Acute Burn Physiotherapy Rehabilitation
Top Contributors - Carin Hunter and Naomi O'Reilly
Role of the Physiotherapist in the Rehabilitation of the Acute Burn Patient
For the purpose of clarity, the following section has been divided into acute, sub acute and chronic rehabilitation. However, rehabilitation is a continuum, and significant crossover may occur. All of the following concepts apply to burns on any part of the body, with specialised treatment addressed for the hand where necessary.
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
∙ 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
∙ Reduce risk of complications
o Reduce oedema, particularly where it poses a risk for
▪ impinging on peripheral circulation or airways
▪ Predisposition to contractures
∙ Prevent deformities/loss of range
∙ Protect/promote healing
Common treatment techniques
∙ Immobilisation
o Bed rest
o Splinting
∙ Positioning
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5.11 Immobilisation
5.111 Rationale for Immobilisation
Acute Stage ∙ Prevent deformities
∙ Maintenance of range of motion ∙ Promote Healing
∙ Protection
(Ashe 2001; Kamolz 2009) Sub-acute Stage ∙ Maintenance of range of motion ∙ Regain range of motion (Kwan 2002; Boscheinen Morrin 2004)
Table 6: rationale for immobilisation
5.112 Positioning in the Acute Stage
- 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
Table 7 Positions of immobilisation, for pictures, see Procter, 2010
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5.113 1mmobilisation post skin reconstruction surgery
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 STSG 3-5 days FTSG 5-7 days
Table 8 Surgical procedure and related immobilisation (ANZBA 2007; Edgar and Brereton 2004)
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 (ANZBA 2007).
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.
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5.114 Immobilisation of the hand
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 (Kamolz 2009). 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).
5.115 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.
Fig 17: 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.
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Management of Oedema
