Acute Burn Physiotherapy Rehabilitation: Difference between revisions
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===== Common treatment techniques ===== | ===== Common treatment techniques ===== | ||
# '''Immobilisation''' | #[[Respiratory Muscle Training|'''Respiratory care''']] | ||
#* Chest clearance can<span class="reference" id="cite_ref-:0_4-0"></span> be achieved by ra<span class="reference" id="cite_ref-:0_4-0"></span>ising the head and chest regi<span class="reference" id="cite_ref-:0_4-0"></span>on. Physiotherapy te<span class="reference" id="cite_ref-:0_4-0"></span>chniques such as deep breathing exercises, vibrations, [[percussion]], postural drainage, coughing and [[suctioning]] can be employed to clear excess secretions. A soft material, preferably, foam can be used to pad the physiotherapist's hands if procedures requiri<span class="reference" id="cite_ref-:1_3-1"></span>ng hand pressure a<span class="reference" id="cite_ref-:1_3-1"></span>re uncomfortable to the patie<span class="reference" id="cite_ref-:1_3-1"></span>nt. However, if in t<span class="reference" id="cite_ref-:1_3-1"></span>he event that the patient sustains burn injuries on the chest with no concomitant respiratory involvement, percussions and vibrations should be avoided <span class="reference" id="cite_ref-:1_3-2"></span>to prevent reinjur<span class="reference" id="cite_ref-:1_3-2"></span>y to already traumatised tiss<span class="reference" id="cite_ref-:1_3-2"></span>ue.<span class="reference" id="cite_ref-:3_1-1"></span> | |||
#'''Immobilisation''' | |||
#* Bed rest | #* Bed rest | ||
#* Splinting | #* Splinting<span class="reference" id="cite_ref-:3_1-1"></span><span class="reference" id="cite_ref-:0_4-1"></span><span class="reference" id="cite_ref-:0_4-1"></span><span class="reference" id="cite_ref-:3_1-2"></span><span class="reference" id="cite_ref-:3_1-2"></span> | ||
#'''Positioning''' | |||
#* Prevention of contractures and stiffness. [[Splinting for Burns|Splinting]] and proper positioning will help achieve this aim. Also performing active or passive range of motion (ROM) 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. | |||
# '''Prevention''' '''of [[Oedema Assessment|Oedema]]''' | |||
## which can be gained by elevating all affected limbs must also commence on the day of injury to prevent sites of burns from deepening. | |||
# '''Positioning''' | |||
#* | |||
# '''Pain Control''' | # '''Pain Control''' | ||
#* is obtainable by performing therapies during wound dressing and debridement, if poss<span class="reference" id="cite_ref-:2_2-2"></span>ible. Analgesics <span class="reference" id="cite_ref-:2_2-2"></span>should also be administered prior to therapy sessions to encourage participation in movement activities. The physiotherapist can use [[Transcutaneous Electrical Nerve Stimulation (TENS)|transcutaneous electrical nerve stimulation]] (TENS) to enhance pain re<span class="reference" id="cite_ref-:3_1-3"></span>lief. | #* is obtainable by performing therapies during wound dressing and debridement, if poss<span class="reference" id="cite_ref-:2_2-2"></span>ible. Analgesics <span class="reference" id="cite_ref-:2_2-2"></span>should also be administered prior to therapy sessions to encourage participation in movement activities. The physiotherapist can use [[Transcutaneous Electrical Nerve Stimulation (TENS)|transcutaneous electrical nerve stimulation]] (TENS) to enhance pain re<span class="reference" id="cite_ref-:3_1-3"></span>lief. | ||
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# '''Prevention of [[Pressure Ulcers|Pressure Sores]]''' | # '''Prevention of [[Pressure Ulcers|Pressure Sores]]''' | ||
== 1. Immobilisation == | == 1. Respiratory Care == | ||
== 2. Immobilisation == | |||
Rationale for immobilisation in the acute stage it to prevent deformities, maintenance of range of motion and to promote healing by protecting the structures involved.<ref name=":0">Kamolz LP, Kitzinger HB, Karle B, Frey M. [https://www.sciencedirect.com/science/article/abs/pii/S0305417908002659 The treatment of hand burns.] Burns. 2009 May 1;35(3):327-37.</ref> | Rationale for immobilisation in the acute stage it to prevent deformities, maintenance of range of motion and to promote healing by protecting the structures involved.<ref name=":0">Kamolz LP, Kitzinger HB, Karle B, Frey M. [https://www.sciencedirect.com/science/article/abs/pii/S0305417908002659 The treatment of hand burns.] Burns. 2009 May 1;35(3):327-37.</ref> | ||
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The position of safe immobilisation of the burned hand is essentially the opposite of the above claw deformity position. This position involves: 20-30 wrist extension, 80-90 degrees flexion MCP joints, full extension PIP and DIP joints and palmar abduction of the thumb (Boscheinen-Morrin 2004). | The position of safe immobilisation of the burned hand is essentially the opposite of the above claw deformity position. This position involves: 20-30 wrist extension, 80-90 degrees flexion MCP joints, full extension PIP and DIP joints and palmar abduction of the thumb (Boscheinen-Morrin 2004). | ||
== 3. Positioning == | |||
== 3 | |||
*Modify according to burn area, patient pain and medical status.* | *Modify according to burn area, patient pain and medical status.* | ||
{| class="wikitable" | {| class="wikitable" | ||
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|} | |} | ||
== 5. Pain == | == 5. Prevention of Oedema == | ||
== 6. Deep Vein Thrombosis == | == 5. Pain Management == | ||
== 7. Pressure Sores == | == 6. Prevention of Deep Vein Thrombosis == | ||
== 7. Prevention of Pressure Sores == | |||
=== Splinting === | === Splinting === |
Revision as of 11:58, 19 September 2022
Introduction [edit | edit source]
Depending on the size and the severity of the injury this stage may last from a few days to a few months (Procter 2010)
Patient[edit | edit source]
∙ Acute phase of inflammation
∙ Pain
∙ Oedema increasing for up to 36 hours post injury
∙ Hypermetabolic response, peaking at five days post injury
∙ Early synthesis and remodelling of collagen
Aims[edit | edit source]
- Reduce risk of complications
- Reduce oedema, particularly where it poses a risk for
- impinging on peripheral circulation or airways
- Predisposition to contractures
- Reduce oedema, particularly where it poses a risk for
- Prevent deformities/loss of range
- Protect/promote healing
- Maintain or improve chest condition
Common treatment techniques[edit | edit source]
- Respiratory care
- Chest clearance can be achieved by raising the head and chest region. Physiotherapy techniques such as deep breathing exercises, vibrations, percussion, postural drainage, coughing and suctioning can be employed to clear excess secretions. A soft material, preferably, 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.
- Immobilisation
- Bed rest
- Splinting
- Positioning
- Prevention of contractures and stiffness. Splinting and proper positioning will help achieve this aim. Also performing active or passive range of motion (ROM) 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.
- Prevention of Oedema
- which can be gained by elevating all affected limbs must also commence on the day of injury to prevent sites of burns from deepening.
- Pain Control
- is obtainable by performing therapies during wound dressing and debridement, if possible. Analgesics should also be administered prior to therapy sessions to encourage participation in movement activities. The physiotherapist can use transcutaneous electrical nerve stimulation (TENS) to enhance pain relief.
- Prevention of Deep Vein Thrombosis
- can be achieved by encouraging early ambulation.
- Prevention of Pressure Sores
1. Respiratory Care[edit | edit source]
2. Immobilisation[edit | edit source]
Rationale for immobilisation in the acute stage it to prevent deformities, maintenance of range of motion and to promote healing by protecting the structures involved.[1]
Immobilisation Post Skin Reconstruction Surgery[edit | edit source]
Stopping movement and function of the body parts involved should be enforced after skin reconstruction for a burn has taken place. When a body part must be immobilised, it should be splinted or positioned in an anti-deformity position for the minimum length of time possible (Edgar and Brereton 2004; ANZBA 2007)
The following is a table drawn up using current literature on the recommended immobilisation times for the various skin grafts:
Surgical Procedure | Immobilisation Time |
---|---|
Biological Dressings | <24hours |
Autograft (superficial to intermediate) | 24-48hours |
Superficial Thickness Skin Graft | 3-5 days |
Full Thickness Skin Graft | 5-7 days |
The times frames for mobilisation post-surgery outlined in this booklet are merely a guide taken from an analysis of current literature and are NOT a replacement for the specific time frames directed by the operating surgeon or consultant[3] .
For a physiotherapist the most important concepts to grasp are:
• What is the minimum timeframe of immobilisation post-surgery
• What structures MUST be immobilised
• Special considerations for movement, function and ambulation dependent on Donor sites and the structures repaired or excised during surgery.
Immobilisation of the Hand[edit | edit source]
Deformity Prevention
The most common deformity associated with burns is the ‘claw’ deformity. It involves extension of the MCP joints, flexion of the PIP joints, adduction of the thumb and flexion of the wrist[1] . This position is also referred to as the intrinsic minus position.
Figure16a. Dorsal hand burn resulting
in claw deformityFigure 16 b: Position of safe
immobilisation (Glassey, 2004)
Position of Safe Immobilisation
The position of safe immobilisation of the burned hand is essentially the opposite of the above claw deformity position. This position involves: 20-30 wrist extension, 80-90 degrees flexion MCP joints, full extension PIP and DIP joints and palmar abduction of the thumb (Boscheinen-Morrin 2004).
3. Positioning[edit | edit source]
- Modify according to burn area, patient pain and medical status.*
Area Of Burn | Common Contracture | Recommended position |
---|---|---|
Anterior neck | Neck flexion: loss of neck contours and extension | Neck in extension. If head needs to be raised, do not use pillows |
Posterior neck | Neck extension. Loss of flexion and other movements | Head in flexion. Sitting or lying with a pillow behind the head |
Axilla | Limited abduction/ protraction with burn to chest | Lying/ sitting with arms abducted. Slings, pillows, figure of eight bandage around chest for stretch. Prone lying |
Anterior Elbows | Flexion | Elbow extension |
Groin | Hip flexion | Prone lying, legs extended, no pillow under knees in supine, limit sitting/side lying |
Back of knee | Flexion | Long sitting/ supine lying, no pillow beneath knees |
Feet | Dependent on area | Aim to maintain 90 degrees at ankle: pillows in bed, sitting with feet on floor |
Face | Variety: inability to open/close mouth/eyelids | Regular change of expression. Soft rolls may be inserted into the mouth |
5. Prevention of Oedema[edit | edit source]
5. Pain Management[edit | edit source]
6. Prevention of Deep Vein Thrombosis[edit | edit source]
7. Prevention of Pressure Sores[edit | edit source]
Splinting[edit | edit source]
Physiological rationale for splinting (Kwan 2002)
Scar tissue is visco-elastic. It will elongate steadily within a certain range. When this stretching force is released, there is an immediate decrease in the tissue tension but a delay in the retractions of the tissue to a shorter length. These stress relaxation properties of visco elastic scar tissue means it can accommodate to stretching force overtime. Dynamic and static splinting provide this prolonged low stretching force.
Categories of Splints[edit | edit source]
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∙ Static or Dynamic
∙ Supportive or Corrective
∙ Rigid or soft
∙ Dorsal or Volar
∙ Digit, hand or forearm based (Boscheinen-Morrin 2004) Static Splinting
∙ A serial static splint is a device with no moving parts designed to be remoulded as a contracture improves. The most common serial static splint you will come across is a thermoplastic palmar splint moulded in the position of safe immobilisation.
Thermoplastic palmar splints in the position of safe immobilisation (Glassey 2004)[edit | edit source]
∙ A static progressive splint is a device designed to stretch contractures through the application of incrementally adjusted static force to promote lengthening of contracted tissue (Smiths 2009). There are various types of static progressive splints available depending on the area affected. One such static progressive splint is a finger flexion strap splint. This type of splint is used in the treatment of MCP extension contractures. The flexion straps serially stretch scar bands along the dorsum of hand and wrist causing extension contracture. The stretching force is localised to the MCP joints by applying the straps via a wrist extension splint. This stabilises the wrist providing static support below the MCP joint (Kwan 2002).
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Dynamic Splinting[edit | edit source]
Fig 18: Velcro flexion straps (Glassey 2004)
A dynamic splint is one which aids in initiating and performing movements by controlling the plane and range of motion of the injured part. It applies a mobile force in one direction while allowing active motion in the opposite direction. This mobile force is usually applied with rubber bands, elastics and springs (Smith 2009).
Dynamic extension splints are most commonly used in the treatment of palmar and / or finger burns (i.e. flexion contractures). All the finger joints including the MCP, PIP and DIP joints are in full extension (Smith 2009).
Fig 19 Dynamic Extension Hand Splint
(Microsurgeon 2013)
Dynamic flexion splints are used in the treatment of dorsal hand burns. During wound healing and subsequent scar maturation, the skin on the dorsal aspect of the hand can markedly contract limiting digit flexion. A dynamic flexion splint in the sub-acute stage of dorsal hand burns can aid in the prevention of MCP joint extension contractures (Kwan 2002).
Fig 20 Dynamic flexion hand splint in glove form
(Microsurgeon 2013)
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Overview of the Evidence:
There is currently no evidence available which identifies the benefit of one hand splint over another in the treatment of the burnt hand. A systematic review carried out in 2006 concluded that there are no studies examining the effectiveness of hand splinting for hand burns, but rather studies describing types of hand splint interventions (Esselman 2006). There are currently no control trials which compares the various types of splints available or which examines the use Vs disuse of splinting the burnt hand. Literature in the area suggests the use of splinting in the initial inflammatory phase to promote a position of safe immobilisation. The use of splinting as an adjunct to treatment in the sub-acute phase is discussed in the literature as an aid to maintain/regain range of motion.
Splinting Precautions[edit | edit source]
∙ Splints need to be cleaned regularly to prevent colonization by microbes which may lead to wound infection (Wright et al 1989; Faoagali et al 1994)
∙ Unnecessary use of splinting may cause venous and lymphatic stasis, which may result in an increase in oedema (Palmada et al 1999)
∙ Precaution must be taken to ensure that splints do not product friction causing unnecessary trauma to the soft tissues (Duncan et al 1989).
∙ Precaution must be taken to ensure that splints do not produce excessive pressure. There is particular risk of pressure injury to skin after burn injuries due to potential skin anaesthesia (Leong 1997).
∙ Splinting should not be used in isolation but as an adjunct to a treatment regime Conclusion on Splinting
The use of hand splinting does not follow a protocol in the treatment of the burnt hand. It is often common practice to splint the burnt hand in the initially inflammatory phase of healing. Despite the level of evidence available it is important as a physiotherapist to be aware of the role splinting can play as an adjunct to treatment of the burnt hand in the sub-acute phase of healing. The application of hand splinting in the areas of burns must be clinically reasoned for each individual patient. A Physiotherapist must identify the appropriate rather than routine use of splinting. This is to promote patient independence and prevent dependence on splinting devices both by patients and physiotherapists alike.
Chest Physiotherapy[edit | edit source]
References[edit | edit source]
- ↑ 1.0 1.1 Kamolz LP, Kitzinger HB, Karle B, Frey M. The treatment of hand burns. Burns. 2009 May 1;35(3):327-37.
- ↑ Edgar D, Brereton M. ABC of burns: Rehabilitation after burn injury. BMJ: British Medical Journal. 2004 Aug 8;329(7461):343.
- ↑ 3.0 3.1 Yuan J, Wu C, Holland AJ, Harvey JG, Martin HC, La Hei ER, Arbuckle S, Godfrey C. Assessment of cooling on an acute scald burn injury in a porcine model. Journal of burn care & research. 2007 May 1;28(3):514-20.