Chronic Burn Physiotherapy Rehabilitation

Original Editor - Carin Hunter based on the course by ReLab
Top Contributors - Carin Hunter

The Role of the Physiotherapist in the Rehabilitation of the  Chronic Burn Patient.

The patient

∙ Healing process may continue for up to two years, as scar tissue remodels and  matures

∙ May require functional retraining and integration back into the community and  activities.

It is important to note that though scar management is initiated in the sub-acute phase, it may  need to be continued long term, as many patients suffer from continuing limitation to range of  motion (Procter 2010).

5.31 Aerobic and Resistance Training Post Burn

5.311 Rationale for Aerobic and Resistance Training

∙ Low cardiorespiratory endurance has been found to be a concern for all (Willis et al  2011)

∙ Aerobic capacity as measured by VO2 peak and time to fatigue has been found to be  lower in adults and children of >15% TBSA at one year post burn, compared to age  matched healthy controls (Willis et al 2011; McEntine et al 2006)

∙ Muscular strength and lean body mass has been found to be significantly less in  patients suffering from burns of >30% TBSA, particularly in exercises requiring a  high velocity (Disseldorp et al 2007; Ebid et al 2012). The systemic effects caused by  large surface area burns means that weakness may be global, not just local to the site  of the injury (Grisbrook et al 2012b)

∙ Reduced lean body mass, endurance and strength has been associated with limited  standing/walking tolerance, reduced upper limb function and lower health related  QOL and ability to participate in activities (Grisbrook et al 2012b).

∙ This has been found to persist beyond discharge from hospital despite routine  physiotherapy and occupational therapy in hospital (Disseldorp et al 2007). Though  protein metabolism begins to normalise 9-12 months post burn, patients are still found

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to have significant strength and aerobic related functional impairment at >2 years post  burn (Grisbrook et al 2012b).  

It is proposed that aerobic capacity and muscular strength is diminished by the following  factors

∙ Prolonged bed rest necessary in the early recovery process

∙ Hypermetabolisim, which may lead to *

o Exhaustion

o Protein catabolism

o Loss of lean body mass

∙ Impaired thermoregulation **

∙ Inhalation injuries and compromised respiratory function***

Recovery of aerobic capacity and strength may also be limited by

∙ Fatigue

∙ Pain

∙ Psychosocial factors  

(Disseldorp et al 2011; De Lauter et al 2007; Grisbrook et al 2012; Suman and Herndon  2007)

  • Hyper metabolism, catabolism, loss of lean body mass and exhaustion

Hypermetabolisim post burn caused by both second and third degree burns, particularly if  sepsis follows. This may begin approximately five days post burn, as the metabolic state is  initially suppressed by the effects of acute shock, and can persist for up to two years post  injury (Jeschke et al 2007; Herndon and Tomkins 2004). The greater the TBSA, the greater  the risk and impact of hyper metabolism (Hurt et al 2000). While it may not be recognised in  the acute stages, it may give rise to long term complications and functional impairment,  particularly with respect to strength and aerobic capacity (De Lauter et al 2007).

A systematic review by Disseldorp et al (2007) found 4 studies involving children with >  40% TBSA

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∙ All found a decrease of up to 20% in lean muscle mass compared to age matched  controls

∙ Adults with a TBSA >30% suffered a significant decrease in torque, work and power  in the quadriceps muscles compared to age matched controls. (De Lauter et al 2007)

Exercise and Hypermetabolism

Though exercise requires an increase in energy expenditure and metabolism for a short period  of time no adverse effects have been found with regard to exacerbating hypermetabolism or  protein catabolism.  

o All studies investigating the effects of exercise on lean body mass found it to increase,  particularly with resistance training ( Grisbrook et al 2012b; Suman and Herndon  2007; Suman et al 2001; Przkora et al 2007)

o Suman et al, 2001, found an increase of 15% in resting energy expenditure in children  with burns of >40% TBSA who were not treated with resistance and aerobic exercise,  while the REE of those who participated in the intervention remained stable.  

o Suggested that exercise may have sympathetic nervous system attenuating  effects

▪ A balance of resistance and aerobic exercise may cause a decrease in  SNS activity, decreasing catabolic effects.

o Exercise is required to integrate dietary amino acids into lean muscle mass (Herndon  and Tomkins 2004)

    • Thermoregulation

Human skin produces sweat to dissipate heat in response to thermal stress (McEntine et al  2006). A proper sweat response requires functional integrity of the

∙ Sweat glands

∙ Skin circulation

∙ Neural control of the skin (McEntine et al 2006)

Full thickness burns damage the dermal appendages including sweat glands. These are not  replaced by grafting. There is also a decreased density of sweat glands in the donor site post  grafting (Esselman et al 2007).

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However, McEntine et al 2006 found that in 15 children with an average of 55% TBSA there  was

∙ No significant difference in core temperature, measured tympanically, pre or post 20  minutes of treadmill exercise at room temperature compared to age matched healthy  controls.

∙ No significant difference in average skin temperature between burned and healthy  children.

∙ Significantly increased skin temperature in healthy versus burned skin per child.  

Austin et al, 2003 studied 3 adults with > 60% TBSA, 3 with between 30-40 TBSA and 2  unburned patients post 1 hr cycling at 35 degrees and 60% humidity

∙ None showed significant intolerance for heat as measured by heart rate and core  temperature, measured rectally

∙ No significant difference in whole body sweat rate

∙ Overcompensation by healthy skin in the burned patients.  

∙ Suggested physical history was a factor in determining patients’ ability to  thermoregulate. Therefore adaptations may occur through training.

However, studies involving heat loads of 40 degrees have found a significant inability to  maintain adequate thermoregulation. Due to the small study numbers of the above, and the  controversy surrounding the efficacy of measuring core temperature accurately, it is advised  that patients are closely monitored initially during aerobic exercise for signs of heat  intolerance.

      • Inhalation injury and pulmonary insufficiency

Long term pulmonary function is compromised in some patients post severe burn

∙ Lasts several years

∙ Documented in both children and adults (Grisbrook et al 2012a)

∙ Caused by

o Smoke inhalation

o Direct thermal damage to airways

o Pulmonary oedema

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o Respiratory tract infection

o Complications from intubation

o Recurrent infection leading to chronic inflammation

Less likely to cause dysfunction in <30% TBSA, no injury over torso, and no  inhalation injury

(Willis et al 2011)

Evidence for impact on aerobic and exercise capacity conflicting (Grisbrook et al 2012a).  However Willis et al (2011) studied 8 males post > 15% TBSA burns at one year post injury,  and found  

∙ Significantly decreased FEV1, peak VO2 and time to fatigue, in the burned patients ∙ No significant decrease in SpO2 at baseline or peak VO2- however, the SpO2 of  burned patients took significantly longer to stabilise at baseline post exercise. ∙ No significant difference in participation levels in physical activity, though burn  survivors were more likely to participate in work rather than leisure activity. ∙ Burns survivors were less likely to participate in vigorous intensity exercise over 9  METs

∙ Therefore, decreased pulmonary function did not prevent them from participating ∙ The lower relative intensity of their exercise may have caused their decreased aerobic  capacity.  

All of the above factors must be considered as both a contributor to the patients’ loss of  strength and aerobic capacity, and a potential limiter of their ability to participate in therapy.  Careful monitoring and modification of treatment according to individual response is advised.

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5.312 Aerobic Training: The Evidence

Article  citation Disseldorp et  al, 2011 De Lauteur et  al, 2007 Grisbrook et  al, 2012 Grisbrook et  al, 2012 Paratz et al,  2012 (ab) Przkora et al,  2007 Design Systematic  

review

Eleven articles  included

Eight RCTs

Pedro 6+

1 RCT<5, 1  non RCT, 2  static group  comparison

Randomised  controlled,  

double  

blinded trial

Non  

randomised  

controlled trial.

Non  

randomised  

controlled trial.

Quasi  

experimental  controlled  

trial

Randomised  

controlled trial

Oxandrolone, vs  osandrolone +  exercise, vs  exercise +  placebo,  

placebo+no  

exercise


Subjec

ts

7 different  cohorts

5 children with  exceptionally  large TBSA

35 adults  mean 37.5  days post  burn, mean  TBSA 19.3% 9 burn injured adults and 9 age  matched healthy controls. 20%+  TBSA, 2 yrs post injury, with  remaining functional deficit. 30 patients,  mean age  34.3 years,  mean TBSA  42.9% 51 children, 7- 17 yrs old,  >40% TBSA Interve

ntion

Aimed to  assess physical  fitness post  burn, and the  effectiveness  

of aerobic  exercise

12 week  rehabilitation  programme,  3 x weekly  30 mins.  Standard  

rehabilitation  vs. work to  quota and  work to  tolerance  

aerobic  

exercise

12 weeks, 3 x weekly, 80 mins.

30 mins of treadmill  walking/jogging in intervals (85  vs 65-70 HR max) and  resistance exercises.

6weeks, 80 %  MHR aerobic  training, with  70% three  RM  

resistance  

training

12 week  inpatient  

physiotherapy  twice daily for 1  hr. aerobic and  resistance  

exercise  

Aerobic 5 days  per week, 20-40  mins, 70-85%  VO2peak


Outco

me  

measur

e

Children and  adults after  extensive  

burns score  worse than  non-burned  

controls in all

Max aerobic  capacity:  

VO2 max.

Spirometry,  

Canadian  

occupational  

performance  

measure, VO2  peak

Burn specific  health scale,  SF 36, quick  DASH 1RM, VO2  peak, shuttle  walk  

distance, LL function  

score, quick  dash, burns

Biodex leg  extension, 3  RM, VO2 peak,  lean body mass,

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aspects of  fitness.

Burn patients  participating in  12 week  training  

programmes  

improve  

significantly  

more than  those without.

specific  

health scale


Results Work to  tolerance and  work to quota  significantly  

improved  

aerobic  

capacity. No  significant  

improvement  in control. No  significant  

difference  

between  

WTQ and  WTT

No significant  improvement  in spirometry  values  

(ex/control)

Significant  

improvement  in VO2 peak  and time to  fatigue in both  groups.  

Significant  

improvement  in satisfaction  with  

personalised  

goals.

Burns patients  scored lower  on HRQOL  and quick dash  both before  and after the  intervention  

compared to  controls. 5/9  burn patients  reached  

clinically  

significant  

improvements  in BSHS post  intervention.  No significant  increase in  DASH

No adverse  effects.  

Significant  

improvement s in  functional,  

physical,  

psychological  measures.

LBM increased  in all groups  except placebo showed average  decrease.  

Steroids+  

exercise=  

highest relative  increase. Both  exercise and  drug only group  showed  

significant  

increase in  strength.  

Endurance  

increased in the  exercise groups,  but not those  with only  steroids/placebo


Limitat ions 4 studies  conducted in  children with  large TBSA  burns. Little  variation in the  protocols  

being  

compared, and  so no objective  evidence of the  efficacy of  individual  

components of  exercise.

Low risk of  bias in  randomisatio n, no  discussion of  blinding to  initial scores.  Unable to  blind  

therapists or  patients to  the  

intervention.  Small patient  numbers

Small subject  numbers, no  untreated  

control,  

blinding not  possible

Small subject  numbers, no  untreated  

control,  

blinding not  possible

Abstract.  

Unable to  identify the  methodologic al rigour of  this study,  and so results  should be  interpreted  

with caution.

Low risk of bias  in  

randomisation,  no discussion of  blinding which  leaves a high  risk of bias  where a placebo  drug is involved.

Table 12 Evidence for Aerobic Training Post Burn

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5.313 Aerobic Training Summary and Recommendations for Practice Exercise prescription:

Frequency: The majority of papers which investigated an aerobic intervention used 3 times  per week as their frequency (De Lauteur et al 2007; Grisbrook et al 2012). These obtained  significant improvements. However, Przkora et al (2007) used a frequency of 5 times per  week with children. There have been no studies investigating optimal frequency.

Intensity: All studies used between 65 and 85% predicted heart rate max, with one study  using interval training of 120 seconds 85% HRM and 120 seconds of 65-70 HRM. All  studies obtained positive effect, with none directly comparing intensities to determine the  optimum. De Lauteur et al (2007), concluded that whether the patient gradually increased  their intensity by working to a specific quota each week, or if they simply worked at their  target heart rate for as long as they could tolerate, there was no significant difference in gains  in aerobic capacity.

Type: All interventions used treadmill training, whether walking or running.

Time: All studies recommended the duration of treatment be 12 weeks, with the exception of  Paratz et al, 2012, who investigated a high intensity six week programme. However, the  specific results of this are unknown. Sessions were 20-40 minutes in length, with the  majority using 30 minutes (Grisbrook et al 2012; De Lauteur et al 2007; Przkora et al 2007)

Please note safety considerations Pg 72

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5.314 Resistance Training: The Evidence

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5.314 Resistance Training Summary and Recommendations for Practice

Exercise prescription: Post two years, Grisbrook et al (2012b) found that burned patients  responded to resistance exercise similarly to controls. Therefore, normal guidelines may be  adequate.  

Frequency: All studies investigating the effects of resistance training used a frequency of  three times per week. There have been no studies to investigate the optimum frequency for  resistance training in this population. Suman et al (2001), suggested that a break of more than  48 hrs must be given between bouts of resistance training.

o Resistance exercise causes microtrauma to muscles already in a compromised state. o Resistance exercise in burned patients stimulates protein synthesis as in unburned  subjects- However; a longer period of recovery may be required for optimum results.  

Type/ Intensity: Children: 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) (Suman et al 2001; Suman and  Herndon 2007).  

Isokinetic training: 10 reps at 150 degrees per second, using 1-5 sets for the 1st-5th  session,6 sets for the 6th-24th session, and 10 sets from 25th to 36th session, with three minute  rests between sets. (Ebid et al 2012).

Mixed and functional strength training: Grisbrook et al (2012b) commenced on the  biodex, targeting specific muscle groups for the desired functional goal, and progressed to  resistive machine and finally free weight training using functional items. Intensity was 50- 60% of 1 RM initially, for 10-15 reps, adjusting as 1 RM increased. While no studies have  compared the optimum type/intensity of exercise, this may be the optimum approach.  Providing functional exercises may also increase motivation and compliance.  

Time: All the studies used a protocol of 12 weeks. There were no studies comparing the  efficacy of shorter or longer time frames, however, given that loss of lean body mass is a  possible cause of strength loss post burn, an exercise programme of longer than eight weeks  is probably required to ensure hypertrophy and optimum gains in the burn patient (Suman et  al 2001)

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5.316 Safety Considerations for Strength and Aerobic Training:

Initiating aerobic and strength training:

∙ studies stipulated a minimum of six months to two years post burn before initiation of  programmes, though many subjects were included who had been burned many years  before. These participants all benefited from the interventions.  

∙ Suman and Herndon (2007) suggested that the time frame of 6 months post burn was  chosen based on clinical experience because by this time paediatric patients with  >40% TBSA burns were

o 95% healed  

o ambulatory  

o had had the opportunity to return home

▪ Therefore, more favourable psychological status

∙ There were no studies investigating early training

o With extensive burns, adequate healing of wounds and medical stability  required before initiating aerobic/strength exercise

Other safety considerations:

∙ Though exercise has been shown to increase lean body mass, liaison with doctors  concerning anabolic steroids and medication and with dieticians regarding optimal  nutrition is recommended in order to ensure correct management of  hypermetabolisim.

∙ Caution should be used with regard to impaired thermoregulation. Monitoring of heart  rate and blood pressure may be advisable, particularly on initiation of exercise and  when exercising with additional thermal stress. Manage the environment to minimise  thermal stress initially in particular.

∙ Particularly those at risk of reduced pulmonary function post burn (i.e., >30% TBSA,  injury to torso, or inhalation injury), monitor SpO2 and RPE during exercise. Allow  additional rest periods to allow SpO2 to return to normal levels post exercise, as this  has been shown to be delayed.