blisters

  • Slow capillary refill

  • Heals in 14-21 days




3rd Degree Burn

  • Full thickness

  • Immersion scalds; flame burns; chemical injuries; electrical insults

  • Anesthetic

  • White or leathery

  • Clotted vessels




4th Degree Burn

  • Structural involvement

  • Causes are similar to 3rd degree injuries

  • Anesthetic

  • Charred or skeletonized

  • Escharotomy, fasciotomy, &/or amputation




Medical Treatment

  • Emergent phase per American Burn Association (ABA) criteria:
    – Gentle cleansing
    – Debridement
    – Fluids
    – Tetanus update
    – Transfer to specialized burn center
    – Wound closure efforts




Wound Coverage

  • Autograft

  • Xenografts

  • Homografts

  • Split thickness versus full thickness

  • Flaps




What Assessments Are Used After Thermal Injury?

Assessment Concerns

  • Biomechanical frame of reference:
    – Emergent versus non-emergent

  • Conduct evaluation with wounds exposed

  • Consider etiology, depth, & total body surface area (TBSA) involvement

  • Identify associated injuries or trauma:
    – Inhalation injury
    – Compartment syndrome

  • Immediate positioning needs

  • Patient or caregiver interview for history




Assessments

  • History:
    – Extent of thermal involvement
    – History of present injury
    – Associated conditions
    – Past medical history
    – Social history

  • Cognition:
    – Arousal
    – Orientation
    – Following directions
    – Higher level functions




Activities of Daily Living

  • Interview

  • Observation

  • Formal assessments

  • Client-centered

  • Need for adaptive equipment




Functional Mobility Skills

  • Bed mobility:
    – Rolling, bridging, supine <-> sit and return

  • Sitting & standing balance:
    – Static progressing to dynamic

  • Functional transfers

  • Ambulation

  • Community mobility




Skin Assessment

  • Total body surface area (TBSA) involvement = percentage of body that is injured

  • "Rule of Nines"




Scar Assessment

  • Assessment of burn scar maturation

  • Characteristics observed & rated

  • Now a “modified” version




Amputations?




Pain




Edema

  • Location on body

  • Severity:
    – Capillary refill time

  • Circumferential assessments:
    – Figure-of-eight wrap

  • Volumetry

  • Type/texture:
    – Pitting? Brawny?




Range of Motion

  • Passive motion

  • Active-assistive motion

  • Active motion

  • Monitor for losses as treatment progresses

  • Anticipate contractures




Strength

  • Manual muscle testing

  • Dynamometer & pinch gauge

  • Hand-held dynamometry

  • Monitor for peripheral nerve involvements




Sensibility

  • Touch

  • Pain

  • Temperature

  • Threshold required

  • Discriminative




Psychological Concerns

  • Pain, fear, & anxiety

  • Grief, depression, & loss of hope

  • Anger & irritability

  • Disturbing dreams

  • Appetite changes

  • Sleep changes

  • Frustration

  • Estrangement

  • Intrusive memories

  • Impaired memory

  • Difficulty concentrating




What Interventions Are Used After Thermal Injury?

Positioning Needs

  • TBSA involvement

  • Depth of the burn

  • Associated injuries

  • Exposed tendons/joints

  • Post-operative status

  • Size of the patient

  • “…the position of comfort is the position most likely to lead into contractures…”




Positioning

  • Methods:
    – Supine
    – Prone
    – Sidelying

  • Begins immediately and continues throughout treatment course




Positioning Benefits

  • Reduces edema

  • Maintains joint alignment

  • Maintains soft tissue lengths

  • Reduces contracture formation

  • Maintains ROM

  • Promotes wound healing

  • Relieves pressure

  • Protects joints, exposed tendons, & surgical repairs




Positioning the Head

  • 30° elevation (with shock blocks)




Positioning the Hips

  • Neutral rotation, 10-15° abduction




Orthotic Devices

  • Vital in burn rehabilitation

  • Utilized throughout recovery

  • To promote best functional outcomes

  • Easy to apply & remove

  • Light-weight & low profile

  • Patient appropriate design/fabrication




Orthotic Needs

  • Positioning restrictions

  • Edema

  • Wounds/exposed structures

  • Stage of healing

  • Ability to follow-through

  • Medical status




The Neck and Shoulders




The Elbows and Hands




Hips, Knees, and Feet




Pain Management

  • Distraction

  • Massage/patting

  • Modalities

  • Relaxation

  • Medications

  • Phantom pain issues




Cognition

  • Arousal & orientation

  • Stress reactions

  • Coping strategies

  • Problem-solving

  • Emotional support

  • Optimism

  • Encourage positive life changes




Therapeutic Exercises

  • Stretching

  • Range of motion

  • Resistive strengthening (begin with isometrics & progress)

  • Conditioning

  • Functional & age-appropriate activities

  • Occupation-based methods




Functional Mobility Retraining

  • Retraining transitional movements at all levels

  • Gait retraining

  • Provide assistive devices

  • Educate on safety

  • Progression by assistance level, distances, surface changes, etc.




ADL/IADL Retraining

  • Begin with feeding & progress:
    – Grooming
    – Toileting
    – Dressing
    – Bathing

  • Provide assistive devices or adaptive equipment




Scar Management

  • Scar replaces normal tissue

  • Average time for maturation = 6 months to 2 years

  • Immature scar:
    – Red, raised, & rigid

  • Mature scar:
    – Pale, smooth, & pliable

  • Hypertrophic scar:
    – Overgrowth outside boundaries of initial injury




Scar Management Techniques

  • Massage:
    – Rotary, parallel, & perpendicular motions

  • Maintain mobility:
    – Free restrictive scars
    – Improve circulation
    – Alleviate itch

  • 2-3 times a day; with lotion

  • Avoid open areas

  • Sun protection (SPF 30+)




Pressure Therapy

  • Early pressure

  • Elastic bandages

  • Tubular bandages

  • Self-adherent wraps

  • Control edema

  • Support vascularity

  • Applied over burn dressings




Pressure Therapy Devices

  • Specialized garments

  • Silicone inserts




Pressure Therapy Benefits

  • Accelerates scar maturation

  • Flattens scar

  • Increases scar pliability

  • Decreases blood flow

  • Realigns collagen bundles

  • Decreases edema

  • Decreases rate of collagen synthesis/increases collagen lysis




Pressure Therapy Guidelines

  • Pre-fabricated or custom-made

  • Worn 22-23 hours/day

  • Average pressure is 25-30 mm Hg

  • 40 mm Hg is destructive

  • Begin use within 2 weeks of wound closure

  • Required until scar maturation is complete




Prosthetic Devices

  • Limb amputations common after electrical injury

  • Surgeons maximize length of residual limb & joints available to power a device

  • Options available for UEs and LEs




Psychological Adjustment

  • Gradual community re-entry

  • Enlist family, friends, & neighbors

  • Prepare individual to answer questions

  • Plan daily routines

  • Support groups & visits with survivors

  • Counseling

  • Church affiliations

  • Pharmacological treatment

  • Camouflage makeup




Discharge Readiness

  • Home & family situation conducive to rehabilitation

  • Functional skills for home, work, or school

  • Independence in home programs:
    – Wound or skin care routines
    – Exercise programs
    – Activities of daily living adaptations/techniques
    – Pressure therapy needs
    – Splint usage




Test Yourself…

  • What are some functional impacts of thermal injuries?

  • What assessment tools are commonly used by occupational therapists?

  • What treatment interventions are used in burn rehabilitation?