Lecture 21 - Burn Rehab

Question 1

villa medica burn victim statistics

Answer 1

Question 2

what are the 3 layers of skin and its functioning?

Answer 2

Question 3

what are the functions of the skin?

Answer 3

protects from:

– Evaporation/dehydration (prevents shock)

– Protein loss (prevents loss of oncotic pressure and edema)

– Infection
– UV rays, wind, cold – Trauma

• Excretion, Absorption, Perception, VitD, Personal ID, Durability, Pliability

Question 4

what are physical properties of the skin? - 2 fibre types - what is the most abundant fibre type?

Answer 4

1) Collagen: provides strength and foundation

– long aligned fibers

– extensible but very resistant

– tensile strength

– most abundant fiber

2) Elastin - interwoven with collagen fibres

– Thinner than collagen

– Brings stretched collagen back to its relaxed position

– Provides elasticity to skin
– Poorly regenerated in burn scar

Question 5

what are the types of burns (what can cause burns)

Answer 5

Thermal (heat and cold)

Electrical
Chemical (from strong acid or base)
Allergic reaction

Skin infection (flesh eating disease - same treatment as burn victim)
Radiation
Friction (degloving - being dragged along the road)
Immune system reaction

Question 6

what are the different burn degree depths?

Answer 6

Subcutaneous burns / 4 degree burn – Adipose layer
– Muscles
– Tendons

– Bone

Question 7

how does % total body surface area affect healing?

Answer 7

Question 8

describe inhalation burns

Answer 8

Question 9

describe the process of surgical management of burns - define fasciotomy, escarrotomy, and debridement

Answer 9

note that sedation can last weeks or months!

Question 10

describe the donor site for a skin graft - whre is it taken from - what to look out for - healing process

Answer 10

A hypertrophic scar is a cutaneous condition characterized by deposits of excessive amounts of collagen which gives rise to a raised scar

Question 11

what are different sources of skin grafts?

Answer 11

Question 12

what are the different types of skin grafts?

Answer 12

1) Split thickness graft - usually in emergrnt phase
2) Mesh graft
3) Full thickness graft
4) skin flap

Question 13

pros and cons to split thickness grafts

Answer 13

Question 14

pros and cons to mesh grafts

Answer 14

Question 15

pros and cons to full thickness grafts

Answer 15

Question 16

pros and cons to skin flap

Answer 16

for covering tendon = skin with its own blood supply - requires many surgeries, bulky

Question 17

what is a z-plasty?

Answer 17

to lengthen a linear scar

Question 18

problems faced by the burn survivor and team - what are some cutaneous issues?

Answer 18

Question 19

problems faced by the burn survivor and team - describe a hypertrophic scar (what tissue types it consists of)

Answer 19

Question 20

what increases the risk of hypertrophic scar contraction - how long can it last for?

Answer 20

Wound contraction leads to scar retraction

Scar contraction: can be present for many months after wound closure and can be active up to 2 years

Question 21

describe the maturation of a hypertrophic scar over time

Answer 21

– Color: mauve -> red -> pink -> white (for Caucasian skin)

– Elasticity: variable

– Thickness: with scar remodelling

– Pigmentation: variable

– Mature when the scar is pale, smoother, and more flexible

• there is a mixed phase and a maturation phase

Question 22

what areas are more susceptible to contacture/cord development?

Answer 22

Question 23

what are other problems faced by the burn survivor and team?

Answer 23

• sleep disorders (sleep helps with healing)
• hypermetabolism (body trying to hel itself and therefore requiers more energy - take energy from muscle cells and muscles hypertrophy - after muscles, take energy from fat - need lots of protein to heal wounds - bc easier to convert muscle to sugar than fat)
• cardiovascular issues (because of prolonged bedrest, stiff chest from scar tissue, inflammation not good for heart)
• itchiness and Pruritus (severe itchy skin)
• pain
• musculoskeletal (correct as a result of scar tissue formation: Posture, Tendinitis / impingement syndromes, Capsulitis)
• neurological
• social (loss, grief, role changes)
• physiological (self-image, self-esteem, depression, anxiety, PTSD)
• complications (OP, Osteomyelitis, Septic arthritis, Fractures, Heterotopic bone formation - bone formation where there shouldn’t be - mostly at elbows, Joint dislocations, Amputations, Abnormal growth-growth plates in children can be shut down)

Question 24

what are the neurological problems faced by burn survivors?

Answer 24

CRPS = complex regional pain syndrome

Question 25

describe itch vs pruritis as experienced by burn victims

Answer 25

_Itch_ Post-burn itch is considered by some to be a form of neuropathic pain - especially on graft site - can last months-years 57-100% of children: 25-87% of adult burn survivors suffer from itch 45% c/o itch 47.3±22.9 months post-burn Can be severely debilitating European survey of burn survivors - #1 research priority _Pruritis_ Pruritogenic (severe itching of skin!) – Inflammatory process – sebaceous/sweat glands/ingrown hairs/ transepidermal water loss Neuropathic / Neurogenic (peripheral + CNS) • Psychogenic \*\*\*Important not to scratch - bc skin is more fragile - can create wound then infection

Question 26

describe pain porblems faced by burn victims (and importance of treating)

Answer 26

– Burn pain is considered as very significant – Pain is very present in burn survivors, and can last a few months to a few years – 20% of subjects experienced shooting pain in their burn scars at \> 30 years post-burn – Influenced by anxiety and depression – Pain scores correlated with PTSD but not injury severity, TBSA, heart rate or blood pressure -- 18% of adult major burn victims report having chronic pain related to the burns 5 years post- burn. -- Pain in acute phase PTSD and general emotional distress -- Pain relative to burns is what most influences sleep, work and mood -- Major burn victims who are not working due to their burns report more pain than those who are working or who are retired.

Question 27

what are the types of burn pain?

Answer 27

_Neuropathic pain_ – Associated with nerve damage (central, peripheral, or mixed) – Ex: tissue reorganization/regeneration 1-3 months for capsules to retract 1-4 days for burn tissue to retract _Muskuloskeletal pain_ (ex: articular) _Emotional/psychological pain_ _Persistent pain_

Question 28

is the pain related to the depth od the burns?

Answer 28

Question 29

describe the subjective evaluation for burn victim rehab and the specific componenets to address

Answer 29

slides 1-12 – \*Pain: VAS, description, McGill Pain Questionnaire, BSHS-B – \*Pruritus (5-D Pruritus scale) – Numbness/ paresthesia – Weakness – Sleeping position and sleep quality – Morale -- \*QOL (burn specific health scale)

Question 30

what is assessed in the O section for a burn victim?

Answer 30

note: EF will come on much quicker and have less give

Question 31

PT - specific "O" evaluation componenets for the burn victim - skin

Answer 31

Question 32

PT - specific "O" evaluation componenets for the burn victim - scar tissue

Answer 32

_Scar tissue_ Contracture sites / cord locations Modified Vancouver Scar scale (use sparingly) – vascularity – flexibility – pigmentation – height or thickness POSAS: Observer scale and Patient scale (pt and PT have very different ratings of this! \*see slides p 23-27

Question 33

PT - specific "O" evaluation componenets for the burn victim - sensation

Answer 33

Question 34

PT - specific "O" evaluation componenets for the burn victim - face

Answer 34

Question 35

describe the overlap btw PT and OT for burn treatment

Answer 35

Question 36

education for burn victims

Answer 36

Question 37

what are pharmacologic pain modalities for burn victims?

Answer 37

Question 38

what are non-pharmacologic pain modalities for burn victims?

Answer 38

slides 38-45

Question 39

what are some pruritis modalities? - pharmacologic and non-pharmacologic

Answer 39

_Pharmacologic_ – Antihistamines(ex: Benadryl, Atarax, Doxepin cream) – Naltrexone – Local anasthetics – Corticosteroid injections _Nonpharmacologic_ – Avoid scratching! – Moisturizer (can be put in fridge) – Ice, cold compresses – Distraction – TENS (needs to be further studied) – Vibration – Massage – Compression – Hydration – Air humidity control / avoid overheating – Stress management

Question 40

what are some scar management techniques?

Answer 40

Goals of hypertrophic scar massage * Maintain joint mobility re contractures • Soften scar tissue * Break down adhesions * Promote remodeling of scar tissue * Desensitisation * Clinically, alleviate pruritis

Question 41

what are the goals of pressure garments?

Answer 41

– decrease oedema – Minimise development and appearance of hypertrophic scars (decrease vascularity and collagen synthesis, reorients collagen) – Improve esthetic aspect of the scar – Avoid scar migration – Limit loss of movement – Favour optimal function \*slides 56-59

Question 42

what are some other modalities used for burn care?

Answer 42

-- Therapeutic activities: biometrics, gait and stair training, biodex, functional balance, Wii (yoga, balance, sports, etc) – Strengthening of weak muscles and/or opposite to contractures: weights, open and closed kinetic chain exercises, active, active- assisted, isometric and resisted exercises, motor control – Endurance training: nu-step, elliptical trainer, treadmill, bike, Wii- be careful of altered thermoregulation! – Edema control (elevation, AROM\>PROM, compression (bandages-\>transition garments-\>made to measure), lymphatic drainage, Intermittent pressure?) – Hydrotherapy: hand shower with waterproof stretcher-cleans skin, cleanses of the skin Whirlpool bath: not used anymore due to risk of infection! – Wound care: * High voltage current + laser * Basic dressings

Question 43

what is the in-patient/out-patient environment for burn victims?

Answer 43

In-patient and out-patient in same room OT, PT, out-patient MD work in the same room aware of each other’s treatments- * Ex: PT notices hypertrophic scars during massage, OT can add compression * Ex: PT stretches in one direction and OT follows with AROM activities in the same direction Psychologist, social worker, nursing and research teams are close by _Out-pt_ Similar to in-patient approach: modalities and evaluation techniques focus on fine-tuning of function, movement, activities and sports Slower progression Can last for months- years depending on the number of reconstructive surgeries (5x/week to 1x/ few months) Inter-disciplinary team approach