Rehabilitation Of Burn Patients

Rehabilitation of burn patientsRehabilitation of burnpatients Should begin soon after burn to try toprevent deformities and poor functionaloutcomesMonratta PanuwannakornDepartment of Rehabilitation MedicineRamathibodi HospitalThe emergent phaseRehabilitation of burn patients Divided into 4 phases Emergent phase Acute phase Post skin graft phase Convalescent phaseThe emergent phaseGoals To evaluate the patient and developtreatment goal & plan To control edema To maintain ROM of the injured part To prevent respiratory complication,esp.in inhalation burnBegin in the first 24 – 72 hrs.afterburn injuryInitial evaluation Depth & area of burn woundsObserve the wound : exposed tendon or jointEdemaPainROMFunctionCooperation of the patient1

Burn evaluationBurn severityEdema Result from fluid shift to extravascular spaceDevelop 8 – 12 hrs. after burn injurypeak 36 hrs.Result in : ischemia & fibrosisplaces the extremities indeforming positionlimited movementinterfere functionControl edema & maintainjoint mobilityEdema In SPT burn : fluid leakage has low proteincontent and transientIn DPT and FT burn: both dermis and papillaryplexus are injuredfluid leakage has high proteincontent and rich in fibroblast causeprolonged and severe edemaControl edemaElevation & positioning- elevate above heart level- avoid position that compromise circulation Active muscle pumping exercise in elevatedposition- depend on conscious & motivation of thepatient and burn wound condition Compressive dressing / wrapping Control edema is imperative in this stageThick inelastic eschar often necessitatesescharotomy to release pressureEscharotomy do not preclude exercise2

Elevation & positioningPrevent respiratory complication Inhalation injury can cause mild to severebronchial and alveolar changesInhalation injury combined with edemaformation and constricting eschar of neckcan obstruct the trachea necessitateintubation and mechanical ventilationPulmonary rehabilitationElevation & positioningPrevent respiratory complicationPulmonary rehabilitation program Bronchial hygiene therapy :- postural drainage , percussion , vibration- cough trainingImprove ventilation & prevent atelectasis:- deep breathing , incentive spirometryAcute phase Extend from emergent phase until woundclosureEarly and proper intervention : necessaryfor collagen fibers orientation to minimizescar formation3

Acute phaseControl edemaGoal Control edema Maintain joint , skin mobility ,musclestrength and prevent stiffness / contracture Promote mobility and ambulation Encourage functional independenceMaintain joint and skin mobility& prevent stiffness/contracture PositioningExerciseContinuous passive motionSplintingAntideformity position ElevationPositioningCompression : EBExerciseFunctional activitiesPositioning Combine appropriate position andcompliance of the patientAppropriate position : antideformityChange every 2-4 hrs.Comfortable positionDesigned to counteract the forces andpatterns of wound contraction and scaringRequired combined effort of rehabilitativeand nursing staffsRequire frequent repositioning4

Antideformity position& repositioningPositioning lower extremitiesSplint for positioning wrist & handExercise Exercise Prolonged immobilization will result in :- decrease cardiovascular fitness- muscle atrophy & weakness- joint stiffness- disuse osteoporosis- increase risk of thromboemboli- decubitus ulcerType and duration depend on conscious,motivation , burn wound condition and painExerciseActive / active assistive exercise- need patient’s motivation & coordination- counteract the effect of prolonged bed rest& muscle atrophy- maintain ROM & strength- provide emotional support to the patient 5

ExercisePassive exercise- for patient who can not or does not willingto actively move : critically ill , sepsis , heavilymedicated patient- to maintain ROM , elongate tissue andassess joint motion Exercise Exercise Do exercise every 1-2 hrs.Add oral analgesics to control pain- oral morphine- paracetamol- gabapentinPerform during hydrotherapy- reduced pain & relaxation- ease of exercise due to bouyancyPassive , active assistive ,active exerciseExercise is best tolerated during wounddressing- bulky dressing are off- use parenteral analgesics allowed moreeffective exercise- topical cream promote pliability of woundsurfaceAvoid unnecessary bulky dressingExerciseChildren Exhibit increased pain reactions duringexercise due to fear and apprehension Playing and group activities are moreappropriate to encourage active movementContinuous passive motion Use to maintain or restore ROMMost benefit in :- extensive burn covering multiple area- impaired cognitive function- can not do appropriate motion due topain,edema and anxiety- require passive motion for a prolongedtime6

Continuous passive motionContraindication/precaution forROM exerciseExposed tendonRuptured tendon , exposed joint or fracture Splinting All burn patient are not necessary routinelysplintedSplinting depend on :- depth and extent of wound- ROM & strength- co-operation with exercise , positioningand ADLFunctional activities Splinting Splinting is necessary in :- unconscious or non co-operative patient- non co-operative children- immobilize the affected part : exposedtendon , exposed joint- muscle weakness or imbalance : peripheralnerve injuryAssisstive & adaptive devicesEncourage performing self care activitiesincreased ROM , strength and enduranceof U/E musclesMay need adaptive devices : built-up utencils, adaptive cup , plate guard7

Encourage functional & playingactivitiesMobility and ambulationAmbulation should begin as soon as themedical condition stable Benefit of early ambulation- Maintain or increase ROM , strength andendurance of L/Es muscles- Provide cardiovascular conditioning- Increase appetite- Improve patient’s well being Progressive ambulationProgressive lower extremities dependencywith bedside sitting May use tilt table- Passive standing with totally support thenpartially support- provide gradual weight bearing- treatment for orthostatic hypotension Contraindication for earlyambulation Progressive ambulation Elastic bandage wrapping prior toambulation to decrease venous stasis andblood poolingUse extrapadding dressing or padded slipperin burn on sole of footUse gait aid to protect , reduce pain orassist weight bearingMobility & ambulationEarly massive edema of L/EsExposed large tendons : Achilles tendon ,Tibialis anterior tendon8

Rehabilitation in post skin graftphase It is crucial to obtain full ROM beforegraftingNeed to immobilized 5-7 days after graftingProper positioningMaintain ROM of unaffected partIsometric exercise of affected partRehabilitation in convalescent phase Goal- Control edema- Decrease fibrosis & adhesion- Increase ROM , strength and endurance- Maximize independent functioning- Control scar- Provide education for skin care- Treatment burn scar contractureElastic bandage / coban wrap ,massageRehabilitation in convalescent phaseExtend from the time of graft adherence orwound closure until scar maturation Control edema Elastic bandage wrap / coban wrapMassageFunctional movementDecrease fibrosis and adhesion Massage to freeing restrictive fibrous band- greater rotatory motion along the scarCocoa butter cream applied beforeDo 2-4 times/dayHeat application : H/P , paraffin , U/S9

Exercise to increase ROMEvaluate total ROM across several joints Active exercise with terminal stretching Prolonged stretching may be needed- slowed sustained stretch is the mosteffective method Strength and endurance trainingExercise to increase strengthand enduranceProgressive resistive exercise- from manual resistance towards the use ofweight and resistive tubing- concentrated on areas of weakness andmuscles opposing scar tissue contracture Maximize independent functioningEncourage ADLUse adaptive devices Progressive ambulation- walk further with the least amount ofsupport- correct abnormal gait Control scar Hypertrophic scar : collagen arranged inrandom orientation with whorls and nodulesHypertrophic scarPathogenesis :- overzealous inflammation- prolonged re-epithelialization- overabandant extracellular matrix &collagen production- increase neovascularization 10

Hypertrophic scarGenerally develop between 2-6 months afterDPT and FT burn ( 8-12 weeks after woundclosure )Increased level between 6-12 monthsRegress during maturation phase , 18-24monthsMore prevalent in areas of high skin tension: chest wall , shoulders and upper arm Hypertrophic scarFactors predispose to development ofhypertrophic scar- depth of burn , healing time , grafting andskin character- race , age , genetics , immunologicalresponse Vancouver Scar ScaleScar assessmentVancouver Scar Scale ( VSS )- vascularity , pigmentation , pliabilityand height- it’s subjective , not accurate describe ,not known which area U/S scanning : thickness of scar VDO camera : color of scar Laser Doppler Flowmetry : perfusion of scar To control and treatment scar Mechanical pressure :- facilitate alignment of collagen fibers inmore parallel , normal orientation- decrease blood flow and O2 to rapidlymetabolizing collagenous tissuePressure 25 mmHg. , at least 23 hrs./dayTo control & treatment scarMechanical pressure- start when the wounds are almost orcompletely closed- early form : elastic bandage , conformingthermoplastic along with bandage- may utilized tubular elastic bandage“Tubigrip “, Coban , prefabricated pressuregarment , custom-made garment Use pressure garment until scar mature ;18-24 months 11

Pressure garment and splintto control scarTo control & treatment scarInserts- adjuncted to achieve effective pressure overcertain anatomical location where pressuregarments do not provide adequate pressure :concave body area ; face , neck , palm , webspace , antecubital area- silicone gel , elastomer , thermoplastic To control & treatment scarTo control & treatment scarScar massage- aids in softening or remodeling scar tissueby freeing adhering fibrous bands , allowingthe scar to become more elastic and stretchy To control & treatment scarPulse dye LASER- flatten & decrease the volume ofhypertrophic scar- improve texture , increase pliability anddecrease erythema : usually seen after 2-3treatment- can be used successfully in the early phaseof wound healing and in establishedhypertrophic scarPulsed Dye LASER inhypertrophic scarPulse Dye LASER- cause photothermolysis- is absorbed by hemoglobin leading tocoagulation necrosistissue hypoxiadecrease the number and proliferation offibroblastcollagen fibers realignment &remodelling 12

Skin dryness and fragileSkin care Skin problems- Skin dryness and fragile- Itching / pruritus- Sunlight and heat intolerance Avoid prolonged water immersionFrequent apply mineral oil or cocoa butteror petrolium jelly / oiled-based lotionApply lotion or oil before exerciseItching/pruritusItching/PruritusSeverity depend on :- burn area involved : burn area 40 %100 % of leg burn70 % of arm burn0 % of face burn- depth of burn : partial thickness greatest risk- duration of time to wound closure : woundleft open 3 weeks very likely to hypertrophicscar & pruritus Incidence 80 – 100 %Severe itching : 70 % in children , 50 %in adultMaximum during proliferative phase ofwound healingItching/pruritus Itch pathwayShare the same neuronal pathway as painPrimary mediator is histamineTransmit by unmyelinated C-fibersSynapse in superficial laminae of dorsal hornof spinal cordTransmitted through anterolateralspinothalamic tractSupraspinal processing in anterior cingulatecortex13