INTRODUCTION
Humans have used fire since the dawn of history and burn injuries have presumably occurred ever since. Burns affect skin directly and all other organ systems indirectly, causing a chain of events with implications far beyond skin loss. Rehabilitation of the burn patient may be considered in 2 phases:
• Acute
• Postacute and longterm.
Assessment
Initially after eliciting a history, the rehabilitation team conducts a physical exam to document the type and extent of burns, neuromuscular and musculoskeletal damage, associated medical conditions, presence of other injuries and social problems.
The pediatric burns patient differs from an adult patient in many ways. Since the body surface area is different, dehydration is greater, temperature control is more difficult and hypertrophic scarring is more severe. In the pediatric patient, mortality is higher and rehabilitation more challenging. The assessment of burns in the acute phase is governed by the rule of 9 (given below) and in the rehabilitative phase the contractures and complications are assessed.
Classification
First-degree burns: shows up as an erythematous white plaque involving only the epidermis. In India, due to the severe heat in summer, people get sunburns and this can be included as first degree burns.
Second-degree burns: occur when there is blistering of the skin, involving mostly the superficial dermis and may also involve the deeper dermal layer it is a second degree burn.
Third-degree burns: This happens when the epidermis is lost with damage to the subcutaneous tissue there is charring with severe pain and even loss of hair. Grafting may be needed for these burns.
Fourth-degree burns: These burns damage deeper tissues like muscles, tendons, and ligaments, thus resulting in charring and later even contractures. These burns are usually fatal if not attended to immediately. Grafting and rehabilitation are required intensively.
Causes of Burns
Heat: including fire, radiation, or from steam, and hot liquids (scalds) and contact with hot objects. Household burns are very common, where contact with cooking utensils is unavoidable. A very unfortunate cause of burns is suicide, by dousing with kerosene and lighting with a match. The victim is often depressed or, as is common in India, uses this as a means of expressing solidarity with a cause or political protest. The rehab program is very tortuous and painful and several counseling sessions are needed.
Radiation: this is a rare but catastrophical cause of burns. Recent example is the disaster from the Chernobyl reactor. Ultraviolet light is also a source of radiation burns.
Light: burns caused by intense light sources. In the tropics, sunlight is also included.
Electrical: Common household and industrial sources of electricity are potential risks for electrical burns. It is also an occupational hazard for electricians and is a cause for bilateral amputation. Lightning is another cause, though rare.
Complications of Burns
• Bacterial contamination of the wound may occur even within a few hours. Burns are often fatal due to contamination leading to sepsis
• There is tremendous loss of body fluids through open wounds that can cause hypovolemia and shock; this is a major danger and could prove fatal
• The body’s immunity is compromised
• The evaporation from open wounds results in heat loss
• Upper airway obstruction and lung infections occur
• Acute gastric dilatation and paralytic ileus.
Contractures
a contracture is a serious complication of a burn. It happens because elastic connective tissues are replaced with inelastic fibrous tissues. It presents as a permanent tightening of skin and underlying tissues resistant to stretching and preventing normal movement of the affected area. It occurs when the burn scar heals with fibrosis, thickens, and tightens (which is normal in wound healing), reducing the range of movement.
Sometimes there is hypertrophy of the scars producing keloids. During the healing stage, pressure dressings to burn wounds are generally advised to minimize hypertrophic scarring. Surgical excision and skin grafting may be done within three days after the burn, for nonscald full thickness burns in children and young adults. For older patients in the same category, it is better to wait before doing the surgery. When there is scalding a period of two weeks can pass before taking a decision for grafting. Hypertrophic scarring is more common when epithelialization takes longer than 2 weeks in children or three weeks in others. The burn wound may take up to a year to heal during which antiseptic, moisturizing cream and sun protection cream are used along with splints. Release of contractures, has to be decided based on the assessment of the surgeon and function planned.
Management in the Acute Phase
Rule of 9’s is a quick way of estimating, the surface area that is affected by a burn. If the surface of the body is 100 percent, the areas can be divided as
• Face and scalp 9%
• Back 18%
• Perineum 1%
• Arm each 9%
• Front 18%
• Upper arm each 9%
• Lower leg each 9%
Goals
• To promote wound healing and prevent infection
• To control edema, lung infections, and electrolyte imbalance
• To maintain joint and skin mobility, with minimal disfigurement.
REHABILITATION
Rehabilitation of the burns patient starts as soon as he or she is stabilized in the burns ward itself.
Positioning
Proper positioning of the patient in bed is fundamental to the rehabilitation program and this can be achieved using splints, foam wedges, pillows, and sandbags. This can be extremely difficult as the patient is in severe pain and seeks relief in a primarily flexed and adducted position which is the position of minimal pain but which unfortunately favors development of contractures rather rapidly.
Antideformity positioning should begin immediately in abduction and extension. Burnt tissues should be maintained in their elongated state, as far as possible. Alternating positions to prevent opposing deformities is important.
Splinting
Splints used in the acute phase in conjunction with gentle sustained stretching help maintain the desired anatomical position and prevent deformity. Splinting is performed at least 4 times a day in between therapy sessions.
A to G: Common hand splints for burns
Indications for Splinting
A splint is given to prevent rupture of exposed tendons, to protect exposed joints or a graft and to prevent excessive scarring in areas where an important body contour would be lost, e.g. neck, face. This prevents too much disfigurement of the face and exposed areas.
Commonly used splints in the acute phase are
• Knee extension splints
• Dorsiflexion splints/posterior foot drop stop splints
• Resting hand splint
• Facial masks and cervical collars
Special splints—splints painlessly maintain the gain in ROM and minimize hypertrophic scarring by applying constant pressure on scar tissue. They are applied as follows:
Mouth: Static or dynamic prevention of contractures around the mouth and microstomia is done using hooks made of acrylic or thermoplastic material and attached to a cervical collar.
Face and neck – Transparent PVC total contact masks, collars
Ears – A semi rigid mask may be taped around the ear to prevent
folding of the helix
Axilla – Aeroplane splint/figure of eight clavicle brace
Elbows, knees – Gutter splints
Hip – Spica
Ankle and foot – Foot drop stop, reverse foot drop stop splints, extra depth shoes with soft inserts.
Electrotherapy
Decreases tendon adherence to scar tissue.
TENS – for pain from faulty positioning
US – for painful joints of the hand
Cryotherapy + Ultrasound – for hypertrophic scar painBiofeedback – for relaxation in insomnia
Exercise and Ambulation
Early limitation of motion is caused by pain and edema. The initial exercise program should focus on preserving the range of movement and maintaining strength. Passive range of movements 2 to 3 times a day for the critically ill patient in the ICU is indicated as long as they are unconscious or medicated, but for patients who can actively move a joint an active range of movement is better.
If the range is not full, active assisted exercises and passive stretching are instituted. Vigorous movements to the trunk like flexion-extension or rotation are done, though painful, to prevent the robot like posture that frequently develops. Gentle sustained stretch is more effective in stretching burnt tissue than multiple repetitive movements. Focus should be on those areas most prone to developing scar tissue contractures. Ambulation should start as soon as the patient is out of danger, his vital signs stabilize and pain is within tolerance limits. Patients with deep burns to the lower extremities should be fitted with extra depth shoes, moulded insoles or inserts. Early ambulation after grafting of the feet and legs is possible with total contact walking casts or Unna’s boots. Unna’s boot is a zinc oxide bandage that sets like plaster of Paris when dry and can be left in place for a week.
Care should be taken for patient with
• Past medical history of cardiovascular or pulmonary disease
• Exposed tendons or bone
• Dystrophic calcification
• Patients on i.v. lines/ventilatory support.
Hand Management
The burnt hand needs static or dynamic splinting after the wounds have healed. Burn injuries to the hands are all the more significant because the patient needs to return to normal function. Common deformities and problems of the burnt hand are:
• Clawing with hyperextension of the MCP joints, with flexion of the PIP and DIP joints. The thumb is in adduction and external rotation.
• Boutonniere deformities of the fingers.
• Edema which should be prevented by elevation of the whole arm immediately after injury.
• Active gentle exercises to increase range of movement and stretch intrinsic muscles. Manual traction applied to the joints stretches the ligaments passively.
A to C: Exercises to prevent burns contracture; (A) MCP joint flexion and extension; (B) IP joint flexion and extension; (C) Adduction and Abduction to stretch web spaces
Contraindications to Exercise
• Thrombophlebitis, deep vein thrombosis and vascular complications
• Fresh unhealed skin graft
• Severe dehydration.
• Septicemia
• Exposed joints
Post-acute/Long-term Rehabilitation
Exercises can be in the form of play and recreational activities. The occupational therapist needs to innovate in order to fabricate splints for various sizes of hands.
Goals of Rehabilitation
• To improve independence in ADL
• To regain full active ROM of all joints, promote return of strength and endurance, and improve dexterity and co-ordination.
• To ensure wound healing and minimize scars
• To extend psychological support to the depressed patient and family
• To have the patient return to school or office.
• To improve looks and cosmesis; this can be very crucial to youngsters.
Management
• The newly formed skin is fragile and exercise, stretching, splints or vigorous movements can cause abrasions and sores.
• Healed burnt skin is different from normal skin and hardly ever regains its original durability, elasticity or color. It remains dry and often lacks normal suppleness, and can be massaged with moisturizers, like aloe vera, calamine lotion or tea tree oil
• Maintaining ROM is more challenging than in the acute phase because of contracting fibrous tissue. Once the scar is mature, stretching is of less benefit. The therapist must give a slow, sustained stretch along the burn length. It also helps to apply paraffin at mild heat before being mobilized. Allowing sustained stretch has been found to enhance patient comfort and gain in ROM, of course taking care of the skin over the wound.
• A regime of generalized strengthening exercises, endurance exercises, and mild aerobics to improve cardiovascular capacity is started. Psychological Rehabilitation: Post-traumatic stress disorder is very common after burns. Sometimes the cause of the burn itself may be psychological; like a failed suicide attempt, often attempted in India. Stress and pain reduction mechanisms like relaxation techniques or hypnosis can be used. Individual and group counseling is done to support and educate patient groups on life after such a trauma.
Vocational Rehabilitation:
The following are done to get the person back to his or her job, or train for a new one:
• Assessment of hand function
• Surgery/splinting to enhance function
• Self help aids
• Transfer of skill or retraining of skill
• Alternate job placement.
CONCLUSION
Even after the patient is totally rehabilitated from a medical point of view, there are residual defects that remain for the rest of his life. They range from sensory impairment, heat/cold intolerance and callused feet, to psychological and social problems. It is during this phase that the patient and family realize how devastating the damage has been to the body, and when rehabilitation rather than survival becomes the primary issue.
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(TEXT BOOK OF REHABILITATION)
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