The principal goal of occupational and physical therapy is the prevention and treatment of scar contracture, deformity, and hypertrophic scarring. In the hospital or in the field, therapy must begin on the same day of admission (beginning with the assessment). This continues daily and is focused on:
∙ Survival: to get wound/graft closed
∙ Function: of hands, feet, joints, face and,
∙ Appearance: psychosocial
• ROM - able to perform active/passive - AROM: active maintaining muscle mass - PROM: passive prevent joint stiffness in limited and debilitated patients • Strength - endurance and muscle strength • Sensation - present on all burned areas specially on upper and lower extremities • Burn wound assessment - open/closed wound and percent of grafting taken
• Positioning – for comfort and prevent skin breakdown • Splinting – to prevent contractures and promote position of function • Range of Motion Exercises • Function and gait – early ambulation • ADL’s and adaptation – self feeding, dressing, oral care, and toiletry • Eschar control (Wolff's law – the principle that changes in the form and function are followed by changes in its internal structure)
• Pain is one the most important factor affecting the daily physical therapy interventions. Assess pain level before/after therapy. The Visual Analogue Scale, VAS, (0-10 points scale) and the Wong-Baker Faces Pain Rating Scale, FPRS, (0-5 scale points) are important tools that measure more effective the sensory component of the patient’s pain (see burn pain chapter) • Itching of the skin is another factor that will prevent to have a good response to therapy. Assess the need for antihistamine, (Diphenhydramine “Benadryl” or Hydroxyzine “Atarax” 25-50 mg PO every 4-6 hours as needed).
• Extent of burn TBSA% • Location/distribution of TBSA% - location – some areas are difficult to optimize ROM - compare location of TBSA% (anterior vs. posterior vs. lateral vs. medial ) • Depth of wounds – 2nd and 3rd degree burn
• Time of day - optimal time in AM • Frequency of treatment – twice a day • Duration of treatment – series of repetitions that last 2 to 30 minutes • Intensity of Treatment – advance as patient tolerate
The goal of exercise is to reduce edema and promote circulation increasing ROM and strength • Prevent scar tissue contractures and deformity • Preserve muscle strength and it mobility • Promote maximum functional and independence • Maintain cardiovascular endurance and muscle strength • Education of patient and family members - compare location of TBSA% (anterior vs. posterior vs. lateral vs. medial ) • Depth of wounds – 2nd and 3rd degree burn
• Control edema • Prevent contractures • Prevent atrophy • Prevent tendon adherence • Prevent joint stiffness
• Fractures – external fixators • Early grafting - mesh graft = 3 to 5 days - sheet graft = 5 to 7 days • Exposed tendons (relative) • Wet donors – too painful
Remember, the patient’s position of comfort promotes the early formation of scar contractures The primary goals of splinting are to: • Prevent the shearing and destruction of newly grafted areas • Control and prevent edema • Prevent tissue destruction • Maintain anatomical position and ROM • Correct and prevent contractures • Assist function – activity of daily living
• Ideally, this is done in the operating room • Protects the integrity of new skingrafts • Joint(s) are splinted in anti-contracture position • Mesh grafts: splint over occlusive dressings to a position of function • Sheet grafts (with or without piecrusting): splints are carefully placed to allow graft exposure, fluid can be expressed from the skingraft edges (use cotton tips applicators). This is commonly used after skingrafting of the hands.
• Compression is necessary for all burned, grafted or harvested areas when dependent • Decreases orthostatic hypotension • Decreases microcapillary trauma (tattoo) • May convert to deeper wound without proper pressure • Prelude to definitive control of hypertrophic scar formation
• Recliner – out of the bed
• Standing/Tilt Table
• Promotes independence • Prevents thromboemboli/decubiti • Maintains strength/cardiovascular conditioning • Maintains bone density • May be preceded with tilt/standing table
• Vital signs • Orthostatic hypotension • Inhalation injury (on mechanical ventilation) • IV lines (feet, groin)
• Collagen deposition forms scar tissue • The optimal management of scar control is preventing formation of contractures and hypertrophic areas • Survivability of coverage with minimal disability • Unfortunately about 80% of all burn patients seen in hospitals will form hypertrophic scars • The treatment is with compression garments or elastic bandage.
Normat Scarring: Scar is soft, flat, and good vascularization minimal to none overgrowth • Hypertrophic Scar: Overgrowth of dermal components within boundaries of wound • Keloid Scar: Scar is overgrowth beyond boundaries of wound.
Inflammatory Phase • From time of injury to 3-4 days post burn • Vascular changes – vasodilatation • Cellular proliferation – epithelialization
Fibroblastic Phase • Last 4 – 30 days post burn • Collagen formation and wound contraction
• Continue epithelialization
Maturation Phase: • Last 1 month to 2 - 5 yrs - pressure speeds up maturity stage of healing
• Immature Burn Scar - red, raised, rigid / firm - risks for contracture and hypertrophic scar
• Mature Burn Scar - avascular / white, flat, pliable / soft - no risks for contracture & hypertrophic eschar
Pressure is used to flatten scar and improve cosmesis
Apply Pressure: • Approximately 24 mmHg (capillary pressure) - Elastic Bandage to trunk about 3-4 mmHg - Elastic Bandage to extremity10-15 mmHg - Tubigrip to extremity 10-20 mmHg - Pressure garment 25 mmHg • Venous insufficiency 40 mmHg • Loose 50% of compression after ~ 4 wks
Pressure Garments: • No pressure support required - burn heals < 10 days • Pressure support may be required - burn wound heals 10 - 14 days • Any race or age advised to use pressure, - burn wound heals in 14 - 21 days • Pressure support is mandatory - all burn wounds that require > 21 days to heal
Types of Pressure Dressings • Elastic Wrap - Ace Wraps • Self-Adherent Elastic Bandage - Coban Tape • Tubular Support Bandage - Tubigrip • Compressed Clothing - Pressure causes thin tissue
Other Forms of Scar Control • Silicone Gel pads • Plastic face mold • Medical interventions - surgical revision
Additional role of therapy • Prevent tissue destruction (skin breakdown, decubiti) • Turning schedule – every 2 hours • Provide devices to assist with alternating positions – side to side • Positioning devices for drying of donor sites