Vol. 24 Issue 6
OT in the Burn Unit
Management of the burned patient in the acute rehabilitation phase
As a young therapist working in acute rehabilitation, hearing that I was "getting my first burn patient" was quite intimidating. Caring for burned individuals has a well-deserved reputation for being a highly specialized part of our field. I and my PT partner viewed the experience as a highly motivating challenge and began the process of educating ourselves as well as we could in advance.
My facility, the Kessler Institute for Rehabilitation (West Orange, NJ), allowed me the opportunity to visit the patient at the Saint Barnabas Medical Center (Livingston, NJ) burn clinic prior to the transfer. Representatives from OT and PT as well as nursing met our prospective patient and had the chance to see acute burn management for the first time, including a trip to the "shower room."
As we learned about wound care, dressing selection, skin grafts and contracture prevention, we also saw the physical and psychological pain that this patient population must grapple with on a daily basis. It changed me and the way I view my profession, forever.
Entering Acute Rehab
By the time a burned patient is ready for acute rehabilitation, he is medically stable and able to do a minimum of three hours of therapy per day. The patient is generally in the maturation (or remodeling) phase of healing, which can last up to two yearspost-injury. During this phase, continued fibroblast activity leads to the production of excess collagen in the dermis that is "laid down" in a disorganized manner. (Fung, 1981)
Also during this phase, hypertrophic scarring begins to develop. A hypertrophic scar is characterized by its raised surface, decreased elasticity and erythematic appearance. This type of scarring can be caused by tension on the wound, excess inflammation in the wound bed, infection, genetic predisposition and/or a lack of dermal elements. (Howell, 1989) A full-thickness or third-degree burn that extends down into the dermal layer leads to the development of this type of scar.
Hypertrophic scars can be insidious, causing contracture, impaired function and deformity. (Howell, 1989) At times, surgical intervention is the most appropriate intervention. However, surgery is generally contraindicated until the scar has matured completely. Therefore, therapy plays an important part in the prevention of the above sequelae.
Compression therapy is a key part of the process of hypertrophic scar prevention. Compression garments can be worn on any part of the body, including the face. These garments are generally custom fitted to the patient; however, interim garments are utilized as well. Their use is initiated at wound closure.
Interim garments and compression bandages (Coban, tubular support bandages, ace wraps) can be used while wounds are still open, over wound dressings. Custom garments are worn 23 hours a day and generate approximately 24 mmHg on the skin. The constant compression provided creates an ischemic environment that can decrease the excess production of collagen. (Jordan, et al., 2000)
The compression also serves to encourage better orientation of the collagen fibers. Management of these compression garments is a key part of ADL retraining during OT sessions. Short- and long-term goals can be developed for donning and doffing garments, distinct from goals set for upper and lower body dressing.
Skin lubrication is a priority in this patient population. The use of an approved body lotion and/or cocoa butter prevents "cracking" of the skin. It can help to minimize a patient's complaint of an "itchy" feeling.
Topical moisturizers are also an important part of scar massage. Manual contact by the therapist to areas of scarring can assist with increasing pliability of the scar tissue in preparation for passive stretch, but is also important for desensitization.
As often as possible, patients should be trained in managing their own skin care, with the understanding that open wounds should be avoided and that moisturizers must be allowed to dry before pressure garments are reapplied.
A properly fabricated splint can function to preserve/increase range of motion, prevent scar contracture formation, correct an established scar contracture, and protect underlying vulnerable structures (such as tendons, nerves, ligaments). (Kwan et al., 2002)
It has been said that the position of comfort will become the position of contracture, implying that patients will rest in positions where pain is minimized, and that over time, that will become the contracted position. (Richard et al., 2005)
On the other hand, the position of function (described by joint in the Table) is the position at which joint integrity and soft-tissue length can be preserved.
How Splints Help
The purpose of any splint can be separated into one of two categories: range of motion and function. A splint can be designed to preserve range of motion in any affected joint. In addition, a splint can be designed to provide a low-load, prolonged stretch to a joint in which range of motion has already been compromised. (Van Straten, 1991)
Splints of this kind can be further delineated into static and dynamic. Dynamic splints are particularly useful at the elbow in that they can be serially adjusted as range of motion increases. A CMC (carpal metacarpal) splint can give the patient the ability to oppose the thumb and index finger in order to perform two-point pinch and fine-motor coordination activities.
As can be seen in the photograph above, splints should be fabricated to fit over compression garments and gloves. Splints provide another opportunity to perform patient education, ensuring that the patient understands the purpose of the splint, precautions associated with it, how to manage it and the schedule for wear.
Range of Motion
During the maturation phase, daily stretching is a crucial part of the plan of care. At the Kessler Institute, inpatients have the opportunity for occupational and physical therapy seven days a week. However, even in settings where daily therapy is not possible, patients should be given a comprehensive home exercise program that includes self stretch and active exercise in order to maintain gains made in therapy.
The stretching regimen that a patient must undergo is often extremely painful. As a therapist, I strive to use any possible motivating factor I can find, whether it's the prevention of deformity, the possibility of return to work or school, or participation in a cherished leisure activity, to assist the patient in this part of treatment. The application of paraffin prior to stretching can help to make soft tissues more pliable, desensitize scarred areas and relax the underlying musculature.
Paraffin should be applied to areas with no open wounds and should be left in place for 15 to 20 minutes, with frequent skin checks. During passive stretch, direct pressure and massage to areas of hypertrophic scar can help to flatten and loosen it, allowing for greater range of motion and flexibility during subsequent exercise and activity. (See photos on page 37.)
Strengthening and Conditioning
Patients often leave the acute care hospital having perhaps been comatose (either medically induced or otherwise), ventilated and immobilized for a prolonged period of time. Because of this, they may have weakness in all extremities and low endurance.
Muscle weakness can simply be a result of non-use or can be neurological in origin. Active and progressive resistive exercises can be performed with splints in place in order to provide passive stretch during activity. For example, in the picture shown above, the patient has burns bilaterally to the cubital region of her elbows. As a result, she lacked elbow flexion range. When performing progressive resistive exercise at the shoulders, she would don elbow flexion splints, in order to produce elongation of the tissue/skin overlying her trunk, axilla and posterior aspect of her upper limb.
As a patient becomes increasingly active in the acute rehabilitation phase, it is vital to consider her caloric intake. Following a severe burn injury, the metabolic rate often increases to a level exceeding twice that of the uninjured individual. This hypermetabolic response necessitates an increase in nutritional support. (Goodwin, 1985) The occupational therapist plays a role in patient education in this area, but also intervenes relative to the patient's ability to feed him/herself, prescribing adaptive equipment as needed.
Planning for Discharge
Prior to discharge home, a patient should trial all options for durable medical equipment (DME) and be educated to their set-up and use. A patient may require the use of a wheelchair, either as a rental or purchase, depending upon his needs. Equipment for toileting and bathing should be considered as well. If possible, patients are granted day passes by their doctors, after family/caregiver training has been performed, that gives them the opportunity to function in their home environments and report any potential barriers to their therapists upon return.
In addition, the Kessler Institute -provides a community skills program, providing patients with the chance to venture out into the community with therapists by their sides. This provides the individual with exposure to the larger community and allows for practice with either ambulation or wheelchair mobility in a variety of environments.
Community reintegration can be a difficult process for anyone adjusting to a disability, but is made more challenging for patients with burn injuries by the presence of physical scarring and deformity.
Burn treatment in the acute rehabilitation phase is a process that is both challenging and rewarding for the patient and therapist alike. It is the combination of treatment techniques (compression therapy, skin care, splinting, range of motion, strengthening/conditioning and effective discharge planning) and the contributions of each member of the multi-disciplinary team that make for the best clinical outcomes in this population.
References available at www.advanceweb.com/OT or upon request.
Sarina Piergrossi, MS, OT, is a senior occupational therapist at the Kessler Institute for Rehabilitation in West Orange, NJ.