an easy guide to outpatient burn rehabilitation

7/24/2019 An Easy Guide to Outpatient Burn Rehabilitation

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AN EASY GUIDE TO

OUTPATIENT

BURN REHABILITATION

Presented by: Rocky Mountain Model System for Burn InjuryRehabilitation, In the Department of RehabilitationMedicine at the University of Colorado Health Sciences

Center; Denver, Colorado

Supported by: National Institute of Disability and Rehabilitation ResearchUnited States Department of Education,Award Number: H133A30015.


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The Rocky Mountain Model System for Burn InjuryRehabilitation was a four year grant (1993-1997) fundedby the National Institute on Disability and RehabilitationResearch in the United States Department of Education.

The grant incorporated five major areas:

Development of a Model System of burn InjuryRehabilitation that is patient centered andcoordinated from the onset of the burn injury untilthe burn survivor is once again integrated into the

community.

Education of burn patients and their families, ruralburn support teams, and other professionals.

New areas of burn research includingdeconditioning of a burn patient, outcomemeasurements, and burn related immunologicstudies.

Surveillance of burns and development ofprograms to prevent burn injury.

Development of a national database in coordinationwith the other Model Burn Systems in the UnitedStates.

Information about this Burn Model System may beobtained by calling (303)315-0320.


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TABLE OF CONTENTS

TOPIC PAGE

Introduction 1

Scar Control1. 2

A. Hypertrophic Scarring 2

B. Scar Massage 2

C. Custom Pressure Garments 3

2. Therapeutic Exercise 8

3. Manually Resisted Exercise 10

4. Work Hardening 18

5. Modalities 26

6. Activities of Daily Living 29

7. Splints 30

8. Outcomes and Interviews 37

9. References 38


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INTRODUCTION


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INTRODUCTION

As the designated adult burn rehabilitation center in the State ofColorado, our facility relies on rural health care providers to continuethe essential outpatient rehabilitation phase. This video,accompanied by a written informational booklet, provides visualassistance to those professionals who may not be familiar withtreating a burn survivor.

More and more, our burn survivors are being discharged and treatedas outpatients earlier. This outpatient care requires complex nursingand Physical and Occupational Therapy services closer to thepatients home. Communication between the burn center and the

outpatient team is essential. The video and educational booklet weredesigned to provide assistance on common outpatient issues.Through the use of brief segments, the outpatient health careprovider can view only those areas needed. By the conclusion of thevideo, the viewer will be able to:

1. Identify hypertrophic scarring.

2. Differentiate between an active and a mature scar.

3. Prioritize a burn survivors exercise needs.

4. Describe the proper fit and care of custom pressuregarments and splints.

5. Adapt self care items for independent ADLs.

6. Understand several patients views of rehabilitation.

It should be noted, there is not just one correct way to approach burnrehabilitation. The information in this video is based on approachesand techniques used at the University of Colorado Hospital. By usingthese few precautions and ideas, a safe and comprehensive programcan be established to help the burn survivor return to living as aproductive member of the community.

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SCAR CONTROL


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SCAR CONTROL

The formation of a scar is an ongoing process for the burn survivor.Scars are dynamic and continue to grow and change throughout the

maturation process. It is the responsibility of both the patient and thehealth care provider to manage scars and decrease the potential forcontractures.

Hypertrophic scarring: Hypertrophic scarring develops due totissue tension, persistent inflammation, and the exaggeratedresponse of the fibroblasts to healing. Fibroblasts deposit excessiveamounts of disorganized collagen which then become adhesed toother structures. The scar is characterized by the three Rs:

It is Red because it is hypervascular.

It is Raised because there is four times as much collagenin a burn wound than in any other wound.

It is Rigid because the collagen is disorganized and doesnot allow for pliability.

The scars are metabolically active for approximately eighteen

months. After that time the scar is mature, as shown in the video withHarry. Hypertrophic scarring is more pronounced in AfricanAmericans, Native Americans, Asians, and Hispanics secondary toincreased pigmentation.

Scar Massage: Scar massage has several important functions:

It promotes collagen remodeling by applying pressure to scars:It helps to decrease itching:It provides moisture and pliability to the burned region and

donor sites.

The video demonstrates the appropriate technique, as well as thehandout on scar massage in page 4 of the booklet.

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Custom Pressure Garments: Pressure applied to a scar decreasesthe excessive collagen formation and helps to realign the presentcollagen. The custom pressure garments are made to conform to apatients normal body contour, thus limiting abnormal scar formationand deformity. It is important that the garments fit properly to assuremaximal benefit of wearing them and avoid complications such asswelling, increased scarring, or abraded areas. Some clues forproper fit:

It is TOO small if:

1. It binds or digs into the skin.2. The fingers or toes become swollen, blue or numb.3. The garment rides up or down with motion.

It is TOO big if:

1. There is any bagging or sagging noted.2. The garment can easily be pinched away from the skin.3. The scar appears larger in one area.

The goal is to wear the custom pressure garments twenty-three hoursa day, removing them only for scar massage and bathing. Manytimes, when a garment covers a concave area, (i.e., between thebreasts, shoulder blades, or fingers) adequate pressure is notapplies. Foam padding and inserts made from silicone gel orelastomer can be used to fill in the concave areas and applyappropriate pressure to scars in those areas.

Garments that have rips or holes no longer apply consistent pressureand should be replaced. It is also important to note that the garmentsshould not be cut or altered in any way except by the vendor who hasprovided the garment.

Refer to Pages 5 and 6 for instructions on care and wear of custompressure garments.

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UNIVERSITY HOSPITALWe practice what we teach

nformation for Patients and Family

BURN CARE

SCAR MASSAGE INSTRUCTIONS

1. Apply lotion to all burned or grafted skin and donor sites, once they are healed.

2. Massage the lotion in, applying enough pressure to make the area blanch (turn white).

3. Massage in all three directions as shown below.

Vertical Circles Horizontal

4. Do this 3 to 4 times each day.

Lotions You may use any lotion that will help make your skin soft.

You should avoid perfumed lotions.

There isno need to use lotions containing aloe vera or vitamin E.

If you have any questions or problems, please call your primary therapist.

This information sheet was developed and funded by:Rocky Mountain Model System for Burn Injury Rehabilitation

Sponsored by the National Institute on Disability Rehabilitation and ResearchUS Department of Education Grant #HI33A30015

June 1995

University of Colorado Health Sciences Center * Ninth Avenue at Colorado Boulevard * Denver, ColoradoCommitted to equal employment opportunity and affirmative action.

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We practice what we teachUNIVERSITY HOSPITAL

Information for Patients and Family

BURN CARE

CARE AND USE OF YOURCUSTOM PRESSURE GARMENTS

You have just received your custom pressure garments. These garments were made especially foryou to fit your normal body contours. Their job is to apply pressure to your burned areas to helpyour scars lie flat. (That is why they are so tight.)

Care of Your GarmentYour garments should be washed daily in warm water either by hand or in the washing machine.Do not use harsh detergents or bleach to clean your garments. They should be air dried flat. Donot put them in the dryer, or in direct sunlight.

When to Wear Your GarmentYour garments should be worn 23 hours a day. You can take them off to have a bath or showerand to perform your scar massage. You can do all your regular activities in your garments,including work and sports! (and therapies!)

Problems with Your Garment

If you have problems with your garments, such as swelling, numbness m your hands or feet, or if

your skin is breaking down, call or see your primary therapist immediately. If your therapist isnot available (after hours or on the weekend) take the garment off until you can reach your

therapist. Do not try to cut or alter the garment by yourself. If you do, it may no longer beeffective. Your therapist, __________________, may be reached at ___________.



University of Colorado Health Sciences Center * Ninth Avenue at Colorado Boulevard * Denver, ColoradoCommitted to equal employment opportunity and affirmative action.

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BURN CARE

APPLYING CUSTOM PRESSURE GARMENTS

Apply your garments after you have done your scar massage.

To put on your footies: Turn the footies 1/2 way inside out with the toe portion remaining right-side out.

Put the footies on so your toes are all the way to the end of the garment. Pull the garment over your heel then up over the front of your ankle.

To put on your pants:

Make sure all the zippers are open. Slowly inch them up each leg. (Women -- this will be like putting on tight panty h Place telfa pads over any open areas as you come to them. Pull the garment up over your waist.

Make sure the pants are on correctly. The zippers should be on the inside portion oyour calf and the seam should run up the center of the back of your leg.

To put on your gloves:

Make sure all the zippers are open. Both gloves are put on the same way. Put on one glove and then the other.

Turn the gloves inside out just up to where the finger holes begin.

Place each finger in its hole and pull the garment down so your fingers go all thway to the end of the garment.

Put your thumb in its hole and pull the rest of the garment up and over your hand Make sure the gloves are on correctly. There should not be any space between theglove and where your fingers join the palm of your hand. There also should not bany space at the end of your finger tips. The zipper is centered over the top part oyour hand (opposite side from your palm).

(OVER)

University of Colorado Health Sciences Center 0Ninth Avenue at Colorado Boulevard 0 Denver, Colorado * 303-329-3066

Committed to equal employment opportunity and affirmative action.

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To put on your vest/bodysuit:

Make sure the zippers are open. Step both legs into the suit. Pull it up over your waist. Put one arm into the sleeve, only up to the forearm. Place telfa pads over any open areas as you come to them. Put the other arm into the sleeve only up to the elbow.

Pull the garment up both arms, taking turns on each arm. Then pull the garmeup over your shoulders.

Zip up the front of the garment all the way. Zip the sleeves. For the bodysuit, cthe Velcro crotch flap.

Make sure the garment is on correctly. The zippers on the sleeves should be onoutside of each arm and the garment should not bunch or dig into the armpits.

To put on your face mask:

Anchor the mask over your chin and pull up and over your head. Make sure your mask is on correctly before you close the Velcro in the back. T

eye and mouth openings should be centered. Your vision should not be limitedThe seam should run over the middle part of your scalp.



June,1995 7


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THERAPEUTIC EXERCISE


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THERAPEUTIC EXERCISE

Exercise should begin on the day of the patient's burn injury and should continueuntil all wounds are closed and the scars are no longer metabolically active (Seesegment on scarring). Fibroblasts, which are responsible for wound contracture,enter a burn wound in the first twenty-four hours and remain active for up to twoyears after the patient's injury. Exercising several times throughout the dayhelps to counter the decreased strength and decreased joint range of motion thatmay occur from scar contracture.

By the time a burn survivor returns to his/her community, he/she will be ready foran aggressive outpatient rehabilitation program designed to:

1.2.3.

4.5.

increase strength;increase endurance;increase range of motion in the involved regions;

promote functional independence; andpromote return to work.

A comprehensive circuit training type program has proven very effective at ourfacility. Continuing the following components in a gym setting helps promotepatient independence and responsibility for his/her own outcome by allowinghim/her to work as independent as possible on most segments, receivingguidance and assistance only in those areas needed.

STRETCHING - Stretch is most effective when performed slowly and until the scar

blanches. A prolonged stretch with a light load of two to three pounds placed at theend of a lever helps to elongate shortened soft tissue. It is important to remember, thatif a burn covers more than one joint, the scar should be elongated at both ends topromote a maximal stretch. Use blanching as your guide for how far to push (SeeHypertrophic scarring video segment).

STRENGTHENING -Active and resistive range of motion can and should beused frequently, using resistance whenever possible and as early as tolerated.

A progressive program using pulleys, therabandtm, free weights, eccentricexercises and weight bearing exercises are started early in the rehabilitation

process, even when burn wounds are still open. Be aware that many burnsurvivors have weakness in the proximal muscles of the shoulders and hips as aresult of decreased activity and immobilization. Extra attention should be paid tothose areas.

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ENDURANCE - Many burn survivors have decreased muscle bulk andlow endurance as a result of a prolonged hospital stay, possible ventilatordependency, and periods of immobilization after skin grafting. Training on the bike,upper body ergometer, or something as simple as repetitions of ascending anddescending stairs, help build endurance. Twenty minutes of aerobic activity,performed at 60% of maximal heart rate three times a week, can help to retrain the

cardiovascular system.

NOTE: Many burn survivors complain of feeling fatigued throughout the dayand of being unable to stay active all day. This is not uncommon. It may takemonths for a burn survivor to feel that their energy will return to normal.Performing endurance training and helping the burn survivor return to a normalsleep cycle (i.e., decreasing naps in the day, increase longer periods of sleepat night) will assist with returning the patient to a ''normal'' level of activity.

COORDINATION -Again, long periods of immobilization and burn scarring canlead to decreased torso rotation and the ability to perform reciprocal activities.Proprioceptive Neuromuscular Facilitation and the therapeutic ball are greatactivities to promote these motor skills.

FINE MOTOR SKILLS - Many times, burn survivors suffer from decreaseddexterity even when the hands are not burned. Patients with grafting to theupper arm require immobilization, which limits use of that hand and facilitatessmall muscle atrophy. Including pinch, grip and fine motor activities in yourexercise program will facilitate good fine motor control and assist with

independence in activities of daily living.

HOME EXERCISE PROGRAMS - Even the most aggressive outpatientprogram needs to be supplemented by a home exercise routine. Scars contractevery minute of every day. Exercising one hour three to five times a week willnot be enough to prevent contractures and deformities. Patients are instructedin written home exercise programs prior to discharge from the hospital and areexpected to perform these exercises and stretches prior to coming to theoutpatient appointments. That way, outpatient therapies can focus on problemareas and exercises that patients are unable to perform at home because ofequipment needs.

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MANUALLY RESISTED EXERCISE


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MANUALLY RESISTED EXERCISE

Proprioceptive Neuromuscular Facilitation (PNF) is the method of promoting orhastening a desired response through stimulation of the proprioceptors. Astaught by Knott and Voss, PNF uses stimulation through tactile, auditory, visualandverbal cues to elicit movements in normal patterns. The patient learns tomove in a coordinated, skilled way as facilitated by the therapist. The goals ofPNF treatment with a burn survivor are to decrease muscular guarding, facilitatenormal movement patterns, encourage reciprocal and rotational movement of thehead, neck, torso, upper and lower extremities, and to strengthen proximalmusculature, thereby facilitating distal coordination.

The video briefly shows some PNF techniques that are effective in treating the

burn survivor. They are as follows:

Contract-Relax: a repeated effort is used without sustained effort from thepatient to stimulate a response in the lengthen range of motion. Contract-Relax can be used to increase passive range of motion.

1.

Rhythmic Initiation: repeated movement without sustained effort from thepatient in order to stimulate muscle contractions and purposefulmovement. This technique is used to teach the patient how to move andincrease strength.

2.

Diagonal 1 (D1) and Diagonal (D2) Movement Patterns: for both the upperand lower extremities, with a flexion component and extension component.Facilitation of rotation is key to a coordinated movement. DiagonalPatterns work well for home exercise programs and increasing activerange of motion.

3.

Developmental Postures - Manual Resistance: facilitating your patientthrough the developmental postures is a great way to gain proximalstability, strength of all extremities, and range of motion in all joints.

4.

The following pages demonstrate a home exercise program in the PNF upperextremity diagonal patterns. If you would like to learn more about ProprioceptiveNeuromuscular Facilitation, please refer to the reference list provided.

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PNF HOME EXERCISE PROGRAM FOR____________________________

PERFORM EACH EXERCISE

_______________ TIMES FOR_______________ REPITITIONS

STOP THE EXERCISE IF YOU FEEL PAINOR DISCOMFORT

REST IN BETWEEN EACH EXERCISE TOPREVENT OVER-FATIGUE

REMEMBER TO MOVE THROUGH THE FULLRANGE OF MOTION THAT YOU HAVE

CONTACT YOURTHERAPIST ______________________

AT ______________________WITH ANY QUESTIONS OR CONCERNS

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EXERCISE #1

USE RIGHT / LEFT / BOTH HAND(S)

PERFORM EXERCISE IN SITTING /STANDING / LYING DOWN

BEGIN THE EXERCISE

AS IN THE PICTURE A.

CLOSE YOUR HANDTURN YOUR ARM

AND PULL UP AND ACROS

OPEN YOUR HAND

TURN YOUR ARM

AND PUSH DOWN AND OU

YOUR ARM SHOULD BE

IN THE SAME POSITIONAS IN PICTURE B.

YOUR ARM WILL BE IN

THE SAME POSITION ASIN THE PICTURE A.

REPEAT

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EXERCISE #2

USE RIGHT / LEFT / BOTH HAND(S)

PERFORM EXERCISE IN SITTING /STANDING / LYING DOWN

BEGIN THE EXERCISE


OPEN YOUR HAND

TURN YOUR ARM

AND PUSH UP AND OUT

YOUR ARM SHOULD BE

IN THE SAME POSITIONAS IN THE PICTURE B.

CLOSE YOUR HAND

TURN YOUR ARM

AND PULL DOWN AND ACROS

YOUR ARM WILL BE IN THE

SAME POSITION AS IN THEPICTURE A.

REPEAT

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EXERCISE: THE LIFT

PERFORM EXERCISE IN SITTING/

LYING DOWN

BEGIN THE EXERCISE AS IN

THE PICTURE A. HOLD

YOUR _______WRIST WITH

YOUR _______HAND.

OPEN YOUR _______ HAND

TURN YOUR ARMAND PUSH UP AND OUT

HOLD ______ SECONDS

YOUR ARMS SHOULD BE

IN THE SAME POSITION

AS IN THE PICTURE B.

CLOSE YOUR _______ HAND

TURN YOUR ARM

AND PULL DOWN AND ACROSS

YOUR ARMS WILL BE IN THE

SAME POSITION AS IN THEPICTURE A.

REPEAT

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EXERCISE: THE CHOP


LYING DOWN

BEGIN THE EXERCISE AS IN

THE PICTURE A. HOLD

YOUR _______WRIST WITH

YOUR _______HAND.

CLOSE YOUR _______ HAND

TURN YOUR ARM

AND PULL UP AND ACROSS

HOLD ______ SECONDS

YOUR ARMS SHOULD BE


OPEN YOUR _______ HAND

TURN YOUR ARM

AND PUSH DOWN AND OUT

YOUR ARMS WILL BE IN THESAME POSITION AS IN THE

PICTURE A.

REPEAT

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EXERCISE: #1

USE BOTH ARMS


STANDING / LYING DOWN

BEGIN THE EXERCISE


CLOSE YOUR HANDS

TURN YOUR ARMS

AND PULL UP AND ACROS

YOUR ARMS SHOULD BE


OPEN YOUR HANDS

TURN YOUR ARMS

AND PUSH DOWN AND OU

YOUR ARMS WILL BE IN

THE SAME POSITION AS IN

THE PICTURE A.

REPEAT

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EXERCISE: #2

USE BOTH ARMS


STANDING / LYING DOWN

BEGIN THE EXERCISE


OPEN YOUR HANDS

TURN YOUR ARMS

AND PUSH UP AND OUT

YOUR ARMS SHOULD BE

THE SAME POSITION AS

THE PICTURE B.

CLOSE YOUR HANDS

TURN YOUR ARMS

AND PULL DOWN ANDACROS

YOUR ARMS WILL BE IN

THE SAME POSITION AS IN

THE PICTURE A.

REPEAT

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WORK HARDENING


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WORK HARDENING

In today's society, feelings of self worth and personal identity are tied to the role

he or she plays as a wage earner. When a person has sustained a burn injury,there are several legal, financial, and psychosocial factors that can facilitate orprevent a person's return to work. Work Hardening and Work Conditioningprograms can help to identify a patient's abilities and potential problems with

re-entering the work force.

APPROPRIATE REFERRAL:

1. All wounds closed

2. Patient wearing custom pressure garments

3. Most surgeries completed

Patient understands precautions4.

Patient off all pain medications5.,

Patient independent with orthotics/prosthetics6.

PT/OT goals met7.

INTERDISCIPLINARY TEAM APPROACH:

VOCATIONAL COUNSELOR:

A professional vocational counselor can be employed through the StateDepartment of Vocational Rehabilitation or through a private agency. They canassist the burn survivor in identifying if they are able to return to the same job.They can also provide retraining for other employment as well as counseling on

career changes. Vocational counselors can be accessed through the attachedlist of regional phone numbers.

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December, 1994

DIVISION OF VOCATIONAL REHABILITATION, DEPARTMENT OF HUMAN SERVICES

ADMINISTRATION

DIRECTOR'S OFFICE - DENVERField Services

Support Services

TELEPHONE303-620-4153303-620-4158303-620-4187

V/TDD303-866-4153303-620-4158

303-620-4153

FAX303-620-4189303-620-4189303-620-4189

REHABILITATION OFFICESACADEMY PARKALAMOSAAURORABOULDERBUENA VISTACOLORADO SPRINGSCOLORADO SPRINGSDENVER CCBDENVER CYP

DENVER EASTDENVER B/DDENVER WESTDURANGOFORT COLLINSFORT MORGANGLENWOOD SPRINGSGOLDENGRAND JUNCTIONGREELEYLAMARLONGMONTMONTROSE

V/TDD303-988-1299719-589-5150-TTD only303-745-8112

FAX303-986-1299719-589-5158

303-145-8112719-589-4474303-750-0098

303-444-9140719-395-2435719-574-2530719-574-2530303-894-2656

303-894-2656303-894-2656303-894-2656303-934-6854970-247-8324970-223-0718970-867-3069

970-945-9175303-271-4887970-248-7118303-353-5752719-336-7713

303-772-6849970-249-2602

303-452-6191719-544-1634719-544-1634719-254-3350970-522-3738719-846-4432

719-395-2434719-574-2200

719-574-2200303-894-2380303-894-2410303-894-2515303-894-2650303-937-0561970-247-3161910-223-9823970-867-3068

970-945-9174303-271-4888

970-248-7103970-352-5180

719-336-7712303-449-7966970-249-4468

303-452-5875719-544-1406719-544-1406719-254-3358970-522-3737719-846-4431

719-395-2434719-574-3606-TTD only719-574-3606-TTD only

303-894-2380

303-894-2515

303-937-0561970-247-3161970-223-9823970-867-3068

970-945-9174303-271-4888970-248-7103970-353-5750-TTD only719-336-7712303-772-2612

970-249-4468

303-452-5875719-544-1406719-544-1406719-254-3358970-522-3737719-846-4431

PUEBLO CYP/BDPUEBLOROCKY FORDSTERLINGTRINIDAD

REHABILITATION CENTER - 303-937-1226 - v/TDD-303-937-1226 - FAX -303-934-6854

BUSINESS ENTERPRISE PROGRAM - 303-922-3658

REHABILITATION TEACHING AND ELDERLY BLIND - 303-937-1226 - V/TDD - 303-937-1226

DISABILITY DETERMINATION SERVICES - 368-4100 - TDD only 752-5650 - (800)332-8087

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PSYCHOLOGISTS:

41% of work related burn injuries and 30% of non-work related injuries reporthaving emotional difficulty with returning to work. Common concerns are a

preoccupation with safety issues, self esteem, and adjustment to a different levelof functioning. Psychologists can assist burn survivors in the return to workprocess by working on coping and relaxation strategies as well as addressingself esteem issues. A referral to your local psychologist can facilitate a burnsurvivors ad ustment to returnin to the communit .

SOCIAL WORK:

Social workers are an excellent resource to assist the burn survivor in both legaland financial recovery. A social worker can make referrals to the appropriateagencies to provide the patient with such services as temporary housing orclothing vouchers, which can be available through the local Red Cross in theevent of a house fire. Social workers can also assist the burn survivor inapplying for appropriate government funding for covering medical bills.

PHYSICAL/OCCUPATIONAL THERAPISTS:

Therapists are the trouble-shooters in assisting the burn survivor in returning towork. They can help to promote maximal physical functioning for return to work.By obtaining a job description, a therapist can simulate worker roles in the clinic.By having a patient perform repetitive, simulated motions for four to eight hours

per day, a therapist can identify problem areas and provide treatment to addressthose areas. Many times these problems can be missed in the outpatient clinic ifthe tasks are not performed for an appropriate amount of time. For instance,many patients will not have a problem with friction or shearing against theirgarments during short periods of activities, but performing the same activities forlonger periods of time can cause skin breakdown.

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COMMON INTERVENTIONS:

TEMPERATURE EXTREMES:

Many burn survivors will have difficulty regulating their body temperature in

weather extremes. Those persons working in a persistently cold environmentshould wear many layers of clothing for insulation. By layering their clothing,they can easily remove what is no longer necessary once their body warms up.Many patients will complain of increased stiffness in the burned regions in coldtemperatures. It would be recommended these patients perform additionalstretching exercises immediately prior to beginning work.

Those burn survivors who work in a particularly hot environment need to takeseveral precautions to prevent heat exhaustion or heat stroke. These patientsshould drink plenty of non-alcoholic, non-caffeinated beverages throughout theirwork shift. Additional suggestions for keeping cool would include the use of a

fan in their work space and dampening their garments with a water bottlethroughout their shift. Placing a cold pack on the head or the wrist can help tocool the entire body.

SKIN PROTECTION:

Burn survivors need to take extra precautions to protect their skin whether theyare working or playing. The use of a sunscreen with SPF of 15 or higher isrecommended on all burned regions, as they tend to burn more readily. Whenworking with detergents and/or chemicals, rubber gloves and/or a protective suit

should be worn over the person's custom pressure garments.

SKIN INTEGRITY:

Hypertrophic scars tend to have problems with friction and shearing. The areasmost commonly affected are the elbows, metacarpal phalangeal joints, kneesand heels. To help prevent shearing, a patient can wear panty hose under theirgarments. While this can get a bit warm, it decreases shearing and makes theapplication of the garments easier. Patients can also use silicone gel pads orTelfa pads on high friction areas. See the splinting catalogs listed in theSPLINTS section for availability of gel pads.

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FACTS ABOUTTHE AMERICANS WITH DISABILITIES ACT

Title I of the Americans with Disabilities Act of 1990, which takes effect July 26, 1992,prohibits private employers, state and local governments, employment agencies and laborunions from discriminating against qualified individuals with disabilities in job application

procedures, hiring, firing, advancement, compensation, job training, and other terms,conditions and privileges of employment. An individual with a disability is a person who:

Has a physical or mental impairment that substantially limits one or moremajor life activities

Has a record of such an impairment; or Is regarded as having such impairment.

A qualified employee or applicant with a disability is an individual who, with orwithout reasonable accommodation, can perform the essential functions of the job inquestion.Reasonable accommodation may include, but is not limited to:

Making existing facilities used by employees readily accessible to andusable by person with disabilities

Job restructuring, modifying work schedules, reassignment to a vacantposition;

Acquiring or modifying equipment or devices, adjusting or modifyingexaminations, training materials, or policies, and providing qualifiedreaders or inter reters.

An employer is not required to lower quality or production standards to make anaccommodation, nor is an employer obligated to provide personal use items such as glasses or

hearing aids.

PRE-EMPLOYMENT INQUIRES AND MEDICAL EXAMINATIONS

Employers may not ask job applicants about the existence, nature or severity of a disability.Applicants may be asked about their ability to perform specific job functions. A job offer may beconditional on the results of a medical examination, but only if the examination is required for allentering employees in similar jobs. Medical examinations of employees must be job related andconsistent with the employer's business needs.

DRUG AND ALCOHOL ABUSE

Employees and applicants currently engaging in the illegal use of drugs are notcovered by the ADA, when an employer acts on the basis of such use. Test for illegal drugsare not subject to the ADA's restrictions on medical examinations. Employers may holdillegal drug users and alcoholics to the same performance standards as other employees.

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EEOC ENFORCEMENT OF THE ADA

The U.S. Equal Employment Opportunity Commission will issue regulations to

enforce the provisions of Title I of the ADA on or before July 26, 1991. The provisions takeeffect on July 26, 1992, and will cover employers with 25 or more employees. On July 26,1994, employers with 15 or more employees will be covered.

FILING A CHARGE

Charges of employment discrimination on the basis of disability, based on actions

occurring on or after July 26, 1992, may be filed at any field office of the U.S. EqualEmployment Opportunity Commission. Field offices are located in 50 cities throughout theUnited states and are listed in most telephone directories under U.S. Government.Information on all EEOC-enforced laws may be obtained by calling toll, free on 800-USA-EEOC. EEOC tool free TDD number is 800-800-3302. For TDDcalls from the Washington,D.C.Metropolitan Area, dial (202) 989-4399 (TDD).

EEOC-FS/E-5December 1990

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Rights DivisionCoordination and Review Section

AMERICANS WITH DISABILITIES ACT REQUIREMENTS

FACT SHEET

EMPLOYMENT

Employers may not discriminate against an individual with a disability in hiring or promotion ifthe person is otherwise qualified for the job.

Employers can ask about one's ability to perform a job, but cannot inquire if someone has a

disability or subject a person to tests that tend to screen out people with disabilities.

Employers will need to provide ''reasonable accommodation" to individual with disabilities.This includes steps such as job restructuring and modification of equipment.

Employers do not need to provide accommodations that impose an ''undue hardship'' onbusiness operations.

Who needs to comply?

All employers with 25 or more employees must comply, effective July 26, 1992.All employers with 15-24 employees must comply, effective July 26, 1994.

TRANSPORTATION

New public transit buses ordered after August 26, 1990, must be accessible to individualswith disabilities.Transit authorities must provide comparable paratransit or other special transportation services toindividuals with disabilities who cannot use fixed route bus services, unless an undue burden woulresult.

Existing rail systems must have one accessible care per train by July 26,1995.New rail cars ordered after August 26, 1990, must be accessible.

New bus and train stations must be accessible.

Key stations in rapid, light, and commuter rail systems must be made accessible by July 26, 1993,with extension up to 20 years for commuter rails (30 years for rapid and light rail).

All existing Amtrak stations must be accessible by July 26, 2010.

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PUBLIC ACCOMMODATIONS

Private entities such as restaurants, hotels, and retail stores may not discriminate againstindividuals with disabilities, effective January 26, 1992.

Auxiliary aids and services must be provided to individuals with vision or hearing

impairments or other individuals with disabilities, unless an undue burden would result.

Physical barriers in existing facilities must be removed, if removal is readily achievable. If not,

alternative methods of providing the services must be offered, if they are readily achievable.

All new construction and alterations of facilities must be accessible.

STATE AND LOCAL GOVERNMENTS

State and local governments may not discriminate against qualified individuals with disabilities.

All government facilities, services, and communications must be accessible consistent with therequirement of Section 504 of the Rehabilitation Act of 1973.

TELECOMMUNICATIONS

Companies offering telephone service to the general public must offer telephone relay services to

individuals who use telecommunication devices for the deaf (TDDs) or similar devices.

This document is available in the following accessible formats:

Braille Large print Audio tape Electronic file on computer disk

and electronic bulletin board (202)-514-6193

For more information about the ADA contact:

U.S. Department of JusticeCivil Rights Division

Coordination and Review SectionP. 0. Box 66118

Washington, D.C. 20035-6118(202) 514-0301 (voice)(202) 514-0381 (TDD)

(202) 514-0383 (TDD)

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MODALITIES


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MODALITIES

As with any other patient, modalities are an excellent way to assist in preparinga region for treatment. However, burn survivors require a note of caution whenusing certain modalities.

COLD MODALITIES:It has been our experience, that few burn survivors can tolerate the use of coldmodalities, such as cold packs, ice massage, etc. The initial vasoconstrictionthat accompanies a cold modality reportedly makes the burned region feel stiffer.

It is more comfortable for the patient to use cold modalities on other concurrentinjuries. As always, be sure to check skin tolerance where sensation may beimpaired.

HEAT MODALITIES:

An area that has hypertrophic scarring also has impaired sensation and analtered vascular system. It is important to be cautious when using heatmodalities over these areas as the scarred region will have difficulty dissipatingheat and can more readily sustain an additional burn injury. As shown on thevideo, use extra toweling with hot packs. Use a lower intensity with other heat

modalities, such as ultrasound. Check the skin frequently for blistering.

ELECTRICAL STIMULATION:TENS can be used for pain control with burn survivors. Be aware that newlyhealed skin may be more sensitive than other areas. Also, burned areas containmany unmyelinated nerve endings which can be hypersensitive and can causegreat discomfort when using electrical current. Be sure to test the TENS on asmall area on the patient's intact skin before using it on burned areas. It hasbeen our experience that using TENS on nerve roots for more diffuse paincontrol works very well. F.E.S. can be used for muscle re-education using thesame precautions.

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PARAFFIN:

The use of paraffin has several benefits when used properly. It works well toheat the collagen fibers of the scar in preparation for stretching. It reportedlyrelieves superficial stiffness and aches. Also, it contains mineral oil whichmoisturizes the scar. As with the other heat modalities, use a lower temperatureand check the skin frequently for signs of burning. Paraffin works especially wellwhen used in conjunction with a prolonged, low load stretch.

IONTOPHORESIS:

There has been little research in the use of iontophoresis with hypertrophic burnscars. Dexamethasone has traditionally been injected into persistent

hypertrophic scars. This process is painful. Our facility has had some successwith iontophoresis using dexamethasone over scarring to decrease the localinflammation. Also, acetic acid in a 2% solution (distilled vinegar) has beenused with the same results. A low intensity should be used to protect thepatient's skin from burns.

FLUIDOTHERAPY:

Fluidotherapy can be used with the same precautions as other heatmodalities once the wounds are completely closed. Even superficial openareas are a contraindication to fluidotherapy.

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We Practice What We TeachUNIVERSITY HOSPITAL

nformation for Patients

HOME PARAFFIN TREATMENT

MATERIALS NEEDED

1.

3.2.

4.5.

Crock Pot

Candy Thermometer - EssentialParaffin Wax

TowelsSaran Wrap

DIRECTIONS FOR APPLICATION

Heat paraffin wax in crock pot to approximately 120 Fo. Use a candy thermometer

to measure temperature.1.

2. Turn off crock pot. Let paraffin cool approximately 1-2 minutes.

3. Place affected area on stretch position.

4. Using your hand (unburned) or a paintbrush paint wax on to a 1/4" thick coat.

Wrap coated area with Saran wrap and two layers of towels.5.5.

Leave wrapped area on-stretch for twenty minutes.6.

7. You can do this safely 1x/day. Exercise immediately after paraffin treatment.

8. Paraffin wax is reusable, but only for one patient. No sharing with family or friends.

Any questions or concerns, please call your therapist ________________ at _____________.

University of Colorado Health Sciences Center - Ninth Avenue at Colorado Boulevard - Denver. Colorado 303-329-3066

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ACTIVITIES OF DAILY LIVING


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ACTIVITIES OF DAILY LIVING

Activities of Daily Living, or ADL's, are the foundation to a burn survivor'ssuccessful outcome. The ability to perform ADL's provides us with increased self-esteem, self worth, and a sense of independence. When performing activities

such as feeding, grooming, or dressing, it is important to realize the burn survivoris working on all of his/her therapeutic goals such as: increase range of motion,increase strength, increase fine motor coordination, increase balance, etc. As acare provider, we must encourage him/her to reach the highest level ofindependence in all ADL's. This may require adaptive equipment, change in aroutine and modification of the task, as well as lots of encouragement due tofrustration and pain.

The video demonstrates a small portion of activities, modifications and equipment.

ADL's include:EatingDressingGroomingBathingToileting

Toilet/tub mobilityDrivingHomemaking skillsVocational skills

Modifications: This may include lowering frequently used items from a high shelf,moving a bathroom mirror for better visibility, or moving furniture for increasedsafety in mobility. Modifying a person's environment involves creativity and

common sense. The patient may be your best resource to adaptations that theyhave thought of in their home.

Equipment:As therapists, we try to anticipate the burn survivor's equipmentneeds. However, we can not always know what they may need when actually athome or their functional status may change as mobility and range of motionincrease. The following catalogs on page 30 are helpful in determining andchoosing a patients equipment needs.

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REFERENCES FOR ADAPTIVE EQUIPMENT

Catalogs

1. Sammons/Preston 1-800-323-5547

2. Smith, Nephew and Roylan 1-800-558-8633

3. North Coast Medical 1-800-821-9319

4. Byrd and Cronin 1-800-328-1095

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SPLINTS

Splinting of a joint or multiple joints is used to:

1. Prevent contractures;

2. Prevent deformities;

3. Apply pressure/stretch to the burn areas for scar control.

Remember, the position of comfort is also the position of contracture for theburn survivor. Therefore, he/she may not like to wear the splint provided. It isimportant to encourage and insist on splint wear as it will place the joint in atherapeutic and functional position. Education is the key to compliance withsplint wear.

The splints shown in the video are the most commonly used on an outpatientbasis.

Positional hand splint: a prefabricated splint to put the hand and wrist in aposition of function. Keep in mind the splint has full contact with the palmand web space of the hand.

Neck conformer: custom-made for the burn survivor, this places the neck inslight extension to decrease the potential for a neck flexion contracture andwebbing of theneck. Again, the splint must be in full contact with the neck in

order to be effective.

Axillary conformer: A custom-made splint to prevent contractures of theshoulder. Although not very comfortable, this splint is of utmost importanceto stretching the region. Non-compliance with this splint often results insurgery to release axilla contractures.

See the chart on proper positioning page 32 for additional positioning ideas.*****

A product and materials list is also provided for additional products and splintsyour facility may want to use to assist with proper positioning.

Splinting and Positioning are to be performed continuously until the burnsurvivor can easily perform range of motion of the joint within a normal limit.At that time splinting and positioning can be decreased or discontinued.

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UNIVERSITY HOSPITAL

POSITION OF COMFORT = POSITION OF CONTRACTURE

JOINT POSITION OFCOMFORT

THERAPEUTIC POSITION

Neck Flexed Extended: towel roll, conformer

Shoulder Flexed, adducted

Int. Rotated

Abduct 90o: wedge

conformer, lat. arm support

Elbow Flexed

Supinated

Extended -5opillow, splint

Pronated

Wrist Flexed Extended 30 60osplint, washcloth

Hand Clawed: MCP ext

PIP + DIP Flex

Thumb adducted

MCP Flexed 70o - splint

PIP, DIP extended splint

Thumb opposed; splint, washcloth

Hip Flexed, IR

Adducted

Extended, Neutral Rotation and

Abduct; Towel roll

Knee Flexed Full Extension

Ankle Plantar flexed

Inverted

Dorsiflexed 0o

Neutral Ever/Invers foot pillow,

Splint

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UNIVERSITY HOSPITALWe practice what we teach


BURN CARE

CARING FOR YOUR SPLINT

Your splint was custom made for you. Please read the following instructions to learn about thecare of your injured area and your splint. Your splint serves the purposes of assuring properbody position and preventing contractures. If you have a doubt as to how it fits, please contactyour primary therapist, _________________, at ______________________.

Precautions

Contact your therapist if your splint causes any of the following:

Excessive swelling

Severe pain

Pressure area or sore

Excessive stiffness

Change in skin color

Adjustments

Please notify your therapist if you feel an adjustment is necessary.

Care of Your Splint

Keep it away from open flames. It will melt.

Keep it away from extreme heat. It will lose its shape in temperatures over 139oF.

Do not leave it in direct sunlight, such as in the window or on a dashboard of the car.

Cleaning Your Splint

Your splint may be cleaned with lukewarm water and soap. Do not submerge your

splint in hot water over 139

o

F. For ink or hard-to-remove spots, use a cleanser with chlorine

If your splint is lined with foam, it may be cleaned easily by putting it in lukewarmwater and gently rubbing the surface with a bar of soap.

Your splint also may be cleaned with alcohol swabs.

University of Colorado Health Sciences Center 0Ninth Avenue at Colorado Boulevard 0 Denver, Colorado * 303-329-3066

Committed to equal employment Opportunity and affirmative action,

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Wearing Your Splint

Your Splint should be worn:

_____Full-time, day and night.

_____Full-time, except for brief periods of exercises, as instructed by therapist and physician

_____At night only.

_____Other schedule:

This information sheet was developed and funded by:


June,199534


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PRODUCT/MATERIALS LIST

SPLINTS AND POSITIONING

DEVICES


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PRODUCTS/MATERIALS LISTSPLINTS AND POSITIONING DEVICES

Soft foam Neck CollarCan use T-Form

Available in 1/2'', I'', 2'', 3" thicknessand x-soft, soft, medium densitiesAliMed, Inc.297 High StreetDedham, MN 02026(800) 225-2610

Interdigital Web SpacersDental Cotton Rolls #2 Medium, 1 1/2-Length, 3/8'' DiameterTidi Products, Inc.P. O. Box 2020Troy, MI 38083(800) 837-1701

Rolyan Finger Rehab SystemSmith and Nephew Roylan, Inc.One Quality Drive P.O. Box 53022

Germantown, WI 53022(800) 558-8633FAX (800) 545-7758

Microstomia Prevention ApplianceMPA, Inc.6526 Meadowbrook DriveDallas, TX 75240(214) 458-0757

Mouth Stretch/MaintainerTherabite, Inc.Suite 3023415 Westchester PikeNewtown Square, PA 19073(800) 322-2650(610) 356-9500 in PAFAX (610) 356-4292

Hip Abduction PillowsDisposable or reusableBird and Cronin Medical Products, Inc.Attn: Marcy Revere, Representative

1200 Trapp RoadEagan, MN 55121(800) 328-1095FAX (612) 688-9855

Spandex I'm Lip and Cheek RetractorWorldwide Dental, Inc.Suite A12890 Automobile Blvd.Clearwater, FL 34622(800) 328-2335

Knee ImmobilizersSeveral models abailableBird and Cronin Medical Products, Inc..See address above

Molded Plastic Hip

Abduction SplintCamp International, Inc.P.O. Box 89Jackson, MI49204(800) 492-1088

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OUTCOMES AND INTERVIEWS


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OUTCOMES AND INTERVIEWS

The first two patient outcomes are examples of two patients who had similar injuries.Both patients were burned over 50% total body surface area primarily to the upper bodyand requiring multiple skin grafts to close their wounds. It is important to note thatRob required skin grafts to his face while Harry's face healed spontaneously. Also,Rob's hands were more severely involved. Both were treated by the same therapist,however Rob refused therapy intervention for the majority of this burn rehabilitation.

The last two interviews are designed to give various examples of other patients viewsof burn rehabilitation. These segments assist the care providers and the burn survivorin understanding the comments and perspectives on surviving a burn injury and therehabilitation process.

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REFERENCESAND

FURTHER INFORMATION


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REFERENCES AND FURTHER INFORMATION

The team at University of Colorado Hospital Burn Unit appreciates your help in

assisting the burn survivor in returning to the community and work. If you have anyquestions or problems, feel free to contact us at the following locations.

Burn UnitUniversity of Colorado Hospital4200 East Ninth Ave.Denver, CO 80262(303) 372-0001

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Selected References:

Bowden, M.L., Thompson, P.D., & Prasad, J.K. (1989). Factors influencing return toEmployment after burn injury. Archives of Physical Medicine and Rehabilitation,(70), 772-774.

Burgess, M. C. (1991). Initial management of a patient with extensive burn injury.Critical Care Nursing Clinics of North America, 3 (2), 165-179

Calistro, A.M. (1993). Burn basics and beyond. RN, March: 26-32

Chapman, R. (1991). The Americans with Disability Act: Civil rights for persons with disabilities. The Colorado Lawyer, 2234-2236.

Cheng, S., & Rogers, J. (1989). Changes in occupational role performance after asevere burn: A retrospective study. American Journal of Occupational Therapy,43 (1). 17-23.

Choiniere, M., Melzak, R., Rondequ, J., Girard, N., & Paquin, M.J. (1989). The pain ofburns: Characteristics and correlates. The Journal of Trauma, 29 (11), 1531-1539.

Dobkin de Rios, M., & Achauer, B. M. (1991). Pain relief for the Hispanic burn patientusing cultural metaphors. Plastic and Reconstructive Surgery, 88 (1), 161-164.

Duncan, D.J., & Driscoll, D.M. (1991). Burn wound management. Critical Care Nursing Clinics of North America, 3 (2), 199-220.

Fisher, S., & Heim, P. (1984). Comprehensive Rehabilitation in Burns. Baltimore:

Williams and Wilkens.

Helm, P.A., & Walker, S. (1992). Return to work after burn injury. Journal of Burn Careand Rehabilitation, 13 (1), 53-57.

Jacobs, K, et. al. (1992). Statement: Occupational therapy services in work place. American Journal of Occupational Therapy, 47 1086-1088.

Johnson, C. L. (1984). Physical therapists as scar modifiers. American PhysicalTherapy Association Journal, 64 (8), 1381-1387.

Key, G. (1991). Working hardening or work conditioning: Semantics or reality? Physical

Therapy Today, 14 (2), 12-16.

Malick, M., & Carr, J. (1 982). Manual on Management of the Burn Patient. Pittsburgh:

Harmarville Rehabilitation Center.

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Malick, M., Maude H. (1980). Flexible elastomere molds in burn scar control. American Journal of Occupational Therapy, 24, 603-608.

Munster, A.M. (1993). Severe burns. Baltimore: The Johns Hopkins University Press.

Patterson, D.R. (1992). Practical applications of psychological techniques in controlling burn pain. Journal of Burn Care and Rehabilitation, 13 (1), 13-18.

Simmons, D. (1983). Family adjustment when the breadwinner is burned. OccupationalHealth Nursing, 38-40.

Smith, P. (1990). Work Hardening. In: L. Williams-Pedretti & B. Zoltan. OccupationalTherapy: Practice Skills for Physical Dysfunction. St. Louis: The C.V. Mosby Co.,272-281.

Velozo, C.A. (1993). Work evaluations: Critique of the state of the art functionalassessment of work. The American Journal of Occupational Therapy, 47, 203-

209.

Voss, D.E., lonta M.K., Myers, B.J. Proprioceptive Neuromuscular Facilitation: Patterns

and Techniques, Third Edition, Philadelphia, Harper and Row Inc., 1985

Wachtel, T.L., Kahn, V., & Frank, H.A (1983). Current Topicsin Burn Care. Rockville,Md: Aspen Systems Corp.

Watkins, P.N., Cook, E.L., May S.R., & Ehleben, C.M. (1989). Psychological stages inadaptation following burn injury: A method for facilitating psychological recoveryof burn victims. Burn Care Commentary - A Forum for Burn Care Issues, 5 (1),

1-23.

Wright, P.C. (1984). Fundamentals of acute burn care and physical therapymanagement. American Physical Therapy Association Journal, 64 (8), 1217-1231.

Zeller, J., Sturm, G., & Cruse, C.W. (1993). Patients with burns are successful in work hardening programs. Journal of Burn Care and Rehabilitation, 14 (2), 189-196.

an easy guide to outpatient burn rehabilitation

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