Rehabilitation of Individuals with Burns

Question 1

Should you expect to achieve full ROM in burn cases

Answer 1

Yes, anything is possible.

Question 2

Should you expect long-term hospital stays in burn cases?

Answer 2

No, stays can be short and independence can be achieved quickly

Question 3

What is a first degree burn?

Answer 3

Superficial burn

Question 4

What is a second degree burn?

Answer 4

superficial partial thickness or deep partial thickness (grafting sometimes indicated)

Question 5

What is a third degree burn?

Answer 5

Full thickness (grafting)

Question 6

What are the 4 PT/OT goals for those w/ burns?

Answer 6

1. Prevent scar contractures, with full AROM at all joints and body parts
2. Minimize hypertrophic scarring
3. Return to baseline independence in ADLs, IADLs, and work, with pre-burn movement patterns
4. Return strength and cardio-pulmonary endurance to baseline

*Predict wound healing to prevent future impairments. Rehab is time-sensitive

Question 7

What are 3 things PTs and OTs need to do quickly?

Answer 7

Assess location/depth with team
Predict burn healing, scar potential, possible ROM losses
Assess patient and family social and emotional resources

Question 8

What is a tool you can use to see if you’re competent enough to treat burns?

Answer 8

Burn Rehab Therapist Compentency Tool (BRTCT)

Question 9

Where are burns most concerning when trying to prevent scar contractures/achieve full AROM?

Answer 9

Burns on or around joints

Question 10

Intervention to attain full AROM?

Answer 10

AROM/PROM frequently throughout the day most effective in maintaining or attaining PROM and strength

Question 11

How much stretching per day is needed in the Rehab phase?

Answer 11

Greater than one hour per day`

Question 12

When is Immobilization Indicated? (4)

Answer 12

48+ hrs after skn substitutes placed, for good adherence, on partial thickness wounds
5 days or more after grafting over full-thickness wounds
When intubated, sedated, and frequent ROM not possible (including possible night time positioning)
To augment PT/PT (??) exercise

Question 13

Where do you want immobilized joint positioned?

Answer 13

Positioned in optimal, functional stretch position

Question 14

What are three ways to predict ROM losses and prevent ROM loss

Answer 14

Exercises
Activity (ADL, IADL, Work, Leisure)
Positioning

Question 15

What tissue should you stretch?

Answer 15

Burn will shorten tissue. stretch to lengthen the burned area

Question 16

Should you use an air mattress in an ICU?

Answer 16

Yes

Question 17

What is a position to avoid in burn patients with burn over the hip?

Answer 17

Side lying on a flat bed on either side.

Question 18

What is a piece of furniture to avoid in patients with knee burn?

Answer 18

Recliner

Question 19

Burn on ant. ankle? What motion do you stretch?

Answer 19

Do PF. If it was posterior, you’d do DF

Question 20

What are 3 considerations in splinting hands and wrists?

Answer 20

Location of burn
Thumb, wrist, palm involvement
Extensor tendon involvement

Question 21

What are two types of splints for the hands/wrists?

Answer 21

Types of splints:

• Instrinsic plus
• Fist position (open and close to get fluid moving

(BioBrane is a good dressing to use, FYI)

Question 22

How do you want wrist positioned?

Answer 22

IPs and DIPs extended

Question 23

What are 4 other areas to consider?

Answer 23

Trunk (rotation, flex, ext, lat rot)
Mouth (microstomia orthosis)
Donor sites
Finger web spaces

Question 24

4 keys for positioning?

Answer 24

Develop positioning and splinting recommendations and schedules
Monitor skin tolerance (and fit)
Adjust as needed
Educate team

Question 25

Considerations for positioning? (6)

Answer 25

Edema management via elevation critical to TOM success, and is included in positioning suggestions - ELEVATE ABOVE LEVEL OF THE HEART Progress to AAROM and AROM ASAP Good outcomes associated with frequent repositioning of ROM throughout day and prolonged stretch May combine positioning device at night and AROM during the day AROM also achieved thru participation in ADL, work, leisure Encouragement and extensive education needed to work through superficial skin tears or synthetic skin 'adhesions' with ROM (use gonio and hand tracings)

Question 26

How long can burn scar take to heal?

Answer 26

12-15 months

Question 27

What length of time indicates hypertrophic scarring?

Answer 27

> 3 weeks

Question 28

What is essential for gaining compliance?

Answer 28

Family education

Question 29

What group of patients are least compliant with ROM and stretching, but most compliant with ADLs?

Answer 29

Pediatrics

Question 30

Should you use scare tactics?

Answer 30

Yes, they sometimes work

Question 31

What is an objective measure of scars?

Answer 31

Vancouver Scar Scale

Question 32

What four things does the Vancouver Scar Scale measure?

Answer 32

Vascularity Pigmentation Pliability Height (pigmentation refers to surface color)

Question 33

What are different pressure garments?

Answer 33

Temporary: tubigrip for limbs, Isotoner gloves hands, inserts where needed, face masks, etc. Permanent: Custom pressure garments (ex. Jobst)

Question 34

What are 3 different inserts used?

Answer 34

50/50 Gel inserts Ensel garment inserts

Question 35

How to do scar massage?

Answer 35

Circular, downward pressure

Question 36

Is there evidence to support scar massage?

Answer 36

No. There is no compelling evidence that it minimizes scarring. May be a psychological benefit though...

Question 37

What has best results in reducing scar thickness?

Answer 37

Combo of pressure therapy combined with silicone gel sheeting on hypertrophic scar

Question 38

Treatment strategies for those with an inhalation injury?

Answer 38

``` Head of bed up Incentive spirometer use Therapeutic coughing Moving, turning Endurance and strength training ```

Question 39

How to maintain or attain strength and balance?

Answer 39

Transfer out of bed ASAP Promote AROM over PROM Combine strengthening and stretching ex prog to minimize complexity and time, to improve chances for follow through Encourage gradual progression back to former activities

Question 40

How to enforce long-term skin protection?

Answer 40

Prevent sun exposure over burned areas, via long sleeved shirts, sun hats, and sun screen Full thickness burned areas are without sweat glands; care in exercise if substantial burns Burned skin can be more fragile than unburned; consider footwear, contact activities, even clothing early post-burn