Post-burn Rehabilitation

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Top Contributors - Cindy John-Chu, Kim Jackson, Chrysolite Jyothi Kommu, Boluwatife Williams, Rucha Gadgil, Chelsea Mclene and Naomi O'Reilly  

Introduction

Rehabilitation is an essential component in the management of patients with burns and should be commenced on the day injury is sustained. To buttress, oedema control, respiratoy care, positioning, functional movements which are pertinent in burns cases must begin without delay.The process of rehabilitation requires efforts from a multidisciplinary team of health professionals who specialise in burns care viz: doctors, nurses, physiotherapists, occupational therapists, dieticians, psychologists, plastic surgeons, psychologists, social workers etc. Family members and suport groups can also be involved in the recovery process of these patients.

Aims of Rehabilitation

A thorough assessment to ascertain the patient's functional status should be done prior to commencement of rehabilitation. This would help guide the development of a customized treatment plan for individual patients. It is also important to provide education on what post-burn rehabilitation entails to patients and their caregivers in order to carry them along and to encourage cooperation. Generally, the aims of post-burn rehabilitation are geared towards returning the individual to as near normal as possible to their pre-injury state. They include:

• Maintaining range of movement
• Minimising development of contracture and the impact of scarring
• Prevention of deformity
• Maximising psychological well-being
• Maximising social integration
• Maximising functional ability and recovery
• Enhancing quality of life

Stages of Rehabilitation

Post-burn management can span from inception to the hospital to several months or years, depending on the severity of the injury. Stages of rehabilitation can divided into early and later stages although there is no clear cut time frame for each as they are both thought to overlap.

Early Stage

Also known as wound healing phase. Essentially, the aims of this stage are as follows:

• Respiratory care. Chest clearance can be achieved through raising the head and chest region. Physiotherapy techniques such as: deep breathing exercises, vibrations, percussion, postural drainage, coughing and suctioning can also be employed to clear excess secretions. A soft material, preferably, a foam can be used to pad the physiotherapist's hands if procedures requiring hand pressure are uncomfortable to the patient. However, if in the event that the patient sustains burn injuries on the chest with no concomitant respiratory involvement, percussions and vibrations should be avoided to prevent reinjury to already traumatised tissue.
• Prevention of oedema which can be gained by elevating all affected limbs. Oedema control must also commence on the day of injury to prevent sites of burns from deepening.
• Prevention of contractures and stiffness. These can be gained through splinting and proper positioning. Also performing active or passive range of motion exercises, depending on the patient's level of consciousness is crucial in the prevention of these complications. As a matter of importance, movement should be incorporated into the patient's daily routine from their inception to the hospital. Immobilisation is only allowed when a part of the body has just been grafted. Even then, the area must be kept in an anti-deformity position.
• Pain control. This can be obtainable by performing therapies during wound dressing and debridement, if possible. Analgesics should also be administered to encourage participation in movement activities. The physiotherapist can use transcutaneous electrical nerve stimulation (TENS) to enhance pain relief.
• Prevention of deep vein thrombosis
• Prevention of pressure sores

Later Stage

This stage, also known as the post-healing stage, focuses more on the following:

• An improvement in muscle strength, endurance, balance and coordination owing to prolonged bed immobilisation
• Scar management
• Ambulation with little or no assistance
• Engaging in functional activities
• Integration into the society

The video below shows some interventions to prevent contractures in a child who may have sustained burns injury. However, they may also be applicable to adult patients.

Rehabilitation After Grafting

Skin grafting is a term used to describe the process of transferring skin from one part of the body (the donor site) to another area, known as the recipient site which has been damaged by burns. Common donor sites for grafting are the upper arm and thighs. Other areas may include the back, buttocks or abdomen. A period of 5 to 7 days is allowed so that the graft can "take" and circulation would not be impaired. This means movement is not encouraged in the grafted areas nevertheless, surrounding parts of the body can still be moved.

Useful Therapeutic Modalities In Post-burn Management

• Therapeutic exercises to maintain and improve range of motion and enhance muscle strength.
• Transcutaneous Electrical Nerve Stimulation (TENS) to relieve pain and pruritus (itching).
• Hydrotherapy to encourage range of motion exercises especially when there is marked pain and patient is fearful to move limbs.
• Ultrasound can be employed to break adhesions and loosen scar tissue e.g. keloids.
• Paraffin wax therapy to especially manage contractures of the extremities
• Extracorporeal shockwave therapy (ESWT). Low-energy ESWT along with traditional physiotherapy have been shown to relieve burn scar pain, pruritus and improve health-related quality of life. It can also be used to improve scar appearance and functional mobility in patients with severe burns.
• Scar tissue massage to improve the pliability of scars.
• Laser therapy. Willows et al (2017) recommend the use of laser therapy, especially ablative fractional lasers in the management of burns to improve the pliability, vascularity and over all burn scar appearance

Therapeutic Adjuvants

These forms of therapies are recommended to relieve symptoms caused by the injuries sustained during the burn such as: pain, paraesthesia, itching and sleep disorder

• Virtual reality. A study conducted by Voon et al (2016) on interactive video games noted how the use of a 3D interface video game, Xbox Kinect improved exercise time and patient satisfaction in patients who sustained minor upper limb burns.
• Robotics. A novel study suggested that robot-assisted gait training in patients who have sustained burn injuries may be beneficial to improve their gait functions
• Music therapy
• Cognitive behavioural therapy
• Hypnosis

Conclusion

According to a guideline developed by the Chinese Association of Burn Surgeons, patients can be discharged when they are able to perform activities of daily living with little or no assistance. This goes to stress the pivotal role physiotherapy plays in the rehabilitation team of patients with burns.

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