Rehabilitation of Burn Victims

Now that more and more burn victims survive serious burns, there has been a demand for advanced techniques to rehabilitate these patients once the acute phase of their recovery has been completed.  Ideally, rehabilitation should start as soon as it is feasible so that the patient doesn’t lose precious muscle and joint function.  Serious burns result in prolonged rehabilitation times and the earlier rehab is started, the better will be the underlying function of the body parts injured.
 
Burn rehabilitation specialists evaluate the burn victim as soon as it is feasible to see what kinds of intervention may be necessary.  Therapists need to know the mechanism injury, the premorbid state of the patient and the total body surface area involved.  If there are other injuries, these need to be known about as well.  The rehabilitation specialist will then get an idea of what the body’s range of motion is and how well the patient can perform activities of daily living.  Finally, short and long-term treatment goals are determined and documented so a treatment plan can begin.  Reassessment is done on a regular basis.
 
Positioning the Burn Victim
 
There are challenges when a burn victim is bed-bound with large total body surface area burns.  The rehabilitation specialist helps position the victim and develops a positioning program so that burned areas don’t have too much pressure on them for long periods of time.  The rehabilitation team works with splints, cut-out troughs, pillows and the bed itself in order to have the best possible chance of healing burned areas.  For example, some patients with back wounds need to be positioned on their stomach to prevent shearing off of the skin grafts placed on the back.
 
Other purposes of victim positioning include the following:
  • To prevent facial swelling
  • To keep the joints aligned
  • To elongate the tissues
  • To maintain range of motion around joints
  • To support and protect joint surfaces from pressure sores
  • To protect skin grafts
  • To promote healing of wounds
  • To help strengthen weakened muscles
Wedges made of foam or wood can be placed beneath the mattress to allow the patient to comfortably lie on one side or another.  Prone positioning is considered a measure of last resort because it can compromise the patient’s airway and is uncomfortable for some patients.
 
Positioning the Head and Neck
 
Ideally, the head and upper torso should be placed at a 30-45 degree angle from the horizontal part of the bed.   If the hips are burned (or buttocks), the entire bed can be placed in a slanted position to take the pressure off the sacrum.  Ear cups may need to be placed on the victim’s ears if they are burned so they don’t come in contact with the bed or bedding materials.  Mouth and nose splints are available to keep these areas from contracting.  Face masks may need to be used to protect facial burns and to decrease scarring.

The neck is generally placed in a neutral position or in slight extension.  Collars can be fabricated in order to keep the neck from contracting in a forward position.  A head strap or special splint can prevent the neck from healing to one side.   The back may be placed in a neutral position in order to prevent scoliosis.
 
Upper Arm Positioning
 
The upper extremities need to be placed in such a way so as to prevent swelling.  There are splints available for keeping the shoulder joint abducted, meaning it is away from the body.  If swelling is not prevented in the first 3 days following the injury, there will be a permanent deformity of the arm and hands.  The elbow joint can be placed in full extension in order to prevent the elbow from permanent contracture.  Measures must be taken so that the forearm can be rotated palm up and palm down without much difficulty.
 
If the hand gets swollen, it can cut off the circulation to the fingers, resulting in a loss of the ends of the fingers.   It is advisable to elevate the hand and to place the wrist in slight extension so as to automatically put the fingers into slight flexion.   A splint can be placed that slightly extends the wrist and places the entire fingers of the hand in full extension, slightly separated from each other as the burn heals.  This is the best way to prevent contractures of the hand and fingers at the wrist and at the knuckles.  A splint may need to be placed across the palm of the hand in order to prevent it from “cupping”.
 
Lower Extremity Positioning
 
If there are burns of the abdomen that extend down to the thigh, it is natural to hold the hips slightly flexed for comfort.  Unfortunately, this is not a good way to prevent permanent back and hip problems later. Ideally the hips should be neutral with a slight 15-20 degree abduction of the hip so the legs are slightly apart.  The knee should be splinted in full extension in order to prevent contractures of the knees.   Finally the foot should be placed at a 90 degree angle to the rest of the body so that the foot doesn’t end up in a permanently flexed position. 
 
Traction Devices

There are numerous ways to apply traction to the fingers, arms, and legs.  The traction is to prevent contractures and to elevate the extremities so they don’t swell so much.  Traction devices can be moved around in order to keep contractures from happening.  If a limb could not be salvaged, an expert prosthetist can create an artificial limb, whether it is the upper or lower extremities.
 
Scar Management of Burn Victims
 
The rehabilitation specialists need to take part in the management of the burn scar.  Scars, by their very nature, contract the skin and this cannot happen for the best in functional recovery of the joints.  In addition, it would be ideal to do whatever it takes to prevent the scar from becoming hypertrophic and, therefore, not cosmetically acceptable.  Hypertrophic scars are difficult to manage and care needs to be taken early on in the course of healing in order to prevent them.  One of the best ways to prevent hypertrophic scars is to use pressure garments that slightly decrease the circulation to the scar and can therefore keep less collagen from forming on the scar.
 
There are pressure garments for any part of the body.  Any burned area that is expected to heal beyond 21 days is one in which pressure therapy may be indicated.  Areas of the body that are concave, such as the face, neck, under-arm, and the palm of the hand can benefit from inserts within the pressure garment in order to mold the skin to have a flatter scar. Burn scars can also be massaged to keep them supple and more yielding.  Massage also helps to prevent as much itching of the healing areas.
 
Exercise
 
Eventually, the burn victim will be able to ambulate and exercise to some degree.  The exercise program must be done gradually, beginning with stretching exercises and ending with aerobic exercise and weight lifting.  This is a slow process—one that can take months to years to complete.  The success of an exercise program depends on the patient’s age, degree of burn, and on the motivation of both the patient and his or her occupational and physical therapists. 
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