Sub Acute Burn Physiotherapy Rehabilitation
Rationale for immobilisation in the Sub-acute Stage ∙ Maintenance of range of motion ∙ Regain range of motion (Kwan 2002; Boscheinen Morrin 2004)
Role of the Physiotherapist in the Rehabilitation of the Sub Acute Burn Patient
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.
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.
The patient
∙ Primary closure of wound
∙ Scar remodelling
∙ Scar contraction
Aims
∙ Optimise scar appearance
∙ Limit effects of scar contraction/prolonged positioning on range of motion and function
∙ Address effects of prolonged bed rest
Common modalities
∙ Mobilisation- both mobility and specific joint mobilisation
∙ Scar management adjuncts
o Pressure garments, silicone, massage
∙ Continuation of oedema/ positioning management where necessary
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5.21 Mobilisation
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).
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.
5.211 Active ROM
∙ 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).
5.212 Passive ROM
∙ 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).
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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
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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)
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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.
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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
