Acute Burn Physiotherapy Rehabilitation

Original Editor - Carin Hunter Top Contributors - Carin Hunter and Naomi O'Reilly

Clinical Practice Guideline: Early Mobilization and Rehabilitation of Critically Ill Burn Patients

Introduction

Purse lip breathing Chest Expansion Exercise Coughing Technique Oral Suction Ankle Toe Movements Active–Assissted Movements Relaxation

Cartotto R, Johnson L, Rood JM, Lorello D, Matherly A, Parry I, Romanowski K, Wiechman S, Bettencourt A, Carson JS, Lam HT. Clinical Practice Guideline: Early Mobilization and Rehabilitation of Critically Ill Burn Patients. Journal of Burn Care & Research. 2022 May 26.

Depending on the size and the severity of the injury this stage may last from a few days to a  few months (Procter 2010)

The acute phase of rehabilitation is also critical for the patient and rehabilitation professional, as common psychological responses reported following burn injury include: fear, anxiety, anger Corresponding author: Tanuja Dunpath, University of KwaZulu-Natal, Physiotherapy Email: [email protected] 266 African Health Sciences Vol 16 Issue 1, March 2016 and emotional distress9,10 and often require intervention of a supportive or psychological nature. The effect on appearance and aesthetic complications of a visible burn injury cannot be undermined, as this may have a significant bearing on the individual’s body image and ability to return to society and professional life11. Disfigurements were found to often result in social stigma and restriction in participation in society12. Physiotherapists are in a prime position to facilitate and motivate these patients to return to their communities with a sense of new hope and purpose. It also emphasises the need for implementation of a specialised and dedicated multidisciplinary team in the holistic management of the burn injured patient to optimise the patients’ physical and psychological recovery4,6. The perceptions and experiences of physiotherapists represent an untapped reserve of insightful and valuable knowledge about patients with acute burn injuries and the challenges they often face during the rehabilitation journey. Family support and care were said to be significant components to facilitate the therapy process and re-integration to their home environment. Family support was identified as a crucial factor that empowered the patient to progress in therapy however therapists also expressed the need to ensure that family members were aware of the treatment goals and encouraged independence in everyday tasks. Blakeney et al (2008) expressed that in some cultures family tend to overprotect individuals with disfiguring conditions in order to express their care, concern and support but this may unintentionally serve as a hindrance to progression in therapy again this emerged as a subtheme in this study9 . Therapists acknowledged that the psychological and emotional impact of the traumatic event seemed to affect the patients’ willingness to participate in the therapy process as patients were still coming to terms with their burn experience. Therapists felt that they were in a prime position to establish a rapport with the patient by providing the patient an opportunity to ventilate their feelings. Participants expressed that they felt comfortable to provide basic counselling and would refer to the psychologist or social worker if further psychological intervention was warranted.

Important Considerations in the Acute Phase

• Be aware of the physiological process as the patient is in the acute phase of inflammation
• Pain
• After a burn injury, oedema can be known to continue to increase for 36 hours
• After a sever burn injury, a patient can suffer from a hypermetabolic response. This is known to reach it's peak at about five days post injury.
• There is often early collagen synthesis and remodelling.

Aims

1. Respiratory care
2. Immobilisation
3. Positioning
4. Pain Control
5. Prevention of Complications
   1. Oedema
   2. Deep Vein Thrombosis
   3. Pressure Sores

1. Respiratory Care

Physiotherapy can facilitate chest clearance with techniques such as deep breathing exercises, vibrations, percussion, postural drainage, coughing and suctioning can be employed to clear excess secretions. If the physiotherapist's hand pressure is uncomfortable or painful to the patient, a soft material can be used to pad the physiotherapist's hands. If the patient has sustained burn injury to the chest area and there is no possible way of avoiding contact with this ares, percussions and vibrations should be avoided to prevent reinjury to already traumatised tissue. Other modalities can be employed to assist with the chest therapy.

If there are signs of an inhalation injury, aggressive, prophylactic chest treatment should commence immediately. After conducting the subjective assessment, if there is evidence that the patient has been in an enclosed space or they are suffering from a reduced level of consciousness, it is advised to rather begin with shorter, but more frequent treatment sessions.

The initial aim of chest therapy should be to remove any lung secretions, prevent any complications and to normalise the mechanism of breathing. There are many ways do achieve this, sitting out of bed and positioning are good as they can be taught to the patient are care givers with ease. A positive expiratory pressure device can be used as well as intermittent positive pressure breathing.

Secondly is is important to increase the depth of breathing. This is commonly achieved with ambulation, a tilt table, facilitation techniques or inspiratory holds.

2. Immobilisation

The aim of immobilisation in the acute phase is to prevent deformities, maintain the of range of motion and to protect the structures involved which will promote healing. The two methods commonly used are splinting and bed rest.

Post Skin Reconstruction Surgery

After skin reconstructive surgery, movement and function of the body part involved should be limited to promote healing and insure the graft take as well as possible. The body part should be splinted or positioned, for the minimum length of time, in an anti-deformity position. (Edgar and Brereton 2004; ANZBA 2007)  

Please note, the operating surgeon or consultant is the authority when treating a burns injury. The guidelines below are to give guidance to the multidisciplinary team as to when mobilisation could potentially begin. Be aware that there are patient factors, surgical complications and other influencing factors for these times not being strictly adhered to.

When working in a team, the following are three important points to clarify for effective treatment of the patient:

1. The minimum timeframe of immobilisation post-surgery
2. Structures to be immobilised
3. Special considerations for movement, function and ambulation dependent on Donor sites and the structures repaired or excised during surgery

Please note, the operating surgeon or consultant is the authority when treating a burns injury. The guidelines below are to give guidance to the multidisciplinary team as to when mobilisation could potentially begin. Be aware that there are patient factors, surgical complications and other influencing factors for these times not being strictly adhered to.

Reconstruction method	Depth of burn	Length of immobilisation
Biological dressings (such as Biobrane, TransCyte)	Any (preferably not full thickness)	<24 hours
Cultured epithelial autograft (suspension)	Superficial to intermediate	24-48 hours
Split skin graft	Intermediate to deep partial thickness	3-5 days
Dermal substitutes (such as Integra, Alloderm)	Deep partial thickness to full thickness	5-7 days
Fasciocutaneous or myocutaneous flaps	Full thickness	7-14 days

Immobilisation times for different types of skin reconstruction

When immobilising specialised areas, please make sure you have referred to the correct individual who has studies further on high impact areas.for example, when immobilising a hand, the main focus are deformity prevention and optimising function. Commonly associated with burn to the hand is the ‘claw’ deformity, also referred to as the intrinsic minus position. This involves extension of the MCP joints, flexion of the PIP joints, adduction of the thumb and flexion of  the wrist. A position of safe immobilisation 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.

3. Positioning

Positing is important to prevent 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.

• Modify according to burn area, patient pain and medical status.*

Table XXX: Positions of immobilisation, for pictures, see Procter, 2010

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

4. Pain Management

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.

In order to achieve desired outcomes and movement habits, ensuring adequate pain control is important. The aim of analgesic drugs should be to develop a good baseline pain control to allow functional movement and activities of daily living to occur at any time during the day. The use of combined analgesics such as paracetamol, non-steroidal anti-inflammatory drugs, tramadol, and slow release narcotics reduces the need for increasing doses of narcotics for breakthrough pain. Codeine should be avoided if possible because of its negative effects on gut motility. Other pain control methods that may be helpful include transcutaneous electrical nerve stimulation (TENS). - ABC

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.Oedema removal should be encouraged from admission. The only body system that can actively remove excess fluid and debris from the interstitium is the lymphatic system. Oedema collection in the zone of stasis of a burn may promote the progression of depth of a burn. The principles of reduction of oedema should be adhered to in totality and not just in part:

Rehabilitation starts on the day of injury

• Compression—such as Coban, oedema gloves​gloves
• Movement—rhythmic, pumping
• Elevation or positioning of limbs for gravity assisted flow of oedema from them
• Maximisation of lymphatic function
• Splinting does not control oedema except to channel fluid to an immobile area. - ABC

Deep Vein Thrombosis

can be achieved by encouraging early ambulation.

Prevention of Pressure Sores

Splinting

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

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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)

∙ 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

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

∙ 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.