burn rehabilitation

Lucretia FitzpatrickPatrick MurphyJill AndrowickDeborah GoldblumPatricia WardiusJohn Wijtyk

Chapter 94

Burn Rehabilitation

There are approximately 1.25 million burn injuries in theUnited States yearly, accounting for 51,000 acute hospitaladmissions and 5500 deaths (1). The cause and the risks ofburn injury and death are influenced by age, economic cir-cumstances, and occupation, with the greatest risk beingeconomically disadvantaged. Seventy-five percent of allburn-related deaths are due to house fires, with young chil-dren and the elderly being most vulnerable. Flame burn isthe predominant type of injury seen in patients admittedto burn centers, followed by scalding with hot liquids (2).

The majority of burns can be treated on an outpa-tient basis. However, the extent of the burn, or a compli-cating factor such as an associated injury or extreme age oryouth, may warrant hospital admission. Inhalation injury,concomitant trauma, and significant preexisting medicalconditions mandate burn center care for patients withburns of lesser extent (2).

Major burns are best cared for in a burn treatmentcenter where the specialized skills of a multidisciplinarystaff and burn-specific equipment ensure optimal survival.Major burns are classified as follows:

1. Greater than 10% of total body surface area(TBSA) at an age younger than 10 years or olderthan 50 years

2. Greater than 20% of TBSA in patients at an inter-vening age

3. Significant burns of the face, hands, feet, genitalia,perineum, or major joints

4. Full-thickness burns greater than 5% of TBSA5. Significant electrical injury6. Significant chemical injury

Burns are coagulative lesions involving surface layersof the body. They are usually caused by thermal agentsbut can also result from chemical agents, radiation, andelectrical injury when electrical energy is transferred tothermal energy.

The skin is the largest organ of the human body andconsists primarily of two layers, the epidermis and thedermis. The superficial cells of the epidermis are cells thatarise from deeper germinal layers of keratinocytes. Theunderlying dermis consists of fibrous connective tissue,blood vessels, ataneous nerves, and the epithelialappendages (sweat glands and hair follicles). The epithelialcells that line these appendages can serve to repopulate lostepithelium when the entire epithelial layer is involved in aburn injury (3).

Clinically, burns are classified based on depth andextent of tissue damage (4). Burn depth classificationsinclude superficial, partial thickness, and full thickness(Table 94-1). Superficial (or first-degree) burns, such as asunburn, are painful. This type of burn is limited to theepidermis and heals spontaneously without scarring.Partial-thickness burns include the entire epidermis andvariable portions of the dermis. They can be superficial ordeep. Superficial partial-thickness burns are usually morepainful but can heal spontaneously from the epidermal

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Figure 94-1. Full-thickness burns sustainedfrom a flame injury. Eschar iswhite/brown and leather-likein appearance.

Table 94-1: Type of Burn Wounds

DEGREE TYPE LAYER OF INVOLVEMENT APPEARANCE HEALING

First Superficial Epidermis Red Spontaneous <>1wkBlanches with pressureSensitive to air, light, touch

Second Partial-thickness Epidermis and upper layer Red or pink skin color Spontaneous 5–21 dayssuperficial of dermis Blistered or mottled

Blanches wellSensitive to touch

Second Deep Destroys epidermis and Soft elastic texture Occurs from dermaldeeper dermal structures Eschar appendages

Wavy white to red color May require grafting:Sensitive to pressure, not if wounds are not

to pinprick healed within 21 daysLarge thick blisters —potental for scarring

Third Full thickness Epidermis and entire dermis White, tan, black charred Slowly from wound edgesSubcutaneous tissue No blanching <>10–35 days

Dry texture Requires graftingLeathery, thrombosed

blood vessels visibleWound is anesthetic—nerve

endings destroyedFourth Bone All epidermis Black Requires grafting or

All dermis Necrotic amputationSubcutaneous fat May need a muscle flapBone for coverage

appendages anchored deep in the dermis. With deeppartial-thickness injury, spontaneous healing is slow, asfewer epidermal cells remain and more scarring mayoccur. A full-thickness burn destroys both the epidermisand dermis; therefore, healing can only occur from thewound edges (Fig. 94-1). Skin grafting is needed to closethe wound (3). Surgical intervention may be required foreither a deep partial-thickness wound or full-thicknesswound.

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An inhalation injury is a chemical burn to theairways and can result in mucosal irritation, airway inflam-mation, interstitial edema, or in most severe injuries,mucosal necrosis and sloughing. Increased secretions canlead to distal airway obstruction, atelectasis, and broncho-pneumonia. Ciliary function is impaired and risk for infec-tion, such as tracheobronchitis, is high. Bronchospasmsand bronchial edema can lead to hypoventilation. Cough-ing, pulmonary toilet, secretion management, bronchodila-

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tor therapy, ventilator assistance, and infection surveillanceare crucial during the initial postinjury phase. Risk forinfection can last for several weeks (5).

WOUND CAREWounds can be treated with an “open” or “closed” tech-nique. An open technique is sometimes used for a smallsuperficial burn, where serum dries to form a scab andserves as an adherent protective dressing. This treatmentcan be uncomfortable and unsightly (5).

Closed methods for wound care consist primarily ofusing 1) topical antimicrobial agents and dressings, 2) bio-logic dressings, and 3) synthetic dressings (Tables 94-2 and94-3). Topical antimicrobial agents include silver nitrate,silver sulfadiazine, mafenide acetate (Sulfamylon),mupiricin (Bactroban), bacitracin, gentamicin sulfate(Garamycin) ointment, and Neosporin. One of the mostcommon agents utilized is silver sulfadiazine (Silvadene),which provides broad antimicrobial coverage and assists inbringing eschar to the surface where it can be débrided.Once the eschar is débrided, the wound can then becovered with Xeroform, which assists in drying the tissueand promotes healing. The involved area can be wrappedin Kerlix or gauze dressing as needed. Fungal infections,which can occur, may respond to an equal-part mixture ofnystatin, hydrocortisone, and mupiricin. With each dressingchange, the old topical agent must be removed and thewound cleansed before reapplication. This method affordsthe opportunity for close surveillance of the wounds. Theantimicrobial action lasts from 8 to 12 hours and the fre-quency of dressing changes will vary among institutions.

Biologic dressings consist of viable or frozen skinallografts and xenograft (pigskin). These can be used as a

Chapter 94 Burn Rehabilitation

Table 94-2: Anti

DRESSING ADVANTAGES

Silver nitrate (solution) Excellent antibacterial spectrumNo allergic reactions, no pain

Sliver sulfadiazine Broad antibacterial spectrumcream (Silvadene Minimal sensitivity, allergic reactioSSD) Eschar will dry after discontinuatio

Gram negative

Mafenide Penetrates eschar wellacetate (Sulfamylon) Excellent gram-negative coverage

Good antimicrobial actionNitrofurazone Dries wound well

Good antibacterial spectrumMupiricin (Bactroban) Effective against gram-positive org

especially streptococcus and staphylococcus

temporary skin covering until use of autografts is indi-cated. They are effective in promoting wound healing inall partial-thickness wounds. Biologic dressings may beused to test the readiness of a wound for autografting. Fur-thermore, these dressings reduce fluid and electrolytelosses, promote healing under grafted areas, minimizepain, and maintain sterile conditions (6).

Synthetic dressings include Opsite (semipermeablepolyurethane film), Duoderm, Comfeel (hydrocolloid dress-ing), Elasto-gel (hydrogel dressing), and Biobrane (7,8). Bio-brane is composed of knitted elastic nylon bonded to aSilastic semipermeable membrane coated with collagenpolypeptides (Fig. 94-2). It will adhere to a viable woundsurface, reduce fluid loss, and provide a wound vaporbarrier. This minimizes fluid accumulation under the dress-ing while preventing the passage of bacteria from the envi-ronment to the wound surface. In selected wounds, thistreatment may have some advantage over traditionalantimicrobial dressings. Biobrane is usually placed on awound under sterile conditions while using an anesthetic.

Wound infections can impede healing, delay woundclosure, and cause skin graft loss. Pseudomonas species,Staphylococcus aureus, Escherichia species, Proteus mirabilis, andStreptococcus faecalis are the most common agents causingwound infections. Bacterial contamination leads to anincreased inflammatory response and local release ofcytokines and proteases, and can lead to local tissuedamage. Local infection alters systemic metabolic activityand nutritional intake and can alter healing (7). Both localand systemic defenses against infection are impaired after amajor burn. Sepsis is a leading cause of morbidity andmortality during the postburn period, owing to the loss ofthe skin barrier to microbial invasion, the decreasedimmunosuppressive state, and the presence of invasive

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microbial Agents

DISADVANTAGES

Ineffective treating established infectionsCauses staining or bleaching of chloride ionsMessy, poor penetrationDelays spontaneous separation of eschar, thus

n delaying wound closingn Reported transient leukopenia

Ineffective against establishment of wound sepsisDoes not penetrate eschar wellMay cause pain (stinging) 10% allergic rateInhibits carbonic anhydrase results in metabolic

acidosisMay cause rash

anisms, No effect on gram-negative bacteria

Table 94-3: Topical Dressings

AGENT ADVANTAGES DISADVANTAGES PROPERTIES

BioBrane Transparent Wound must be débrided and SemipermeableInexpensive cleaned in sterile environment Silcone membraneAvailable in variety of Performed in operating room Bonded to nylon

sizes Fabric coated with collagenAdheres to woundBarrier to pathogenic

organismsOP-SITE Inexpensive Not permeable Semipermeable polyurethane

Transparent Depends on location filmNeeds good 1-inch border

Cadaver (graft) Lower infection rates Availability Human skinTemporary dressing Rejection

ExpensiveFragileSurgical procedure

Xenograft Lower infection rates Rejection of tissue Pig skinClosely resembles human Fragile

skin Not readily availableTemporary dressing

Duoderm Barrier to pathogenic Lower success with larger burns Hydroactive occlusivebacteria dressing

Higher absorption rate Unable to view progress of Water resistantInfrequent dressing changes wound Skin contact, adhesive inner

layerXeroform Direct application to Minimal antibacterial effect Fine-mesh absorbent gauze

wound surface when used alone impregnated with 3% Sterile prepackaged bismuth tribromophenateDries wound in nonmedicinal

petrolatum blendAdaptic Can be combined with No antibacterial effects when Meshed open-knitted fabric

topical agents used alone made of cellular-acetate-Will not stick to wound rayon, petroleum basedSterile prepackaged

Scarlet red Applied directly to wound Messy, stains Fine-mesh absorbent gauze Sterile prepackaged Patient sensitive to azo dyes impregnated with 5% Helps promote epithelial scarlet red in nonmedicinal

cell growth No antibacterial effects blend of lanolin, olive oil, and petrolatum

N-TERFACE Can be combined with No antibacterial effects when Perforated high-densityConformant 2 topical agent used alone polyethylene sheeting

Will not stick to wound NonadherentAllows wound to be observed

Vaseline gauze Applied directly to wound No antibacterial effect Petroleum basedWill not stick to wound

catheters. The most common sites of infection are thelungs, the burn wound, and vascular catheters (5). Cell-mediated immunity is impaired, as is macrocyte andphagocyte function. Complement, required for chemotaxisand phagocytosis, is depleted after a large burn. Centrallines, endotracheal tubes, and urinary catheters all serve assites for colonization and possible infection (5).

Systemic antibiotics should be used as indicated.Blood cultures should be obtained on admission and thenas needed. Side effects as well as overall clinical responseneed to be monitored closely. It is not unusual for multipleantimicrobial agents to be used together for broad-spectrum coverage.


NUTRITIONNutritional support can affect the outcome of a burn-injured patient. Providing the nutritional requirements ofthese patients is often difficult. The metabolic response tothermal injury can be greater than that seen with serioussepsis (9). Nutritional support is ideally managed by theenteral route. Parenteral or central nutrition may be neces-sary in the patient with a burn exceeding 50% of TBSA.Increased metabolic activity usually peaks between theseventh and tenth postburn days, and caloric requirementsshould be completely met by this time. The magnitude ofincrease is directly related to burn size and depth.

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Figure 94-2. Biobrane utilized for paincontrol in a Stevens-Johnsonsyndrome patient.

Figure 94-3. An example of culturedepithelial autografting. Theepithelial cells are placed ona petroleum jelly gauze thatresembles a “patch”-likeconfiguration.

However, young patients appear to generate a higher post-burn metabolic rate than elderly patients (3). Continuousmonitoring is needed to promote wound healing throughthe acute and rehabilitative phase.

GRAFTINGThe goal of burn wound care is to permanently close thewound. For full-thickness burns, autografts provide ulti-mate wound closure. Allografts, xenografts, and artificialskin substitutes are temporary dressings used until they canbe replaced by autografts. Mechanical dermatomes areused to harvest skin from the donor site and skin meshersare used to expand the size of the autograft and allow forcoverage of wider areas (10). The skin at a donor site has a


definite thickness, and is thinner in the very young andelderly. Each time a graft is harvested from a donor site,the skin becomes thinner or is replaced by scar tissue (11).With large burns, donor sites are limited; therefore, cul-tured epithelial autografting (CEA) may be employed (Fig.94-3). With this technique, a skin fragment no larger thana postage stamp can be grown to a square meter in thecourse of a few weeks. This in vitro process is commer-cially available but costly, and time is needed to grow thegrafts. Because only epithelial cells are utilized, CEA isfragile and nonadherence may occur (12). Periods ofimmobilization and bed rest may be significantly longer ascompared to split-thickness grafting, leading to longerperiods of rehabilitation. Despite its disadvantages, survivalrates have increased and cosmetic outcomes are improved.A new development in wound management has been the

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Table 94-4: Common Short- and Long-Term Goals

Short-term goalsControl painPrevent contractures, deformityPreserve joint mobilityPreserve strength, coordination, endurancePromote ADL participationPromote wound healingMinimize edemaPatient and family education

Long-term goalsMinimize burn scar formationIncrease strength, coordination, enduranceIncrease independence with ADLsCompensate for physical impairmentAdjustment to disabilityReintegration into societyEducation regarding skin care and scar management

ADL = activity of daily living.

creation of Integra artificial skin, which received Food andDrug Administration (FDA) approval in March 1996.Integra is a biologic, bilayer skin replacement system. Thedermal layer is composed of fibers of bovine tendon colla-gen and glycosaminoglycan and serves as a template forfibroblasts and capillaries from the uninvolved dermis. Ashealing occurs, a neodermis is formed as new collagenreplaces the bovine collagen. The temporary epidermallayer is composed of silicone and functions to controlmoisture loss from the wound. After 14 to 21 days, ade-quate vascularization of the dermal layer has occurred.The silicone layer is removed and a thin, meshed layer ofepidermal autograft is placed over the neodermis. Theadvantage is immediate physiologic wound closure untildonor skin is available, thus decreasing pain and the risk ofinfection. The epidermal autografts used also allow forthinner, quicker-healing donor sites and improved cosmeticand functional outcome (13).

ROLE OF REHABILITATION IN BURN CARERehabilitation of a burned patient is a process that beginson arrival to the burn treatment center, continues through-out the hospital course, and often continues for years fol-lowing injury. A team approach ensures a comprehensiveand holistic perspective for each individual who is facedwith this significant impairment. Team members caninclude general and plastic surgeons, pulmonary and criti-cal care specialists, physiatrists, psychologists, nurses, socialworkers, occupational therapists, physical therapists, speechtherapists, dietitians, orthotists, dysphagia services, voca-tional counselors, and aesthetic therapists. Rehabilitationprofessionals are an integral part of the acute phase inburn care and serve to complement other members of theteam who provide critical care and surgical intervention.Survival among burn patients has improved dramatically,but equally important is for rehabilitation efforts to trans-late into returning survivors to the highest functional leveland quality of life.

Rehabilitation should be viewed on a continuumwith short- and long-term goals being established (Table94-4). The ultimate goal is to heal the wound while main-taining and restoring maximal function. Acutely, life-threat-ening problems may hamper rehabilitation at times. In thesetting of medical instability, restorative intervention maybe passive in nature, with the patient becoming moreactive in the rehabilitative program as the conditionpermits.

Occupational and physical therapists may beinvolved in all stages of patient care and rehabilitation.Therapists begin their assessment of a patient during theacute phase of injury in conjunction with medical manage-ment. Patient evaluation begins with observation of theextent and location of the wound as well as its effects onjoint range of motion (ROM), mobility, and activities ofdaily living (ADLs). In the case of electrical injury, muscle


strength and sensation are assessed. A treatment plan isdeveloped based on a comprehensive evaluation withongoing assessment and modification.

Therapeutic exercise is a vital part of the burnpatient’s care because contractures and resultant loss offunction can occur rapidly. Burn wound depth and loca-tion are determinants of the type and intensity of exercise.Deep partial- and full-thickness wounds have a higher inci-dence of decreased joint motion and scar contracture (Fig.94-4). Therefore, the therapist must prioritize specific areasto exercise.

During the acute phase, ROM exercises are initiatedwith the goal of minimizing edema to ensure functionalROM. ROM may be passive, active-assisted, or active,depending on a patient’s medical status (pain medications,affect, associated trauma) or wound status (thick eschar,tendon exposure). Although exercise will vary with patientstatus, there are circumstances that must be given specialconsideration. The clinical guidelines for starting ROMafter excision and grafting vary among institutions (Table94-5). Other conditions that may modify treatment includetendon, bone, or joint exposure; preexisting joint disease;periarticular calcification; deep venous thrombosis; andassociated trauma.

Passive ROM (PROM) exercises are performed whenthe patient is unable to actively participate in the program.Guidelines to performing PROM exercises depend on apatient’s physiologic status, placement of intravenous lines,eschar tightening or tearing, associated orthopedic or neu-rologic trauma, or preexisting joint conditions. ActiveROM exercises are encouraged to ensure patient participa-tion and assisted ROM exercises are especially effective ina multijoint stretch where the goal is to elongate the scartissue over adjacent joints.

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Figure 94-4. Circumferential full-thicknessburns of both lowerextremities, with the potentialfor decreased range of motiondue to the location of theburns, crossing both kneejoints.

Table 94-5: Clinical Guidelines forStarting Range of Motion (ROM) Exercise

PROCEDURES CLINICAL GUIDELINES

Autografting Postop day 4—active ROM.Postop day 5—active-assisted

ROM.Postop day 6—passive ROM.

Use of biobrane Initiate ROM 24–48hr after application.

Aggressiveness depends on appearance.

Allografting Same as for autografting.Cultured epithelial Initiate active ROM after take

autografting down, which is 7–10 days after grafting. Aggressiveness depends onappearance.

ROM exercises can be implemented during a dress-ing change, giving the therapist the opportunity to continu-ally assess the wound and make appropriate modificationsto the program. Additional exercise sessions can occur atthe bedside or in the clinic. A continuous passive motion(CPM) machine is often used to complement ROM exer-cises. Conditioning, coordination, and strengthening activi-ties are also included in the rehabilitation program. Jointmobilization may also be part of a rehabilitation program,especially in the patient with prolonged immobility andsoft-tissue contractures.

While ROM exercises are vital to maintaining jointmotion, functional exercises should be emphasized todecrease progressive dependency, increase self-esteem, and


promote independence. Functional exercises and ADLsshould begin in the early phase of recovery as the patient’smedical and surgical status allows. Treatment may includeself-care activities such as feeding and personal hygiene. Ifpossible, therapists should avoid the use of adaptive equip-ment for ADLs. It is better to increase the patient’s jointmotion through functional activities and prevent relianceon such devices.

Therapeutic intervention involves a balance betweenmobility and exercise versus positioning and splinting.Splints are used for a variety of purposes, including pre-vention of joint contracture and dysfunctional posturing,protection of an anatomic instability, postoperative immo-bilization, and scar control. If splints are used as position-ing devices to prevent or minimize contractures, it isimportant that the splints be taken off multiple times perday for ROM exercises.

In the rehabilitative phase, the goals of therapy focuson preventing or minimizing joint contractures, controllingscars, and promoting return to functional independence.ROM exercises continue, especially for those areas predis-posed to joint contractures. The use of reciprocal pulleysfor upper-extremity stretching and prolonged positioningstretches over wedges and bolsters for the trunk and neckhave been advocated. Therapeutic balls, foam bolsters, andwedges are useful in encouraging active motion. Given thephysiology of scars and the development of additional soft-tissue tightness, therapeutic exercise in any form should beperformed daily to four times a day.

Therapeutic exercises and functional activities areinitiated during the acute phase and continued into therehabilitative phase, which may extend for months afterdischarge from a burn or rehabilitation center. Outpatienttreatment continues to focus on scar management, stretch-ing, conditioning, and strengthening. Therapeutic exercise

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following surgical scar release is also essential and in mostpatients extends years after the burn occurred.

HAND BURNSOne of the most commonly involved and structurally vul-nerable parts of the body in a burn injury is the hand (Fig.94-5). Because of the natural human tendency to protectthe face, dorsal hand burns are more common thanpalmar burns. In particular, the dorsum of the hand is atrisk, owing to the superficial location of the extensortendons and the minimal layers of subcutaneous fascia.Without early intervention, permanent damage to thehand can occur. Traumatic shedding of the extensor hood,ischemic changes secondary to edema, and increasedtension at the proximal interphalangeal (PIP) joints are alltoo frequently present. In particular, with a burn trauma tothe hands, the central slip and the lateral bands are jeopar-dized. In normal function, the lateral bands lie volar to theaxis of flexion at the metaphalangeal (MP) joint and dorsalto the axis of flexion at the PIP joint. When injury occurs,the central slip is often disrupted, allowing the lateralbands to slip volarly, becoming flexors at the PIP joint andforcing the distal interphalangeal (DIP) joint into hyperex-tension. This is known as a boutonnière deformity. This andother deformities can be prevented by splinting, ROM,exercises and stretching, and proper positioning (14).

As with splinting in general, the hand should besplinted in a position opposite the expected deformity. Theburn resting hand splint is one of the most common toolsused to protect the hands. This splint varies slightly fromother resting splints as it places the wrist in approximately30 degrees of extension, the MP joints at approximately 70degrees of flexion, the interphalangeal (IP) joints in fullextension, and the thumb in opposition and maintains a


Figure 94-5. Partial degloving of the lefthand to reveal a full-thicknessburn injury.

good palmar arch (15). Straps are contraindicated for theacute stage of injury, for they may interfere with circula-tion and cause an increase in edema or edema “pocketing”(14). Instead, Ace wraps are used to secure most splints,wrapping in a distal to proximal manner. If the burnrequires a skin graft, a modified hand splint is used duringthe operative procedure to position and immobilize thehand, allowing for optimum stretch and graft take (Fig. 94-6). These modifications include slits between the fingers,holes at the distal tip of each finger, notches around theside, and a “roll bar” attached to the thenar area of thesplint. The digits are sutured, by a surgeon, into the holesat the top of the splint, while the slits allow for adequatedrainage and the roll bar provides extra protection againstdamage to the graft. Other splints that are frequently indi-cated for the burned hand include, but are not limited tothe following:

1. The gutter splint, which maintains or increasesextension of one particular digit

2. The saddle splint, which prevents contracture of thethumb-index web space

3. The wrist cock-up splint to provide wrist extension,which aids in hand function

Splint requirements will change as the patient’smedical status and functional needs change. Therefore, it isimportant to monitor a patient’s splint on a daily basis toassess fit, reassess splinting needs, and check for pressureareas.

ROM exercises, another important aspect of burntherapy, are necessary not only to prevent skin contrac-tures, but also to prevent joint stiffness and tendon adhe-sions. Active ROM exercises are always preferable, as theymaintain muscle mass and strength. However, since this isnot always feasible, PROM exercises may be performed.ROM exercises with burned joints need to be frequent and

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Figure 94-6. An example of a sheet graftplaced on the dorsal aspect ofa left hand. The fingertips aresutured and secured to thesplint. The splint helps tomaintain a functional posi-tion and keeps the handimmobilized to facilitate grafttake.

aggressive but special attention must be paid to the delicatestructures of the hand. With a full-thickness burn to thedorsum of the hand, a multijoint stretch is contraindicated.To maintain mobility while preserving tendon integrity, amodified flexion technique is performed. This involvesachieving MP flexion with IP extension and then IP flexionwith the MP joints extended. Patients should make a fullfist only if the therapist is positive of the tendon status or ifthe wound has healed or been grafted. PROM is best com-pleted while the patient’s dressings are off. If possible, it isimportant to have the patient participate in active exercisesand functional activities. This can be done in a gym or atthe patient’s bedside. Without daily exercise, muscleatrophy, tendon adherence, capsular shortening, andedema can be ongoing problems.

Proper positioning of the burned hand is essentialfor minimizing edema. When the body is subjected tothermal trauma, there is an immediate and rapid increasein capillary permeability. As a result, massive fluid accumu-lates in the area of trauma. This fluid can be very destruc-tive to the fragile structures of the hand. One of the mostcommon problems seen in the hand secondary to edema isthe claw hand deformity. The result is that the MP jointsare pulled into hyperextension; the IP joints, into flexion;and the thumb, into adduction (14). Elevation of theburned extremity and splinting will assist with the decreaseof edema.

It must also be remembered that the hand functionsas part of the upper extremity. Full hand motion is almostuseless if significant contractures of the elbow or axillaprevent the patient from positioning the hand so that thismotion can be utilized (16).

PAINPain in burn patients must be managed carefully butaggressively. The patient’s level of pain should not be


underestimated. There is great variability in individualpain thresholds. Patients with “minor” surface area burnsmay report significant pain, while conversely a patient witha “major” surface area burn may have only minimal complaints.

Pain can occur with activity or at rest. Variousapproaches are used to measure pain. The most applicableto the burn patient appears to be the horizontal VisualAnalog Scale (VAS) or the Verbal Descriptive Scale (VDS).In the pediatric population, the VAS and Pain Thermome-ters or the Procedural Behavior Checklist are useful.However, more research is indicated in this area.

Pain medications include opioids (morphine, meperi-dine, fentanyl, sufentanil), anti-inflammatories (ibuprofen,etc), local or general anesthetics (midazolam, nitrous oxide,lidocaine), and benzodiazepines (lorazepam). Each of thesemedications must be administered cautiously and thepatient closely monitored for desired outcome and sideeffects. The response to opioids in particular can be signifi-cantly altered for months after burn injury. Administrationof other medications, prior medical conditions, fluidvolume status, and parenteral nutrition can affect the phar-macokinetics of drugs.

The route of medication delivery may include intra-venous injections, patient-controlled epidural perfusion(PCA), oral route, or less preferable, intramuscular injec-tions. Some patients will require opioids as well as behav-ioral modification, psychological supportive counseling,relaxation therapies, and in extreme cases, hypnosis.

Particularly with the pediatric population, the magni-tude of pain must not be underestimated. Opiates, seda-tives, behavioral modification, and even PCA have beenused successfully with this population.

Aggressive pain management can lead to improvedparticipation in burn rehabilitation as well as improvedoverall patient care. The most effective plan of care is tai-lored to the individual patient’s needs.

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COMPLICATIONSBurn injuries can lead to significant compromise of theneurovascular system (Fig. 94-7). There are a number ofneurologic complications seen after a burn injury. Onesuch complication, burn encephalopathy, is a poorlydefined clinical entity that may occur more frequently inchildren. Seen in about 30% of patients, it may be trig-gered by systemic factors, including fever. Peripheral neu-ropathies are seen more with burns of increased severity.They are commonly due to direct thermal, chemical, orelectrical injury or secondary to treatment regimens (i.e.,neurotoxic drugs, tight bandages, faulty positioning, orimproper splinting). Mononeuritis multiplex is seen most

1770 Part V Medical Rehabilitation

Figure 94-7. An exit site of a high-voltageelectrical injury. Anamputation was indicatedsecondary to neurovascularcompromise.

Figure 94-8. A fasciotomy allows deeptissues to expand, to preventincreased compartmentpressures.

frequently. Axonopathy of the critically ill is not uncom-mon. Burn injuries can be overwhelming and a prolongedrecovery period can lead to generalized neural collapse.These patients may require mechanical ventilation, posi-tioning, splinting, and a medical regimen.

Compartment syndrome can quickly develop as edema increases and compartment pressures rise. Escharcan contribute to the development of compartment syn-drome because it lacks the compliance needed to accommodate a massive fluid shift. Compartment pressuresmay be monitored and decompressive surgery such as an escharotomy or fasciotomy of the involved area can beemployed to reduce pressure and salvage tissue (Fig. 94-8).

for Diagnostic Groups

Heterotopic ossification is commonly found in burnpatients who sustained deep burn wounds and have beenimmobile, particularly following grafting procedures over ajoint. Diligent ROM exercises within surgical guidelinesare optimal to reduce the risk of heterotopic ossification.Even with proper treatment, heterotopic ossification maystill occur. Treatment for heterotopic ossification fluctuatesfrom institution to institution.

HYPERTROPHIC SCARRINGThe scarring process can limit ROM, cause contractures,and severely limit function. Most ongoing rehabilitationdifficulties are secondary to the strong contractile proper-ties of immature scars (17). Full scar maturation may takeup to 12 to 18 months (18), with the most active scarringperiod being 4 to 6 months after injury (17). Early andaggressive treatment of the scars, via use of pressure,stretching, splinting, and positioning, is essential for goodfunctional outcomes.

A healed wound is characterized by increased vascu-larity and an increased number of fibroblasts. Fibroblaststhen synthesize excessive collagen, which redevelops inirregular shapes and whorl-like masses at four times therate of normal skin (19). Early scar is readily influenced byexternal forces because cross-linking collagen bonds areweak and fewer in number in the early stages. Therefore,these bonds are likely to align themselves in a more orga-nized parallel format. Pressure may also control collagensynthesis by producing ischemia in the scar (17) anddecreasing wound vascularity.

The severity of scarring is affected by wound depthand the time needed for wound closure. If a woundrequires skin grafting or takes longer than 14 days to heal,pressure therapy will be indicated (Fig. 94-9). Other factors


influencing the severity of scarring include age, race,genetic disposition, anatomic location of the burn, and thetype of grafting performed. Pediatric patients and patientswith very fair or dark skin tend to be at higher risk forincreased scarring. Burns of the hand, head, and axillaalso tend to be more vulnerable to increased scar forma-tion. Grafts placed on granulation tissue also tend to scarmore than tangentially excised wounds (17).

Early pressure can be provided via Ace wrapping,tubular support bandages, interim garments, and prefabri-cated pressure gloves. These can be tolerated as early as 7to 10 days after grafting or when open areas are no largerthan the size of a dime (19). These methods of pressureare used while body weight and edema stabilize prior tohaving the patient measured for custom-fit pressure gar-ments. Custom garments are made of a Dacron/spandexelastic fabric and provide capillary level pressures of atleast 25mmHg (17). The wearing time may need to beincreased gradually to 23 out of 24 hours per day, and thegarments may need to be worn until full scar maturationhas occurred. Proper fit is essential so the fit must be peri-odically examined and alterations or entire new garmentsmay be needed.

The sustained use of capillary level pressure on thegrowing bones and tissues of small children has been con-troversial. However, it is now believed that if the fit ismonitored closely to allow for growth, garment use isacceptable, with the exception of the head.

To maintain uniform pressure in concave areas ofthe body, inserts such as elastomer putty, Silastic elastomerwith prosthetic foam, Plastizote, or thermoplastic conform-ers may be used. Silicone gel sheeting is another option forthe treatment of hypertrophic or keloid scars. Althougheffective, the mechanism is not fully understood. The gelmay promote hydration and the degree of occlusion may

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Figure 94-9. Scarring occurs along themargins of a meshed graftand between interstitial sites.This graft is ready for theinitiation of pressuregarments to help improve thecosmetic outcome.

Figure 94-10. Exit site from a high-voltageelectrical injury requiringbilateral transmetatarsalamputations.

also play a role (20). Silicone gel sheets may only be usedon completely healed skin surfaces, as internal absorptionremains controversial.

Proper pressure therapy can lead to favorable func-tional and cosmetic gains. Patient compliance is essential;otherwise, surgical intervention may be needed (Fig. 94-10).

COSMESISFollowing scar maturation, changes in the texture andcolor of the skin may still be present. The visible scarringmay alter a patient’s self-esteem. To minimize discolorationand disfigurement, cosmetics that camouflage these areaswere developed. Paramedical camouflage is a process bywhich the appearance of scar or skin pigment alterations isnormalized. This is achieved through the application ofproper shades and placement of cosmetics. The makeup isspecific for each individual. The patient is instructed in theproper use of these cosmetics so the desired effect can beachieved. Creams utilized usually contain a sunscreen andare waterproof.

DISABILITYThe evaluation of disability is an appraisal of the patient’spresent and future ability to engage in gainful activity as itis affected by factors such as age, sex, education, econom-ics, and social relationships. These diverse and subjectivefactors are difficult to measure (7). For this reason, perma-nent impairment is the major criterion used in arriving ata permanent disability determination. Unlike disability,permanent impairment can be measured with a reasonabledegree of accuracy and uniformity (21).

The American Medical Association’s Guides to the

Evaluation of Permanent Impairment is a widely accepted aid


and provides a standard framework and method of analy-sis through which physicians can evaluate, report on, andcommunicate information about the impairments of anyhuman organ system. Many state workers’ compensationagencies mandate or recommend use of the Guides. Eventhough rating or estimating impairment cannot be totallyobjective, use of the Guides increases objectivity andenables physicians to report impairment in a standardizedmanner, so that reports from different observers are morelikely to be comparable in content and completeness (22).The effects of a burn injury on the skin and itsappendages are combined with the estimated impairmentpercentages of other body systems, including the muscu-loskeletal system, the nervous system, the respiratorysystem, the ears, the nose, the throat, and related struc-tures. Additionally mental and behavioral disorders are dis-cussed in the Guides.

PSYCHOLOGICAL ISSUESAlthough the costs of burn treatment are tremendous interms of health care dollars, time, effort, pain, suffering,and mental anguish to patients and families, it is rewardingif the patient emerges from this ordeal as a functioningmember of society with self-respect and dignity intact.Certainly, some patients do emerge intact, and someresume their lives in a more productive and gratifyingmanner than before the injury. However, many patients,despite the best burn treatment, develop psychologicalcomplications that hinder their recovery. Healing on theoutside may not always reflect healing on the inside.

Anxiety, denial, depression, grief, and mourning maybe experienced. Depression may be transient and showimprovement with the healing process or may intensifywith time as the patient realizes what has been lost.

r Diagnostic Groups

Many burn injuries are due to premorbid psychologi-cal problems. This includes a possible history of alcohol ordrug abuse, violence, or fire starting. Depression, alcohol ordrug abuse, and organic brain syndrome can be accompa-nied by poor concentration, impaired judgment, and slowmotor response, all of which contribute to a high risk ofburn trauma.

Symptoms of posttraumatic stress are expected inthe postburn period. However, if they exacerbate, reinte-gration into society may be hindered.

Patients need to recover physically and psychologi-cally after burn injury. All members of the team need tobe aware of how these problems can impact on the


patient’s ultimate functional outcome. Emotional support isnecessary, and patients may require additional assistancefrom mental health professionals.

FUTURE TRENDSThe changing health care milieu will affect burn care ofthe future. When feasible, outpatient management of burninjuries will replace more expensive inpatient services.Future trends also include new wound care technologiessuch as developments in artificial skin. A deeper under-standing of new technology is required to keep pace withthe frequent changes in burn care delivery.

REFERENCES

1. Brigham P, McLaughlin E. Burnincidence and medical care use inthe U.S.: estimates, trends anddata sources. J Burn Care Rehabil1996;17:95–105.

2. Sabistan D, ed. Textbook ofsurgery. Philadelphia: WB Saunders, 1991:178.

3. Greenfield LJ. Surgery—scientificprinciples and practice. Philadel-phia: JB Lippincott-Raven, 1997.

4. Clark JA. Color atlas of burninjuries. New York: Chapman &Hall Medical, 1992.

5. Demling R, LaLonde C. Burntrauma. New York: ThiemeMedical, 1989.

6. Fitzpatrick T, et al. Dermatology ingeneral medicine. Vol. I. New York:McGraw-Hill, 1993.

7. Richard R, Staley M. Burn care &rehabilitation—Principles andpractice. Philadelphia: FA Davis,1994.

8. Gerding RL, Emerman CL, EffronD, et al. Outpatient managementof partial-thickness burns: Bio-brane versus 1% silver sulfadi-

azine. Ann Emerg Med 1990;19:121–124.

9. Lown D. Use and efficacy of nutri-tional protocol for patients withburns in intensive care. J BurnCare Rehabil 1991;12:3371–3376.

10. Constable JD. The state of burncare past, present and future.Burns 1994;20:316–324.

11. Heimbach DM. A non-user’s ques-tions about cultured epidermalautograft. J Burn Care Rehabil1992;13:127–129.

12. Cultured autologous keratinocytessuspended in fibrin glue to coverburn wounds. In: Plastic surgerynerve repair burns. Stark, et al.New York: 1995:143.

13. Medical economics of Integra arti-ficial skin. Plainsboro, NJ: IntegraLife Sciences, 1996.

14. Malick and Carr. Manual on man-agement of the burn patient Pitts-burgh: Harmarville Rehab Center,1982.

15. Androwick, Goldblum, et al. “OTintervention for people with burns.

Advanced Magazine for Occupa-tional Therapists May 22, 1995.

16. Robson MC, Smith DJ Jr, Van-derZee AJ, Roberts L. Making theburned hand functional. Clin PlastSurg 1992;19:663–671.

17. Ward RS. Pressure therapy for thecontrol of hypertrophic scar forma-tion after burn injury: a historyand review. J Burn Care Rehabil1991;12:257–262.

18. Trombly CA, ed. OT for physicaldysfunction. 2nd ed. Baltimore:Williams & Wilkins, 1983.

19. Willard & Spackman’s OT. 5th ed.Philadelphia: JB Lippincott, 1978.

20. Cica Care pamphlet. Smith &Nephew Rolyan, 1994.

21. Fisher S, Helm P. Comprehensiverehabilitation of burns. Baltimore:Williams & Wilkins, 1984.

22. Doege TC, ed. Guides to theevaluation of permanentimpairment. 4th ed. Chicago:American Medical Association,1993.

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