Post-burn Rehabilitation

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Introduction

Rehabilitation is an essential component in the management of patients with burns and should be commenced on the day injury is sustained. In other words, oedema control, respiratory care, positioning, functional movements which are pertinent in burn cases must begin without delay[1].The process of rehabilitation requires efforts from a multidisciplinary team of health professionals who specialise in burn care viz: physiotherapists, doctors, nurses, occupational therapists, dieticians, psychologists, plastic surgeons, psychologists, social workers etc. Family members and support groups should also be involved in the recovery process of these patients.

Aims of Rehabilitation

A thorough assessment to ascertain the patient's functional status should be done prior to commencement of rehabilitation. This would help guide the development of a customized treatment plan for individual patients[2]. It is also important to provide education on what post-burn rehabilitation entails to both patients and their caregivers in order to carry them along and to encourage cooperation. Generally, the aims of post-burn rehabilitation are geared towards reintegration of the individuals back to the society. The aims of rehabilitation may include:

  • Maintaining range of movement
  • Minimising development of contracture and the impact of scarring
  • Prevention of deformity
  • Maximising psychological well-being
  • Maximising social integration
  • Maximising functional ability and recovery
  • Enhancing quality of life[2][3]

Stages of Rehabilitation

Post-burn management can span from inception to the hospital to several months or years, depending on the severity of the injury. Stages of rehabilitation can be divided into early and later stages although there is no clear cut time frame for each as they are both thought to overlap.

Early Stage

Also known as wound healing phase. Essentially, the aims of this stage are as follows:

  • Respiratory care. Chest clearance can be achieved through raising the head and chest region[4]. Physiotherapy techniques such as: deep breathing exercises, vibrations, percussion, postural drainage, coughing and suctioning can be employed to clear excess secretions. A soft material, preferably, a foam can be used to pad the physiotherapist's hands if procedures requiring hand pressure are uncomfortable to the patient[3]. However, if in the event that the patient sustains burn injuries on the chest with no concomitant respiratory involvement, percussions and vibrations should be avoided to prevent reinjury to already traumatised tissue[3].
  • Prevention of oedema which can be gained by elevating all affected limbs must also commence on the day of injury to prevent sites of burns from deepening[1].
  • Prevention of contractures and stiffness. 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[4]. As a matter of importance, movement should be incorporated into the patient's daily routine from their inception to the hospital. Immobilisation is only allowed when a part of the body has just been grafted. Even then, the area must be kept in an anti-deformity position[5].
  • Pain control. This is obtainable by performing therapies during wound dressing and debridement, if possible[2]. Analgesics should also be administered prior to therapy sessions to encourage participation in movement activities. The physiotherapist can use transcutaneous electrical nerve stimulation (TENS) to enhance pain relief[1].
  • Prevention of deep vein thrombosis can be achieved by encouraging early ambulation.
  • Prevention of pressure sores.

Later Stage

This stage, also known as the post-healing stage, focuses more on the following:

  • An improvement in muscle strength, endurance, balance and coordination owing to prolonged bed immobilisation
  • Scar management
  • Ambulation with little or no assistance
  • Engaging in functional activities
  • Integration into the society
The video below shows some interventions to prevent contractures in a child who may have sustained burn injuries. However, they may also be applicable to adult patients.
[6]

Rehabilitation After Grafting

Skin grafting is a term used to describe the process of transferring skin from one part of the body (the donor site) to another area, known as the recipient site which has been damaged by burns[3]. Common donor sites for grafting are the upper arm and thighs. Other areas may include the back, buttocks or abdomen. A period of 5 to 7 days is allowed so that the graft can "take"[7] and circulation would not be impaired. This means movement is not encouraged in the grafted areas nevertheless, surrounding parts of the body can still be moved.

Useful Therapeutic Modalities In Post-burn Management

  • Therapeutic exercises to maintain and improve ROM as well as enhance muscle strength.
  • Transcutaneous Electrical Nerve Stimulation (TENS) to relieve pain and pruritus (itching).
  • Hydrotherapy to encourage ROM exercises especially when there is marked pain and patient is fearful to move limbs.
  • Paraffin wax therapy when applied to contractures in the extremities can improve ROM[8]
  • Extracorporeal shockwave therapy (ESWT). Low-energy ESWT along with traditional physiotherapy have been shown to relieve burn scar pain, pruritus and improve health-related quality of life[9][10]. It can also be used to improve scar appearance and functional mobility in patients with severe burns[11].
  • Scar tissue massage to improve the pliability of scars. The video below shows different scar tissue massage techniques.
[12]
  • Laser therapy. Willows et al (2017) recommend the use of laser therapy, especially ablative fractional lasers in the management of burns to improve the pliability, vascularity and over all burn scar appearance[13].

Therapeutic Adjuvants

These forms of therapies are recommended to relieve symptoms caused by the injuries sustained during the burn such as: pain, paraesthesia, itching and sleep disorder[2]

  • Virtual reality. A study conducted by Voon et al (2016) on interactive video games noted how the use of a 3D interface video game, Xbox Kinect improved exercise time and patient satisfaction in patients who sustained minor upper limb burns[14].
  • Robotics. A novel study suggested that robot-assisted gait training in patients who have sustained burn injuries may be beneficial to improve their gait functions[15]
  • Music therapy. This has been shown to significantly decrease pain, anxiety and muscle tension associated with interventions of burn care[16][17][18].
  • Cognitive behavioural therapy
  • Hypnosis has been demonstrated to lower pain and anxiety levels in patients who have sustained burn injuries[19]

Conclusion

According to a guideline developed by the Chinese Association of Burn Surgeons, patients can be discharged when they are able to perform activities of daily living with little or no assistance[2]. This goes to stress the pivotal role physiotherapy plays in the rehabilitation team of patients with burns.

References

  1. 1.0 1.1 1.2 Edgar D. ABC of Burns: Rehabilitation after burn injury. British Medical Journal.2004; 329(7461): 343-345
  2. 2.0 2.1 2.2 2.3 2.4 Chai J, Chen H, Chen J, Guo G, Han C, Hu D et al. Guidelines for burn rehabilitation in China. Burns and Trauma 2015; 3(1): 1-10
  3. 3.0 3.1 3.2 3.3 Dean S. Management of burns and plastic surgery. In: Porter S editor. Tidy's Physiotherapy. Churchill Livingstone: Elsevier, 2009. p95-113
  4. 4.0 4.1 Procter F. Rehabilitation of the burn patient. Indian Journal of Plastic Surgery. 2010; 43(Suppl): S101--S113
  5. Edgar D. ABC of Burns: Rehabilitation after burn injury. British Medical Journal.2004; 329(7461): 343-345
  6. Children's National Hospital. After the Burn:Physical and Occupational Therapy. Available from: https://youtu.be/gU0y2mgwZbl [last accessed 1711/2020]
  7. Braza ME, Fahrenkopf. Split-Thickness Skin Gratfs. In: Stat Pearls. Treasure Island (FL): StatPearls Publishing; 2020
  8. Holavanahalli RK, Helm PA, Kowalske KJ, Hynan LS. Effectiveness of paraffin and sustained stretch in treatment of shoulder contractures following a burn injury. Arch Phys Med Rehabil. 2020; 101(1S): S42-S49
  9. Samhan AF, Abdelhalim NM. Impacts of low-energy extracorpreal shockwave therapy on pain, pruritus, and health-related quality of life in patients with burn: A randomized placebo-controlled study. Burns. 2019; 45(5): 1094-1101.
  10. Cho YS, Joo SY, Cui H, Cho SR et al. Effect of extracorporeal shock wave therapy on scar pain in burn patients. Medicine. 2016; 95(32): 4575.
  11. Chan SYJ. The effectiveness of extracorporeal shockwave therapy on hypertrophic scar appearance and hand mobility in a severe burn patient. Burns Open. 2020; 4(2): 72-77.
  12. APROQUEN. Massage Techniques-Burned Patient Rehabilitation. Available from: http://www.youtu.be/oKszhYKy-9w [last accessed 19/11/2020]
  13. Willows BM, Ilyas M, Sharma A. Laser in the management of burn scars. Burns 2017; 43(7): 1379-1389.
  14. Voon K, Silberstein I, Eranki A, Philips M, Wood FM, Edgar DW. Xbox Kinect based rehabilitation as a feasible adjunct for minor upper limb burns rehabilitation: A pilot RCT. Burns 2016; 42(8): 1797-1804.
  15. Joo SY, Lee SY, Cho YS, Lee KJ, Kim SH, Seo CH. Effectiveness of robot-assisted gait training on patients with burns: a preliminary study. Computer Methods in Biomechanics and Biomedical Engineering 2020; 23(12): 888-893.
  16. Li J, Zhou L, Wang Y. The effects of music intervention on burn patients during treatment procedures: a systematic review and meta-analysis of randomized controlled trials. BMC Complementary and Alternative Medicine. 2017; 17: 158
  17. Tan X, Yowler CJ, Super DM, Fratianne RB. The Efficacy of Music Therapy Protocolsfor Drecreasing Pain, Anxiety, and Muscle Tension Levels During Burn Dressing Changes: A Prospective Randomized Crossover Trial. Journal of Burn Care & Research. 2010; 31(4): 590-597.
  18. King L. "Is music therapy intervention effective in decreasing pain after standard wound care in hospitalized burn patients?" PCOM Physician Assistant Studies Student Scholarship. 2019; 444
  19. Provençal SC, Bond S, Rizkallah E, El-Baalbaki G. Hypnosis for burn wound care pain and anxiety: A systematic review and meta-analysis. Burns. 2018; 44(8): 1870-1881.