Sub Acute Burn Physiotherapy Rehabilitation

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

Introduction

One of the primary goals in the sub-acute stage of burn recovery is to preserve and enhance the patient's range of motion. This is crucial for preventing contractures and ensuring optimal function during rehabilitation (Kwan 2002; Boscheinen Morrin 2004).

Effective interventions during the sub-acute stage include pressure garment therapy, silicone therapy, scar massage, and various mobilization techniques. These aim to address scar remodelling, scar contraction, and the potential adverse effects of prolonged bed rest on range of motion and overall function (Schneider et al, 2012).

Role of the Physiotherapist in Sub-Acute Burn Patient Rehabilitation

Following the acute stage, a comprehensive rehabilitation plan is essential for burn patients. This plan encompasses pressure garment therapy, silicone therapy, scar massage, range of motion exercises, mobilization techniques, strengthening exercises, functional and gait retraining, as well as balance and fine motor retraining (Schneider et al, 2012). Each intervention should be tailored based on a thorough patient assessment.

While the ethical considerations limit rigorous investigation of physiotherapy interventions, Schneider et al (2012) observed significant improvements in contractures, balance, and hand function through inpatient rehabilitation in an observational study.

Mobilisation in Burn Rehabilitation

Active Range of Motion (AROM)

Gentle active ROM exercises are preferred during the acute stage as they effectively reduce oedema through active muscle contraction (Glassey 2004). If active exercises are not feasible, positioning the patient appropriately is a suitable alternative.

Passive Range of Motion (PROM)

In the acute stage, passive ROM exercises are contraindicated due to the risk of future damage to burned structures. Passive joint mobilizations become appropriate during the scar maturation phase when the scar tissue gains sufficient tensile strength to tolerate mobilization techniques (Boscheinen-Morrin and Connolly 2001).

Frequency and Duration Recommendations

Physiotherapy interventions, including both active and passive exercises, should be performed twice daily. Sedated patients may require gentle passive ROM exercises three times a day (Boscheinen-Morrin and Connolly 2001).

Contraindications

Avoid active or passive ROM exercises if there is suspected damage to extensor tendons or post skin grafting, as a period of immobilization is crucial for graft healing (Boscheinen-Morrin and Connolly 2001).

Evidence for Hand Mobilization

Limited evidence exists for the effectiveness of hand exercises specifically for burned hands. Okhovation et al (2007) conducted an RCT comparing routine rehabilitation with burn-specific rehabilitation. The burn rehabilitation group showed a significant decrease in post-burn contractures compared to the routine rehabilitation group.

Functional Rehabilitation of the Hand

Salter and Chesire (2000) recommend using the burnt hand for light self-care activities as tolerated by the patient. Regular movements during daily activities promote intrinsic flexion, gross gripping, and maintenance of hand function.

Practical Considerations for Mobilization

• Coordinate mobilization with dressing changes.
• Time pain relief appropriately for maximum benefit during treatment.
• Observe and assess the patient's ability to perform exercises and use splints.
• Monitor for post-exercise pain and wound breakdown.
• Be cautious of prolonged blanching to avoid compromising vascularity.
• Consider the patient's reduced exercise capacity due to increased metabolic rate, altered thermoregulation, and increased nutritional demands (ANZBA 2007).

Scar Massage in Burn Rehabilitation

Principles of Scar Massage

1. Prevent Adherence
2. Reduce Redness
3. Reduce Elevation of Scar Tissue
4. Relieve Pruritus
5. Moisturize (Glassey 2004)

Massage Techniques

• Retrograde massage for venous return and lymphatic drainage.
• Effleurage to increase circulation.
• Static pressure to reduce swelling.
• Finger and thumb kneading to mobilize scar and surrounding tissue.
• Skin rolling to restore mobility to tissue interfaces.
• Wringing the scar to stretch and promote collagenous remodeling.
• Frictions to loosen adhesions (Holey and Cook 2003).

Guidelines for Massage during Healing Stages

• Inflammatory Phase: Gentle massage to decrease edema and increase blood supply.
• Proliferative Phase: Massage with gentle stress to ensure correct collagen alignment.
• Remodeling Phase: Prolonged stretching to minimize adhesions (Glassey 2004).

Evidence for Scar Massage

Studies (Field et al 2000; Morien et al 2008; Shin and Bordeaux, 2012) suggest psychological benefits from scar massage, including decreased depression, anger, pain, and anxiety. However, limited evidence explores the effect of massage on range of motion in burn patients (Morien et al 2008).

Recommendations and Safety Considerations

• Maintain clean hands.
• Use non-irritating lubricants.
• Modify practices based on the patient's stage of healing, sensitivity, and pain levels.
• Contraindications include compromised epidermis, acute infection, bleeding, wound dehiscence, graft failure, intolerable discomfort, and hypersensitivity to emollient (Shin and Bordeaux 2012).

In conclusion, a multidimensional approach, including mobilization and scar massage, plays a crucial role in the rehabilitation of sub-acute burn patients. Tailoring interventions to individual patient needs and considering safety factors contribute to the overall success of burn rehabilitation programs.