Acute Burn Physiotherapy Rehabilitation

Original Editor - Carin Hunter

Top Contributors - Carin Hunter and Naomi O'Reilly

Introduction

Introduction

The beginning of the recovery journey for critically ill burn patients involves a set of therapeutic techniques and exercises aimed at promoting early mobilization and rehabilitation. Among these techniques are purse lip breathing, chest expansion exercises, coughing techniques, oral suction, ankle toe movements, active-assisted movements, and relaxation methods. The significance of this early rehabilitation phase is highlighted by its duration, which varies based on the size and severity of the injury, ranging from a few days to several months (Procter, 2010).

The acute phase of rehabilitation holds immense importance for both patients and rehabilitation professionals. Burn injuries often trigger psychological responses such as fear, anxiety, and anger. Additionally, emotional distress is a common occurrence, necessitating supportive or psychological intervention. The visible impact of burn injuries on appearance and aesthetics cannot be understated, influencing an individual's body image and their ability to reintegrate into society and professional life. Disfigurements may lead to social stigma and participation restrictions, emphasizing the role of physiotherapists in motivating patients towards a hopeful return to their communities.

The holistic management of burn-injured patients requires a specialized and dedicated multidisciplinary team. Physiotherapists, being integral members of this team, play a crucial role in optimizing both the physical and psychological recovery of patients. The insights and experiences of physiotherapists provide valuable knowledge about the challenges faced by patients during the rehabilitation journey. Family support emerges as a significant component, facilitating therapy and reintegration into the home environment. While acknowledging the empowering role of family support, therapists also stress the importance of ensuring that family members are informed about treatment goals and encouraged to promote independence in everyday tasks.

Cultural nuances may impact therapy progress, with some families tending to overprotect individuals with disfiguring conditions as an expression of care and support. This overprotection, while well-intentioned, may inadvertently hinder therapy progression. Therapists recognize the psychological and emotional impact of the traumatic event on patients' willingness to engage in therapy, highlighting the need for establishing a rapport with patients. Therapists feel comfortable providing basic counselling, with referrals to psychologists or social workers for further psychological intervention when necessary (Cartotto et al., 2022; Blakeney et al., 2008).

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
   4. Contractures

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

In the acute phase of burn injury, the primary objective of immobilization is to prevent deformities, preserve the range of motion, and safeguard the involved structures, thereby fostering optimal healing. Two commonly employed methods for achieving this are splinting and bed rest.

Post-Skin Reconstruction Surgery

Following skin reconstructive surgery, restricting movement and function of the affected body part is imperative to facilitate healing and ensure the successful graft take. It is recommended to immobilize or position the body part in an anti-deformity stance for the minimum required duration. (Edgar and Brereton 2004; ANZBA 2007).

It is essential to emphasize that the operating surgeon or consultant holds the authority in the treatment of burns injuries. The guidelines provided here serve as guidance for the multidisciplinary team regarding potential commencement of mobilization. However, it is crucial to recognize that patient-specific factors, surgical complications, and other influencing variables may lead to deviations from these suggested timelines.

In a collaborative team setting, the following three key points need clarification for effective patient treatment:

1. The minimum recommended immobilization duration post-surgery.
2. Identification of specific structures to be immobilized.
3. Special considerations for movement, function, and ambulation based on donor sites and the structures repaired or excised during surgery.

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 immobilizing specialized areas, it is crucial to consult individuals with expertise in high-impact areas. For instance, when immobilizing a hand, the primary focus is on preventing deformities and optimizing function. A common issue associated with hand burns is the 'claw' deformity, characterized by extension of MCP joints, flexion of PIP joints, adduction of the thumb, and flexion of the wrist. The recommended position for safe immobilization is essentially the opposite of the claw deformity, involving 20-30 degrees wrist extension, 80-90 degrees flexion of MCP joints, full extension of PIP and DIP joints, and palmar abduction of the thumb.

3. Positioning

Proper positioning is crucial to prevent contractures and stiffness. Immobilization is specifically recommended post skin grafting to ensure optimal healing. Beyond this phase, incorporating movement into the daily routine is essential for the patient's well-being and functional outcome. Commencing from the day of admission, the inclusion of movement depends on the patient's level of consciousness, allowing for either passive mobilizations or active mobilization.

It is important to highlight that the authority in treating burns injuries lies with the operating surgeon or consultant. The guidelines provided aim to offer direction to the multidisciplinary team regarding optimal positioning. However, it is essential to acknowledge that patient-specific factors, surgical complications, and other influencing variables may result in deviations from strictly adhering to these suggested positions.

Recommended Positioning Post Burn

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

To optimize the effectiveness of the rehabilitation team, scheduling treatment sessions to align with the pain relief medication schedule is essential. Ideally, therapy sessions should follow the administration of medication to mitigate the impact of pain on compliance, thereby promoting active participation in movement activities. Additionally, a physiotherapist may employ alternative methods like transcutaneous electrical nerve stimulation (TENS) to complement pain relief efforts.

When administering analgesics, it is commonly recommended to combine medications, incorporating options such as paracetamol, non-steroidal anti-inflammatory drugs, and tramadol. Utilizing slow-release medications is also advisable, as this approach typically reduces the necessity to escalate the analgesic dose, minimizing the likelihood of breakthrough pain episodes for the patient.

5. Prevention of Complications

Oedema

Initiating the prevention of edema is crucial from the moment a patient is admitted to the hospital. Elevating all affected limbs and carefully positioning drainage can effectively impede the progression of burns into deeper layers.

The practice of elevating affected limbs to prevent burn sites from deepening should commence on the day of the injury. It is imperative to encourage the removal of edema right from the time of admission. The lymphatic system stands as the sole body system capable of actively eliminating excess fluid and debris from the interstitium. The accumulation of edema in the zone of stasis in a burn may contribute to the advancement of burn depth. It is vital to adhere to the complete principles of edema reduction, ensuring comprehensive application rather than partial implementation.

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

Prevention of Deep Vein Thrombosis

can be achieved by encouraging early ambulation.

Splinting

Physiological rationale for splinting (Kwan 2002)

Scar tissue exhibits viscoelastic properties, elongating gradually within a specific range. Upon releasing the stretching force, there is an immediate decrease in tissue tension, but the retractions of the tissue to a shorter length are delayed. The viscoelastic nature of scar tissue allows it to adapt to stretching forces over time. Both dynamic and static splinting methods offer prolonged, low stretching force to facilitate this accommodation.

Categories of Splints

• 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

Thermoplastic palmar splints positioned for safe immobilization, as discussed by Glassey in 2004, serve as a preventive measure for deformities. On the other hand, a static progressive splint, designed to gradually stretch contractures by applying incrementally adjusted static force, aids in lengthening contracted tissue, as per Smith's 2009 explanation. A specific example is the finger flexion strap splint, used to address MCP extension contractures. This type of splint applies stretching force to scar bands on the dorsum of the hand and wrist through flexion straps, causing extension contracture. The force is localized to the MCP joints with the application of straps through a wrist extension splint, providing static support below the MCP joint, as described by Kwan in 2002.

Dynamic Splints

Dynamic splinting, which facilitates movements by controlling the plane and range of motion, is characterized by applying a mobile force in one direction while allowing active motion in the opposite direction. Typically utilizing rubber bands, elastics, and springs, dynamic extension splints are commonly employed in the treatment of palmar and finger burns, ensuring full extension of all finger joints, as outlined by Smith in 2009. Conversely, dynamic flexion splints find application in dorsal hand burns during the sub-acute stage, preventing MCP joint extension contractures as the skin contracts during wound healing and scar maturation, as suggested by Kwan in 2002.

Despite an absence of evidence favouring one hand splint over another in the treatment of burned hands, literature emphasizes the initial use of splints in the inflammatory phase for safe immobilization. The lack of controlled trials comparing different types of splints or exploring the use versus disuse of splinting necessitates cautious consideration. Regular cleaning is crucial to prevent microbial colonization, and precautions must be taken to avoid venous and lymphatic stasis, friction-induced trauma, and excessive pressure that may lead to pressure injuries.

In conclusion, the utilization of hand splinting lacks a standardized protocol in treating burned hands. While it is common to employ splints in the initial inflammatory phase, physiotherapists should be mindful of their role as adjuncts to treatment in the sub-acute phase. Clinical reasoning should guide the appropriate use of splints for each patient, aiming to promote independence and prevent overreliance on splinting devices for both patients and physiotherapists.

Prevention of Contractures

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.