Sub Acute Burn Physiotherapy Rehabilitation: Difference between revisions

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<div class="editorbox"> '''Original Editor '''- [[User:Carin Hunter|Carin Hunter]] based on the course by ReLab<br> '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>
<div class="editorbox"> '''Original Editor '''- [[User:Carin Hunter|Carin Hunter]] based on the course by ReLab<br> '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>


Rationale for immobilisation in the Sub-acute Stage ∙ Maintenance of range of motion ∙ Regain range of motion (Kwan 2002; Boscheinen Morrin 2004)
== 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).


Role of the Physiotherapist in the Rehabilitation of the Sub  Acute Burn Patient
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).


Beyond the acute stage of immobilisation, inpatient and outpatient rehabilitation typically  consists of a variety of interventions including pressure garment therapy, silicone therapy,  scar massage, range of motion and mobilisation techniques, strengthening, functional and gait  retraining, and balance and fine motor retraining ( Schneider et al, 2012). Interventions  should be tailored according to a full patient assessment.  
== 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.


As it would be unethical to withhold treatment, physiotherapy intervention as a whole is not  well investigated. Schneider et al (2012) found a significant improvement in contractures; balance and hand function with inpatient rehabilitation, through a longitudinal observational  study of eleven people. However, in the following section, we will attempt to display the  evidence for commonly used modalities.  
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.


The patient
== Mobilisation in Burn Rehabilitation ==


∙ Primary closure of wound
=== 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.


∙ Scar remodelling
=== 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).


∙ Scar contraction
=== 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).


Aims
=== 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).


∙ Optimise scar appearance
== 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.


∙ Limit effects of scar contraction/prolonged positioning on range of motion and  function
== 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.


∙ Address effects of prolonged bed rest  
== Practical Considerations for Mobilization ==


Common modalities
* 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).


∙ Mobilisation- both mobility and specific joint mobilisation
== Scar Massage in Burn Rehabilitation ==


∙ Scar management adjuncts
=== Principles of Scar Massage ===


o Pressure garments, silicone, massage
# Prevent Adherence
# Reduce Redness
# Reduce Elevation of Scar Tissue
# Relieve Pruritus
# Moisturize (Glassey 2004)


∙ Continuation of oedema/ positioning management where necessary
=== Massage Techniques ===


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* 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).


5.21 Mobilisation
=== Guidelines for Massage during Healing Stages ===


The advantages of general mobilisation for a burns patient to counteract the effects of  prolonged bed rest are no different to that of a surgical or medical patient. Burns patients  should be mobilised as early as possible to avoid deconditioning and possible respiratory  complications associated with prolonged bed rest (Esselman 2007).
* 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).


As outlined in the above introduction, due to the ethical issues surrounding withdrawal or  modification of treatment the evidence surround the optimal duration, frequency and methods  of physiotherapy interventions in the treatment of burn patients is unclear. Despite this lack  of clarify surrounding these issues it is clear that both active and passive mobilisation plays a  key role throughout the stages of burn recovery. Below is a summary of the  recommendations from the currently literature on passive and active mobilisation of burns.  
=== 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).


5.211 Active ROM
=== Recommendations and Safety Considerations ===


∙ Depending on the need for immobilisation gentle active ROM exercises is the  preferred treatment during the acute stage of injury as it is the most effective means of  reducing oedema by means of active muscle contraction (Glassey 2004). If this is not  possible due to sedation, surgical intervention etc. then positioning the patient is the  next best alternative (see immobilisation and position).
* 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).


5.212 Passive ROM
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.


∙ Passive ROM exercises in the acute stage are contraindicated as applying passive  stretching forces may result in future damage to the burned structures (Boscheinen Morrin 2004). Applying these passive manoeuvres in the acute stage will result in  increased oedema, haemorrhage and fibrosis of the burned tissues (Cooper 2007).
∙ The biomechanical principle of creep when passive stretching. A slow sustained  stretch is more tolerable for patient and more effective for producing lengthening  (Kwan 2002).
∙ Passive joint mobilisations can begin during the scar maturation phase once the scar  tissue has adequate tensile strength to tolerate friction caused by mobilisation  techniques (Boscheinen-Morrin and Connolly 2001).
47
Frequency, Duration Recommendations
∙ Physiotherapy intervention should be twice daily with patients prescribed frequent  active exercises in between sessions.  
∙ For the sedated patient gentle passive range of motion exercises should be done 3  times a day once indicated (Boscheinen-Morrin and Connolly 2001).
∙ Dependent on the severity of the burn active and very gentle passive range of motion  exercises for the hand and fingers are begun from day one of injury.  
Contraindications
∙ Active or Passive range of motion exercises should not be carried out if there is  suspected damage to extensor tendons (common occurrence with deep dermal and full  thickness burns). Flexion of the PIP joints should be avoided at all costs to prevent  extensor tendon rupture. The hand should be splinted in the position of safe  immobilisation or alternatively a volar PIP extension splint until surgical intervention  (Boscheinen-Morrin and Connolly 2001) is discussed.  
∙ Range of motion exercises are also contraindicated post skin grafting as a period of 3- 5 days immobilisation is required to enable graft healing (Boscheinen-Morrin and  Connolly 2001).
Evidence for hand mobilisation
There is currently limited evidence which examines the effectiveness of hand exercises for  the burned hand specifically. Studies in the area of burns generally include subjects who  have extensive % TBSA in which their hand/hands may be involved.  
Okhovation et al (2007) carried out an RCT in which they compared a routine rehabilitation  protocol with a burn rehabilitation protocol. This study is particularly relevant form a hand  burn rehabilitation perspective as 83% of subjects recruited had partial / full thickness hand  burns
Subjects: 30 burn admissions to Tehran Hospital in 2005. Matched in pairs based on clinical  details (sex, age, TBSA, depth of burn). Randomly assigned into two groups
Intervention: The routine rehabilitation protocol included chest physiotherapy and  active/passive movements 15-20 minutes daily commenced 2/52 post admission. The burn  rehabilitation protocol involved routine protocol plus targeted stretching program to
48
contracture risk areas for 30-45min 2-3times daily commenced on day1 of admission.  Outcome measures: Outcome measures used were Presence of burn contracture  (goniometry) Occurrence of thrombosis Length of Hospital Stay Skin grafting requirement.
Results: Development of post burn contractures on discharge from hospital was 6% in the  burn rehabilitation group versus 73% in the routine rehabilitation group. No significant  difference regarding thrombosis, duration of stay and number of skin grafts
Limitations: There were several limitations to the study. The recruitment process was not  clearly defined. Information on the group matching and randomised allocation process was  not provided. No inclusion/exclusion criterion was defined. Frequency, duration and  commencement of the two protocols unequal and appear very bias towards targeted stretching  program.
Functional Rehabilitation of the Hand
Salter and Chesire (2000) suggest that the burnt hand should be used for light self-care  activities as soon as tolerated by the patient. This is based on the principle that everyday  activities will promote regular movement patterns of the affected hand. Emphasis should be  placed on intrinsic flexion of the MCP joints and intrinsic IP joint extension, gross gripping  (i.e. composite flexion), maintenance of the web spaces and opposition of the thumb.
Practical factors to consider when mobilising
∙ Be aware of dressing clinic/daily dressing changes. Mobilisation should coincide with  this as it is important to monitor the wound during AROM frequently.
∙ Timing of pain relief. This should be timed appropriately to ensure maximal benefit  during treatment sessions.
∙ Observe the patient carrying out the AROM and PROM exercises prior to beginning  treatment. Also observe the patient taking on/off splints.
∙ Always monitor for post exercise pain and wound breakdown.
∙ Avoid blanching for long period as you may compromise vascularity. ∙ The patient may present with a reduced capacity for exercise secondary to increased  metabolic rate, altered thermoregulation and increased nutritional demands.  ∙ Postural hypotension may be present due to prolonged bed rest and low haemoglobin. (ANZBA 2007)
Massage
Five principles of scar massage:
1. Prevent adherence
2. Reduce redness
3. Reduce elevation of scar tissue
4. Relieve pruritus
5. Moisturise (Glassey 2004) Scar Massage Techniques
∙ Retrograde massage to aid venous return, increase lymphatic drainage, mobilise fluid  ∙ Effleurage to increase circulation
∙ Static pressure to reduce pockets of swelling
∙ Finger and thumb kneading to mobilise the scar and surrounding tissue ∙ Skin rolling to restore mobility to tissue interfaces
∙ Wringing the scar to stretch and promote collagenous remodelling
∙ Frictions to loosen adhesions
(Holey and Cook 2003)
Guidelines for Massage during 3 Stages of healing
Inflammatory Phase gentle massage to decrease oedema and increase blood supply  (currently no high level evidence to support this)
Proliferative Phase Massage that applies gentle stress to the healing scar is recommended  to ensure collagen is aligned correctly.
Remodelling Phase Massage should be progressed to include prolonged stretching to  minimise adhesions. This is proposed to aid in scar tissue breakdown
Table 10 Guidelines for scar massage during healing stages (Glassey 2004)
58
Table 11. Evidence for the use of massage in scar management
Article Field et al 2000
RCT
Morien et al 2008
Pilot Study
Shin and Bordeaux,  2012 Lit review
Subjects 20 subjects in remodelling phase of  wound healing.  Randomly assigned into  2 groups
Massage Vs Control
8 Children  
Mean age 13.5 years  (10-17years)
All thermal burns  including hand burns
Not burn specific,  though the majority  of scars were of this  origin
10 articles: n=144  adult and children
Intervention Massage Therapy Group:
30minutes massage with  cocoa butter twice  weekly for 5 weeks
Control Group:
Standard Treatment
20-25 minute  massage session  once daily for 5 days
(effleurage,  
petrissage, friction,  lengthening rolling)
Session followed by  discussion of  psychosocial issues
Time to Rx: mean  4.3 months. +  variation in  protocols. 20  mins/day- 30 mins 2x  weekly. 1 Rx-6  months Rx
Outcome  
measures
Itching: VAS
Pain: McGill Pain
Questionnaire
Anxiety: State Trait  Anxiety Inventory
Mood: Profile of Mood  States
Likert pictorial scale  
Goniometry Range of  Motion
Patient and observer  scar assessment  scale, Vancouver  scar scale, thickness,  vascularity, colour,  pain, pruritus, mood,  anxiety, and  depression.
Results Massage Therapy Group  Reported: decreased  itching, pain, anxiety and  increased mood  
Ratings improved from  the 1st-last day of the  study
Increased ROM in  massaged tissue.  Decreased ROM in  unmassaged tissue
No significant  difference in mood  across time
45.7% improved in at  least one of the above  parameters. 54.7%  had no improvement.  
Noted massage was  more economical  than silicone/PGT.
59
Limitations Small Sample Size
No follow up
Paediatric  
population. Mood Instrument may have  been influenced by  other factors.  Recruitment and area  to be massaged not  random
Small sample size
No follow up
No discussion of  quality or statistical  tests.
Conclusion on Scar Massage
Evidence suggests that burn patients receive psychological benefits from massage in terms of  altered mood (decreased depression, anger), decreased pain, and anxiety (Field et al 1998).  Evidence also indicates that massage increases ROM in non-burned patients, but little  evidence exist examining the effect of massage on ROM in burn patients (Morien et al 2008).
Recommendations for practice and safety considerations.
Insufficient consistency in literature with regards to protocols on frequency or duration of  treatment. Suggestions for practice include (Shin and Bordeaux, 2012, Morien et al, 2008)  
∙ Clean hands essential
∙ Use non irritating lubricant, free of any known sensitisers.  
∙ Modify practice according to patient stage of healing, sensitivity and pain levels. Contraindications: Shin and Bordeaux 2012
∙ Compromised integrity of epidermis
∙ Acute infection
∙ Bleeding
∙ Wound dehiscence,  
∙ Graft failure
∙ Intolerable discomfort
∙ Hypersensitivity to emollient
[[Category:Burns]]
[[Category:Burns]]
[[Category:Rehabilitation]]
[[Category:Rehabilitation]]

Latest revision as of 16:23, 18 January 2024

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

Introduction[edit | edit source]

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[edit | edit source]

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[edit | edit source]

Active Range of Motion (AROM)[edit | edit source]

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)[edit | edit source]

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[edit | edit source]

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[edit | edit source]

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[edit | edit source]

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[edit | edit source]

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[edit | edit source]

  • 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[edit | edit source]

Principles of Scar Massage[edit | edit source]

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

Massage Techniques[edit | edit source]

  • 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[edit | edit source]

  • 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[edit | edit source]

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[edit | edit source]

  • 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.

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