Face and Neck Burns Rehabilitation

Original Editor - Rhiannon Clement

Top Contributors - Rhiannon Clement  

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Introduction

Burns injuries can be the result of thermal (flames, hot liquid, contact with hot surfaces), or non-thermal (electrical, chemical, friction or radiation) contact[1].

Burns injuries to the face and neck can have a long-term impact on an individuals function, as well as on their social interactions [2]. Therefore, the use of both objective and patient-reported outcome measures are important to get an idea of the impact of injuries on an individuals life. There should be a focus on both the physical and psychological impacts of the trauma.

The treatment of facial burns aim to[2][3][4]:

  • Pain control
  • Address inhalation injury
  • Encourage movement and function
  • Odema Management
  • Tissue repair
  • Scar Management
  • Patient education
  • Exercise regimen
  • Optimise psychological well-being
  • Cosmetic optimisation.
  • Optimising the individuals' self-management of scar tissue

If a patient is able to comply with physiotherapy and occupational therapy advice in the long-term, this can make a huge difference to the overall outcome[2].

Healing

The skin in made up of a number of layers[1]:

  • Epidermis:Superficial layer which is avasular
    • Capable of regeneration. However, cannot regenerate if a large portion of this layer is destroyed.
  • Dermis: Deeper, thicker layer of connective tissue
    • Contains blood vessels, nerves, glands and hair follicles.
  • Subcutaneous tissue: Deep, contains arelar and adipose tissue
    • Contains large blood vessels, fat cells and connective tissue overlaying muscle and bone.

See page on Skin for further information.

A first degree burn damages the edipermis, a second degree burn will also damage the dermis layer, a third degree burn is deep and damages the subcutneous tissue. The depth of the burn will affect the risk of skin pigmentation, risk of scaring and also the length of time to heal.

See page on Wound Healing for information around usual skin healing processes and timeframes.

Healing Timeframes Post-Burn Injury

Table adapted from Glassey 2004[5]
Degree MOI Scar / contracture Healing time
1st Sun exposure, hot liquid (low viscosity) None 3-7 days
2a (superficial) Hot liquids, chemical burns, flash Minimal 1-3 weeks with pigment change
2b (deep) Flame, electrical, hot liquid (high viscosity) High risk 3-6 weeks with scar
3rd Flame, electrical, chemical, blast Severe risk Requires skin graft
4th Prolonged exposure to flame, chemical, blast Definite Requires excision

Odema:

Your face and neck are at high risk of burns, as it is rarely covered by clothing or other protective gear.

However, there are protective characteristics that often reduce the depth of burns injuries to these areas [2]:

  • People tend to protect their face and shake / wipe off substances.
  • Less likely to have materials over face that could absorb the heat and increase time in contact with skin.
  • Skin on face is relatively thick (except eyelids) with a good blood supply to dissipate heat.

Widespread complications of deep or widespread burns can include sepsis due to loss of barrier to infection, burn shock due to hypovolemia, vascular resistance, hypoperfusion and anti-inflammatory processes, as well as contracture due to formation of scar tissue. Burns can also lead to dehydration due to a loss of bodily fluids due to the death of skin cells[6].

Risks by area[2][7]

Back of head: Area of thin skin with risk of exposure of underlying bone. May also result in areas of alopecia.

Ears: Risk of exposure of underlying cartilage, which is relatively avasular and at risk of infection.

Forehead: Less fat and muscle in this area can increase risk of exposed bone.

Eye lids: Also thin skin and at risk of exposure of underlying tissue / eye balls. They also provide little resistance to forces of contracture and are prone to forming ectropios, exposing the inner eyelid.

Eyes: Ocular burns may lead to infection or tissue ischemia. Chemical burns, particularly to the cornea, are an opthamologic emergency [8].

Nose: Risk of shrinkage of nostrils and nasal alar. Also at risk of exposure of underlying cartilage and bone, which are relavitly avascular and at risk of infection. Singed nasal hairs may indicate inhalation injury.

Cheeks: This areas has mobile, thick skin with good resistance to skin contracture. However, difficult to immobilise for healing post-surgery.

Lips: Prone to shrinkage or eversion as a result of contractures. Significant swelling of lips or tongue may compromise the airway.

Neck: More prone to contractures in younger patients, due to reduced laxity. The skin loosens with age, creating more tolerance for shrinkageSignificant or circumferential burns may impact of respiratory function or swallow, as well as neurovasular systems.

Assessment [7]

Physiotherapists will be involved in a patients care from initial presentation and assessment, including airway management, any ICU admission, odema and scar tissue management, as part of a multi-disciplinary team. The will be involved in the assessment and promotion of patient function from admission. They are also likely to follow that patient through the care pathway and promote self-management.

On patient presentation, the following areas will be assessed:

  • History of burn
    • Time of injury
    • Mechanism of injury
    • First aid given: e.g. time started (within 3 hours), agents used, clothes/ jewellery removed?, decontamination used (for chemical burns).
    • Other non-burn injuries
    • Consider non-accidental injury / possible safe-guarding
  • Airway assessment - for the following, consider early intubation
    • Airway burn / inhalation injury: stridor, hoarseness, black sputum, respiratory distress, singed nasal hairs or facial swelling
    • Oropharyngeal burn: soot in mouth, intraoral odema and erythema
    • Significant neck burns
    • Deep facial burns
    • Reduced GCS
    • Burns > 40% of total body surface area
  • Breathing - consider affect of burns to chest expansion, especially neck, chest or circumferential burns
  • Circulation - consider shock, fluid balance, peripheral perfusion (capillary refill), especially in circumferential burns
  • Disability - altered state of consciousness and neurovascular status of body area affected
  • Exposure - assessment of burn area and depth
  • After facial injury, patients should have an assessment for ocular burns and given saline irrigation. Patients presenting with tearing, conjunctivitis blepharospasm (eye twitching) or otherwise suspected ocular burns should be referred for urgent opthamology review.
  • Assessment of Total Body Surface Area (TBSA) - assess using Lund and Brower chart (specific to adult or paediatric) or palmar method (specific to individual), not including burns to erythema only.

The video below gives and overview of types and pathophysiology of burns, and gives more detail of TBSA (14min and 20 seconds in).

[9]
  • Assessment and monitoring of odema
  • Pain scale at rest and during functional tasks
  • Rang of motion at shoulder, spine, jaw, mouth and eyes.
  • Functional assessment and assessment of activities of daily living (ADLs) - Early assessment and consistent implementation of rehabilitation needs is essential as delays may cause contraction of skin or scaring, and impact patient progression[10].
  • Psychological well-being - Individuals should be screened for psychosocial risk factors on presentation and with regular follow-ups and referral for psychological assessment if required[4].

All areas should be reassessed regularly to monitor success of interventions.

Early Stages of Rehabilitation

FACADE: First aid, Analgesia, Clean, Assess, Dress, Elevate[7]
The early management of a patient will be based on assessment of TBSA, and the degree of the burn. This will determine the optimal management and treatment pathway, such as the possible need for surgery. If the patient gives consent, photographs of the burn site may be useful for assessment and monitoring [7].

All face and neck burns will require the following interventions

Pain Control

Background and breakthrough analgesia should be optimised and regularly monitored. Poor pain management may have negative impacts on rehabilitation compliance and possible increased pain perception and risk of chronic pain [11].

Wound management

The wound needs to be cleaned and dressed soon after injury to provide a moist environment of wound healing and reduce risk of infection [11].

Odema management

Maintaining upright position: Encourage drainage of fluid and allow it to reabsorb. Lying flat may encourage the fluid to collect around eyes and head, resulting in difficulty opening eyes and may affect breathing.

Compression


Positioning and splinting

Positioning is important for patient, particularly when they are maintaining a static position for a period of time, e.g while asleep. This helps to maintain tissue length [10].

Passive Range of motion

Passive range should be completed daily, if possible, to help maintain range in the early stages after burns [10].


Exercise

Early exercise is also important in maintaining tissue length and range of motion, as well as limiting deconditioning [10].

Nutrition and hydration advice
Individuals should also be assessed by a dietitian with the aim to maintain pre-injury body mass index (BMI) and retain fluids to promote wound healing and prevent electrolyte imbalance and possible renal and circulatory failure [6].

Tissue Repair and Scar ManagementInterventions aim to avoid poor tissue healing and possible resulting scar tissue, including formation of keloid and hypertrophic scars.


More severe burns may also require surgical intervention

Skin Graft
Excision
Full-thickness burns may require excision of tissue[11].

See page on Reconstruction Post Burn for further information.

Ongoing Rehabilitation and Self-Management

Function: Screened by physiotherapist and occupational therapist

Self-mangment of scar tissue:

Exercise/ stretching regime

Taping

Moisturising

Lazer


Precautions

  • Damage to bone or tendon
  • Tissue repair

- Both may require a period of immobilisation for healing or to allow skin graft adherence[3].

Tetenus prone burns wounds

Outcome Measures[4]

On admission / follow up

Total Burns Surface Area (TBSA): Used to determine the optimal management and treatment pathway.

Numerical / Visual Rating Scale (pain)

Passive Range of Motion

Active Range of Motion

Patient and Observer Scar Assessment Scale (POSAS)

Vancouver Burn Scar Scale (VBSS/VSS)

Modified Vancouver Burn Scar Scale (mVSS)

Dermalab Combo

Assessment of functional tasks using the International Classification of Functioning, Disability and Health (ICF)[14].

Adult Specific

Young Adult Burn Outcome Questionnaire (YABOQ) [15]

Burns Specific Health Scale (BSHS-B)

Satisfaction with Appearance Scale

Euro-Qol - 5 Dimensions (EQ-5D-5L)

Short Form - 36 (SF-36)

Functional Assessment for Burns (FAB)

Chelsea Critical Care Physical Assessment Tool (CPAx)

Functional Independence Measure (FIM)

Quick Disabilities of the Arm, Shoulder and Hand (Quick-DASH)

Tissue tonometer

Paediatric Specific

Burns Outcomes Questionnaire (age 5-18)

Health Outcomes Burns Questionnaire (age <5)

Family Impact Module (Age 2-4, 5-7, 8-12 or 12-18)

Resources

References

  1. 1.0 1.1 Hale A. et al Physiotherapy in Burns, Plastics and Reconstructive Surgery. [Online: Available from: https://physio-pedia.com/images/3/30/Burns_and_Plastics.pdf?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal] <Accessed 27.12.20>
  2. 2.0 2.1 2.2 2.3 2.4 Greenhalgh D. G. Management of facial Burns. Burns and Trauma (2020) vol 8
  3. 3.0 3.1 Edgar D and Brereton M. Rehabilitation after burn injury BMJ (2004) 329(7461): 343-345
  4. 4.0 4.1 4.2 British Burn Association. Outcome Measures for Adult and Paediatric Services: Second Edition [online: Available from: https://www.britishburnassociation.org/wp-content/uploads/2018/05/BBA-Outcome-Measures-for-Adult-Paediatric-Services-2nd-Edition.pdf] <accessed 28.12.20>
  5. Glassey N. Physiotherapy for Burns and Plastic Reconstruction of the Hand.(2004) Wiley ISBN: 978-1-861-56386-6
  6. 6.0 6.1 Shpichka A. et al. Skin tissue regeneration after burns injury . Stem cell research and therapy (2019)10:94
  7. 7.0 7.1 7.2 7.3 RCH. Burns - Acute Management RCH clinical practice Guidelines (2020)[online: available from: https://www.rch.org.au/clinicalguide/guideline_index/Burns/#classification] <Accessed on 16/1/20>
  8. Solano J. et al Ocular Burns and Chemical Injuries. WebMd [Available from: https://emedicine.medscape.com/article/798696-overview] <Accessed 16/1/21>
  9. Hasudungan A. Burns Overview: Types, Pathophysiology and TBSA. Available from: https://www.youtube.com/watch?v=j4v7PFw5wA0 [last accessed 16/1/21]
  10. 10.0 10.1 10.2 10.3 Procter F. Rehabilitation of the Burn Patient. Indian Journal of Plastic Surgery (2010) Sep; 43(Suppl): S101–S113
  11. 11.0 11.1 11.2 Richardson P, Mustard L. The management of pain in the burns unit. Burns 2009; 35: 921-936
  12. UW Surgery. Burns308:Burn Neck Stretches. Available from: https://www.youtube.com/watch?v=eKg_m_BkJD4 [last accessed 11/1/21]
  13. UW Surgery. Burns309:Face Stretching. Available from: https://www.youtube.com/watch?v=rYAziBODWho [last accessed 11/1/21]
  14. Wasiak J. et al Measureing Common Outcome Measures and Their Concepts using the International classification of Functioning, Disability and Health (ICF) in Adults with Burn Injury: A systematic Review. Elsevier (2011) DOI: 10.1016/j.burns.2011.02.012
  15. Ryan C.M. et al The Effect of Facial Burns on Long-Term Outcomes in Young Adults: A 5-Year Study, Journal of Burn Care & Research (2018) Volume 39, Issue 4 Pages 497–506, https://doi.org/10.1093/jbcr/irx006