2nd Lecture Burn Rehabilitation 7 10 2024 PDF

Burn Rehabilitation Prof. Mahmoud Hamada Associate Prof of Physical Therapy for Surgery & Burn PhD of Physical Therapy Cairo University  DEFINITION Burn is defined as a tissue injury due to thermal application (heat and cold), absorption of physical energy (electri...

Burn Rehabilitation Prof. Mahmoud Hamada Associate Prof of Physical Therapy for Surgery & Burn PhD of Physical Therapy Cairo University  DEFINITION Burn is defined as a tissue injury due to thermal application (heat and cold), absorption of physical energy (electricity, ionizing radiation and friction) and chemical contact (acid and alkali).  CLASSIFICATIONS OF BURN (1) ACCORDING TO THE DEPTH: 1st degree Epidermal burn 2nd degree Superficial Partial thickness- (superficial dermal) 2nd degree Deep Partial thickness- (deep dermal) 3rd degree Full thickness  Epidermal burn: epidermis and very superficial part of dermis Superficial Partial thickness- : epidermis, papillary dermis and part of reticular dermis Deep Partial thickness- : both epidermis and dermis involved sparing skin appendages Full thickness : both epidermis and dermis including skin appendages are involved, may be with subcutaneous tissue, muscle or bone  (2) ACCORDING TO THE CAUSE: Epidermal burn : sun burn, minor scald Superficial Partial thickness- : major scald, minor flame burn, contact with hot object for short time Deep Partial thickness- : major scald, minor flame burn, contact with hot object for long time Full thickness : flame burn, severe scald or contact with hot object, chemical burn, electrical burn  (3) ACCORDING TO SURFACE/COLOR: Epidermal burn : dry, erythematous Superficial Partial thickness- : moist, reddish color with blisters Deep Partial thickness- : moist, white color, blisters, mottled Full thickness : dry, whitish  (4) ACCORDING TO CAPILLARY RETURN : Epidermal burn: brisk Superficial Partial thickness- : brisk Deep Partial thickness- : sluggish Full thickness : absent  (5) ACCORDING TO PAIN SENSATION: Epidermal burn : burning sensation Partial thickness- superficial : severe burning sensation Partial thickness- deep : burning sensation with variable severity Full thickness : painless  (6) ACCORDING TO HEALING TIME: Epidermal burn : 3-7 days Partial thickness- superficial : 10-14 days Partial thickness- deep : 2-3 weeks Full thickness : skin grafting is needed, otherwise contracture, deformity and disability SCALD  ELECTRICAL BURN High resistance of skin transforms electrical energy into heat, which produces burns around the entrance point. (dark spot in center of wound).  ELECTRICAL BURN Current flows through the body from the entrance point, until finally exiting where the body is closest to the ground. This foot suffered massive internal injuries, which weren't readily visible, and may be amputated later.  INTERNAL INJURIES IN ELECTRIC BURN Same hand a few days later, when massive This worker was shocked by a tool he was subcutaneous tissue damage had caused holding. The entrance wound and thermal severe swelling. To relieve pressure which burns from the overheated tool are would have damaged nerves and blood apparent vessels, the skin on the arm was cut open.  INVOLUNTARY MUSCLE CONTRACTION This worker fell and grabbed a powerline to catch himself. The resulting electric shock mummified his first two fingers, which had to be removed. The acute angle of the wrist was caused by burning of the tendons, which contracted, drawing the hand with them. CHEMICAL BURN CHEMICAL BURN Chemical burn can affect the eye  PATHOPHYSIOLOGY: Most affected organ is skin –burn wound Can also affect respiratory system- inhalation injury Infection from the burn site, lungs, lines and catheters Malabsorption from the GIT Abdominal compartment syndrome Circumferential burns may compromise circulation to a limb  TBSA ASSESSMENT (THE RULE OF NINE’S) An adult who has been burned, the percent of the body involved can be calculated as follows: Head = 9% Chest (front) = 9% Abdomen (front) = 9% Upper/mid/low back and buttocks = 18% Each arm = 9% (front = 4.5%, back = 4.5%) Groin = 1% Each leg = 18% total (front = 9%, back = 9%) The rule of nine’s  LUND AND BROWDER More precise method of estimating Recognizes that the percentage of BSA of various anatomic parts. By dividing the body into very small areas and providing an estimate of proportion of BSA accounted for by such body parts Includes, a table indicating the adjustment for different ages Head and trunk represent larger proportions of body surface in children.  LUND AND BROWDER CHART Area* Birth to 1 year 1 to 4 years 5 to 9 years 10 to 15 years Adult Head 9.5 8.5 6.5 5.5 4.5 Neck 1 1 1 1 1 Trunk 13 13 13 13 13 Upper arm 2 2 2 2 2 Forearm 1.5 1.5 1.5 1.5 1.5 Hand 1.25 1.25 1.25 1.25 1.25 Thigh 2.75 3.25 4 4.25 4.5 Leg 2.5 2.5 2.5 3 3.25 Foot 1.75 1.75 1.75 1.75 1.75 Buttock 2.5 2.5 2.5 2.5 2.5 Genitalia 1 1 1 1 1  AMERICAN BURN ASSOCIATION BURN SEVERITY CATEGORIZATION Major burn injury Second-degree burn of > 25% body surface area in adults. Second-degree burn of > 20% body surface area in children. Third-degree burn of > 10% body surface area. Most burns involving hands, face, eyes, ears, feet, or perineum. Moderate burn injury Second-degree burn of 15–25% body surface area in adults Second-degree burn of 10–20% body surface area in children Third-degree burn of < 10% body surface area COMPLICATION OF BURN: Shock –hypovolemic or neurogenic Renal failure Acute respiratory distress syndrome Pneumonia Laryngeal edema Acute GIT ulcer: Curling ulcer Hypothermia EVALUATION OF BURN PATIENT Sources of information Goals of evaluation: available to the therapist: 1- To determine the 1- Medical chart. patient's present status. 2- To identify the current 2- Physician rehabilitation problems. 3- Nurse 3- To anticipate the 4- Patient's family patient's potential 5- Patient problems by assessing all the necessary information 6- Other member of burn available. team. CAUSES OF DEFORMITY (WITH BURN CASES) 1- Skin and soft tissue contractures. 2- Destruction of tendon and muscles. 3- Changes related to prolonged immobilization. 4- Orthopedic Complications. 5- Neurologic Complications COMPONENTS OF AN EVALUATION 1- Patient demographic data Information. 2- Burn Severity Index: Age. Gender. Burn wound assessment: (Extent of burn injury, Depth of burn injury, Location of burn injury & Respiratory status). 3- Edema and Limb Circumference Assessment: Tape measure form. Water displacement method. Wring method techniques. 4- Sensory assessment: 5- Range of Motion Assessment: 6- Muscle Strength Assessment: 7- Endurance Assessment: 8- Ambulation Assessment: 9- Functional Activities Assessment: 10.MEASUREMENT OF BURN WOUND SURFACE AREA: A. Invasive method: By Doctor B. (Non-invasive method): a- Microbiology (micro-orgasmic a- Photo instrumentation. analysis). b- Observation of wound contractor. b- Serum analysis (measurement of collagen protein) (procollagen peptide c- Doppler (laser Doppler). 3). d- Physical therapy methods c- Surgical method. d- Taking of blood sample. PHYSICAL THERAPY METHODS: a- First method calculated surface area by multiplying the dimensions of the wound. The product of the two dimensions of a wound can serve as an accurate indicator of wound surface area only if a wound is rectangular b- Second method focused on practiced by physiotherapist that entailed tracing ulcers on transparent paper. Placing the tracing over metric graph paper and counting the number of square centimeters within the tracing. c- Third method questioned the ability of observers to delineate the edge of the wound. They preferred to take photographs of open wounds and to use a planimeter to determine the wound area from the photographs.  BURN REHABILITATION TEAM Due to complex nature of burn injury care, a multidisciplinary approach is important Team includes: Burn Surgeons, Nurses, Anesthesiologists, Respiratory therapists, PTs, OTs, Dietitians, Psychosocial experts, Social work. Patient and family also members of team – need to be included.  AIMS OF BURN PHYSICAL THERAPY MANAGEMENT Enhance wound and soft tissue healing. Reduce risk of infection and complications. Reduced risk of secondary impairments. Achieve Maximal range of motion. Restore preinjury level of cardiovascular endurance. Achieved good to normal strength. Achieve independent ambulation. Minimize Scar formation Increase independent function in ADL.  CONTRAINDICATIONS: Presence of femoral IV access will make repetitive hip ROM contraindicated as it can cause introduction of bacteria into access. Arterial access precludes any hip ROM as it increases the risk of arterial bleeding from site.  ROLE OF THE PHYSIOTHERAPIST IN THE REHABILITATION OF BURN PATIENT  (1) IMMOBILIZATION Rationale for immobilization in acute stage of burn: Prevent deformities. Maintenance of range of motion. Promote Healing. Protection.  (2). PROPER POSITIONING Begins upon therapy evaluation (if not sooner). Burn wound healing begins as soon as injury occurs = need for early intervention. Patients will rest in a position that creates least amount of pain. "Position of comfort = Position of contracture".Typically a flexed position. Importance of Patient and family education.  PROPER POSITIONING The goals of a positioning program are to: Minimize edema. Prevent tissue destruction. Maintain soft tissues in an elongated state. Preserve function.  THERAPEUTIC POSITION Extended: towel roll/NO PILLOWS/collar Abduct 90 deg: wedge/air plane splint Extended (-5deg): pillow/splint Extended 30-60 deg: towel; splint MCP flex 70 deg/PIP&DIP ext/thumb abd : splint/wash cloth Extended/neutral rotation/abduction: Pillow/wedge/abd pillow - NO PILLOWS Full Extension: NO PILLOWS DF/neutral inv/ever: foot board  (3). SPLINTING Continuous splinting is indicated in treatment of: (1) burn wound edema in the hands (2) exposed tendons (3) peripheral neuropathies (4) uncooperative or unresponsive patients.  THE GOALS OF SPLINTING PROGRAM ARE TO: Using of splints and protection of Joints and tendons: Splints play an important role in prevention further trauma to joints and tendons or preserving anatomical structure and function. Stabilizing joints reduces external stresses, such as shearing or pressure, which can cause tissue damage. Role of splinting in edema reduction: Supportive splints are used to maintain maximal limb elevation for resolution of edema. The pressure support of air splints may assist edema reduction THE GOALS OF A SPLINTING PROGRAM ARE TO: (CON) Splinting following skin grafting: Splints are applied intraoperatively to immobilize a skin graft recipient site and prevent accidental shearing of the graft. Splints for uncooperative or unconscious patient: Splints are used to maintain a function joint position or prevent contracture development when a patient is unable or unwilling to participate in therapy programs. Adults may develop joint stiffness following immobilization more than children. Continuous use of a splint assures proper positioning until a patient is able to actively participate in the rehabilitation program or the risk of contracture is reduced.  INDICATIONS FOR THE USE OF SPLINTS: (1) In Acute phase: Protection of exposed tissues, Reduce the overall pain and edema formation (2) In wound healing phase: Prevention of contractures, prevent disruption of newly healed tissues (3) In rehabilitation phase: Maintenance of ROM achieved during an exercise session (4) In reconstruction phase: Protect the skin graft and the graft healing, Give better cosmetic appearance after graft healing & Allow observation of wound  PHYSIOLOGICAL RATIONALE FOR SPLINTING Scar tissue is visco-elastic. It will elongate steadily within a certain range. When this stretching force is released, there is an immediate decrease in the tissue tension but a delay in the retractions of the tissue to a shorter length. These stress relaxation properties of visco elastic scar tissue means it can accommodate to stretching force overtime. Dynamic and static splinting provide this prolonged low stretching force.  SPLINTING PRECAUTIONS Splints should conform to the body part, and care must be taken to ensure that there are no pressure points that may cause a breakdown in healing or normal skin. There is particular risk of pressure injury to skin after burn injuries due to potential skin anesthesia. Splints should be checked routinely for proper fit and revised if necessary. Splints need to be cleaned regularly to prevent colonization by microbes which may lead to wound infection. Unnecessary use of splinting may cause venous and lymphatic stasis, which may result in an increase in edema. Precaution must be taken to ensure that splints do not product friction causing unnecessary trauma to the soft tissues. Splinting should not be used in isolation but as an adjunct to a treatment regime.  TYPES OF SPLINTS Primary splints: During the acute phase and pre grafting period, static splints (without movable parts) are used to position the involved joints during sleep, inactivity, or periods of unresponsiveness. Whenever possible, these splints should be applied to adjacent intact skin. Postural splints: During the immediate post graft phase, splints are used to immobilize joints in proper functional position, but must allow access for continued wound care. These splints are worn continuously for 5 to 14 days until the graft is secure. Follow up splints: The chronic phase of burn care begins with wound closure and continues until full maturation of the wound (one to two years). Dynamic splints (movable parts) are used to increase function. They can provide support to the joint without restricting antagonistic movements, provide slow steady force to stretch a skin contracture, or provide resistive force for exercise.  NECK DEFORMITY SPLINT Soft cervical collar Molded neck splint or collar Halo Neck splint  NECK DEFORMITY SPLINT Philadelphia collar Watusi collar (plastic tubes) EARS SPLINT MICROSTOMIO SPLINT MPA Microstomio prevention Appliance Cheek Retractors MICROSTOMIO SPLINT MPA Microstomio prevention Appliance Custom SHOULDER ADDUCTION INTERNAL ROTATION DEFORMITY SPLINT Axillary splint or conformer SHOULDER ADDUCTION INTERNAL ROTATION Shoulder abduction brace SHOULDER ADDUCTION INTERNAL ROTATION Clavicle strap or brace ELBOW AND KNEE DEFORMITY SPLINT Gutter or trough Elbow knee conformer Point splint Air splint ELBOW AND KNEE DEFORMITY SPLINT Gutter or trough Elbow knee conformer Point splint Air splint (4) MOBILIZATION (STRETCHING & EXERCISES) 1) Active ROM Depending on the need for immobilization gentle active ROM exercises is the preferred treatment during the acute stage of injury as it is the most effective means of reducing edema by means of active muscle contraction. If this is not possible due to sedation, surgical intervention etc. then positioning the patient is the next best alternative.  2)PASSIVE ROM AND STRETCHING Passive ROM exercises in the acute stage are contraindicated. Applying these passive maneuvers in the acute stage will result in increased edema, hemorrhage and fibrosis of the burned tissues. The biomechanical principle of creep when passive stretching. A slow sustained stretch is more tolerable for patient and more effective for producing lengthening. Passive joint mobilizations can begin during the scar maturation phase once the scar tissue has adequate tensile strength to tolerate friction caused by mobilization techniques.  PRECAUTIONS OF MOBILIZATION Be aware of dressing clinic/daily dressing changes. Mobilization should coincide with this as it is important to monitor the wound during AROM frequently. Timing of pain relief. This should be timed appropriately to ensure maximal benefit during treatment sessions. Observe the patient carrying out the AROM and PROM exercises prior to beginning treatment. Also observe the patient taking on/off splints. Always monitor for post exercise pain and wound breakdown.  Avoid blanching for long period as you may compromise vascularity. The patient may present with a reduced capacity for exercise secondary to increased metabolic rate, altered thermoregulation and increased nutritional demands. Postural hypotension may be present due to prolonged bed rest and low haemoglobin.  MOBILIZATION CONTRAINDICATIONS Active or Passive range of motion exercises should not be carried out if there is suspected damage to extensor tendons (common occurrence with deep dermal and full thickness burns). Flexion of the PIP joints should be avoided at all costs to prevent extensor tendon rupture. The hand should be splinted in the position of safe immobilization or alternatively a volar PIP extension splint until surgical intervention is discussed. Range of motion exercises are also contraindicated post skin grafting as a period of 3-5 days immobilization is required to enable graft healing.  3) MUSCLE STRENGTHENING Most patients do not have decreased muscle power, only a decreased range of motion due to a contracture of skin and tendons. However, physiotherapists should work on strengthening the muscles that would counteract contracture. For example, if a patient has a flexion elbow contracture, the physiotherapist should stretch the biceps and strengthen the triceps. Another time physiotherapist must concentrate on muscle strengthening is when patients have nerve or muscle damage as a result of the initial burn. The edema caused by the burn can cause compartment syndrome, a condition that makes the muscles and nerves within a ‘compartment’ ischemic. Physiotherapists should help these patients improve the strength of the remaining muscles.  EXERCISE RECOMMENDATIONS Aerobic exercises are recommended for 3 times per week, with intensity between 65 and 85% predicted heart rate max increased gradually every week and sessions duration of 20-40 minutes for 12 weeks. Resisted exercises are recommended for 3 times per week, using free weights or resistive machines: 1 set of 50-60% of the patients 3 RM week 1, followed by a progression to 70-75% for week 2-6 (4-10 repetitions), and 80-85% week 7-12, (8-12 repetitions), for 12 weeks.  4) SCAR MASSAGE After a wound has closed and scar tissue has begun to develop, it is important to massage the scar. This is particularly important to do in areas where scar formation has made the skin tight, hard, or difficult to move, a condition known as adhesion. In an effort to keep the skin soft, malleable, and elastic, press one’s thumbs down over the scarred area and make circular motions. One could also press one’s thumbs down on the scar and then pull them apart, stretching the skin in between them. Use as much pressure as the patient can tolerate. Because it is important to do this massage for at least 10 minutes every day until the scar softens, it is crucial to teach the patients and their parents how to perform scar massage Best Wishes Prof. Mahmoud Hamada