This article summarizes current interventions for several of the most common challenges faced by patients during their rehabilitation from burn injury. These include preservation of range of motion through scar contracture management, and achieving maximal independence through exercise, and training in activities of daily living.
Key points
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A patient’s range of motion can be preserved through thorough scar management.
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Burn rehabilitation programs should include elongation, splints, positioning, and edema management.
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Maximal independence after burn injury can be gained through early mobility, exercise, and training for activities of daily living.
Introduction
Overcoming a burn injury, especially a large burn injury, places great physical and psychological demands on the individual injured. The team trained to facilitate recovery is faced with the challenge of identifying and managing barriers to recovery. Key to the prevention and management of potential impairment is the ability to predict potential barriers and prioritize interventions based on best practices. Although the effects of no two burn injuries are identical, there are common challenges for most individuals striving to overcome burn trauma. This article endeavors to address 2 of these areas including: preservation of range of motion (ROM) and maximizing postburn mobility during hospitalization. Our second article, Heather Dodd and colleagues’ article, “ Current Concepts Burn Rehabilitation, Part II: Long-Term Recovery ,” in this issue, addresses scar management and exercise through the long term rehabilitation phase; additionally, it explains the role of child life specialists and recreation therapists in the psychosocial recovery for the burn injured patient.
Introduction
Overcoming a burn injury, especially a large burn injury, places great physical and psychological demands on the individual injured. The team trained to facilitate recovery is faced with the challenge of identifying and managing barriers to recovery. Key to the prevention and management of potential impairment is the ability to predict potential barriers and prioritize interventions based on best practices. Although the effects of no two burn injuries are identical, there are common challenges for most individuals striving to overcome burn trauma. This article endeavors to address 2 of these areas including: preservation of range of motion (ROM) and maximizing postburn mobility during hospitalization. Our second article, Heather Dodd and colleagues’ article, “ Current Concepts Burn Rehabilitation, Part II: Long-Term Recovery ,” in this issue, addresses scar management and exercise through the long term rehabilitation phase; additionally, it explains the role of child life specialists and recreation therapists in the psychosocial recovery for the burn injured patient.
Preservation of normal range motion
Burn Scar Management Through a More Complete Understanding of Cutaneokinematics
The deposition of scar, even hypertrophic scar, after a burn injury, is a normal process. However, loss of ROM owing to burn scar ought to be considered a pathologic condition. The presence of hypertrophic scar, even over a joint, need not result in loss of ROM. This observation can serve to highlight the importance of not conflating hypertrophic scars and loss of ROM. Nevertheless, loss of ROM owing to burn scar remains a significant hurdle on the road to recovery from burn. Much work remains to determine the most effective management of burn scar contractures. However, relatively recent advances in the understanding of skin movement and the study of burn rehabilitation are providing significant guidance.
Although not considered in this article, it is critical to any discussion of scar management (and thereby preservation of ROM) to understand the components of skin and how they interact under the normal as well as the scar condition. Also taken for granted is the readers’ comprehension of biomechanical principles related to soft tissue lengthening. These include successive length induction, tissue creep, and stress relaxation. These principles serve as a theoretic basis for the interventions discussed elsewhere in this article.
Closely associated with the study of skin biomechanics and its material properties is the study of normal and pathologic cutaneokinematics or, for the sake of this discussion, how skin moves in response to local or distant joint movement. An understanding of normal skin movement is based on the aforementioned knowledge of skin composition and biomechanics as well as joint arthrokinematics. However, this discussion begins simply with the understanding that the length of a body segment and the length of a limb will change during normal ROM and that skin is a single contiguous veil of soft tissue that must move and deform to accommodate limb and body segment motion.
Studies of skin movement: findings pertinent to burn scar management
Simple clinical observation seems to reveal that the majority of skin movement, during ROM, seems to be closest to a joint axis undergoing the motion. This observation has been more closely studied with skin marking and double exposure photography, skin marking with mathematical analysis of angular and dimensional distortion, serial magnetic resonance imaging, and sophisticated motion analysis technology. Some significant findings pertinent to the current discussion include the following: (1) certain physiologic rules may exist for skin movement, (2) volar forearm skin is recruited (for movement during wrist extension) in a serial fashion, (3) during pronation and supination, volar forearm skin demonstrates significant changes in skin tension patterns, (4) there are (about the knee during squatting) contours of skin that remain constant in length, (5) skin motion was detected further than anticipated from the joint axis of rotation, (6) skin compression occurs opposite the side of tension, (7) the magnitude of skin movement across 1 joint can be affected by the position of an adjacent joint, and (8) skin recruitment necessary for joint motion may not be related to body fat or body mass index.
Studies of skin movement: application of findings
Original observations in skin motion and lines of tension have been used to guide surgical incision orientation and to minimize scarring. Generations of subsequent work have led to current studies of skin motion that will likely inform the development of “second skin” space suits, guide scaffolding design for engineered skin, improve wearable orthotics, optimize autograft orientation, improve wound dressing design, and continue to improve human motion analysis accuracy.
Pertinent to the cause of burn rehabilitation are advances in the understanding of cuteneokinematics, which have already led to useful improvements in burn rehabilitation research as well as clinical practice.
Building on his previous work in quantifying skin motion, Richard and colleagues published in 2009 results of a skin movement investigation and introduced the label “cutaneous functional unit” (CFU). Similar to the manner in which facial aesthetic units are associated with skin consistent in color, texture, thickness, and mobility, CFUs are defined as the fields of skin functionally associated (by virtue of their movement) with normal ROM. These fields were identified by measuring the magnitude of local skin marker movement observed after completing ROM for a body segment.
The following example taken from Richard and colleagues (2009) demonstrates that the field of skin recruited for neck extension can extend from the sternal notch to the pubic bone. When this field was divided into tenths, 4 subjects recruited 90% to 100% of the marked skin in this area, 6 subjects recruited 80% to 90%, 8 subjects recruited 70% to 80%, and 2 recruited between 60% and 70% ( Fig. 1 ).
Nine body segments frequently subject to burn scar contracture were observed in this study. With the exception of knee extension (for which all subjects recruited 100% of available skin within the defined CFU) some variability between subjects was shown. The mean skin recruitment across all 9 defined CFUs was determined to be 82.6%.
This significant step forward in the attempt to objectify the magnitude and direction of skin motion during human movement has had several applications. One immediate application of the identification of CFUs was to further refine the Lund and Browder burn body diagram by basing body surface areas on the CFU concept. To that end, the digital surface area graphic evaluation (SAGE) program now includes a body diagram mapped with CFUs. This tool allows a user to digitally select an area on the body surface diagram (eg, the margins of a burn wound) and discover which body segments have the potential to be affected by a wound in that location. In the following example, a burn wound has been “entered” on the left head, neck, and torso of the SAGE-CFU burn body diagram. Skin in this area has been shown to be functionally associated with ROM in the body segments listed to the right ( Fig. 2 ).
The SAGE-CFU tool has been used to help demonstrate that (1) the percentage of CFU scarred is predictive of loss of ROM at the shoulder, (2) CFUs serve as a better index for patient outcomes than total burn surface area, (3) small and large burns benefit from more rehabilitation time, and (4) increased rehabilitation time means better outcomes. Additionally, this application played a key role in the creation of a national rehabilitation study database.
The understanding of skin motion and recruitment patterns that serve as the foundation for the CFU concept has led to suggestions for areas of additional study. This includes the suggestion that, in the presence of skin mobility restrictions, such as burn scar, joint ROM test positions should be reconsidered. Current standardized ROM test positions are based on an orthopedic model, which accounts well for muscle length and joint mechanics, but does not take into account altered cutaneokinematics.
Also, modified uses of existing splinting devices or development of new devices may be warranted. Currently, static–progressive splinting devices designed to restore shoulder loss of ROM have been shown (for patients with adhesive capsulitis) to restore glenohumeral elevation by delivering low-load, prolonged stretch into external rotation. This “orthopedic” approach to gaining shoulder elevation will likely be of little to no assistance to an individual whose elevation restriction is due to decreased skin length or impaired skin extensibility in the associated CFUs.
Inherent to effective evaluation and management of burn scar and its potential effects on motion is an understanding of the relationship between CFUs and joint ROM. Perhaps nowhere is this understanding more important than in the design of a patient’s elongation, splinting, positioning, and edema management programs.
Improved range of motion through elongation
When confronted with ROM restriction owing to burn scar, the burn injured patient and their treatment team will likely use a multimodal treatment approach including elongation interventions. For the purposes of this discussion, the term “elongation” refers to the manual intervention involving the application of tension through the integument in a sustained fashion with the goal of lengthening the integument within that line of tension. When applied thoughtfully and based on biomechanical principles, integument (scar or unscarred skin) lengthening can take place, thereby increasing ROM. This intervention is most often referred to as stretching or ROM exercise.
When elongation is applied by a therapist or caregiver over a lengthy period of time several guidelines should be considered. The patient should assume a position that, when the body segment is lengthened, allows the line of tension to extend through the greatest number of CFUs associated with that body segment. Because the patient will be in this position for a lengthy period of time, it should be a position conducive to relaxation. The therapist or caregiver should assume a safe posture, which will allow them to avoid frequent repositioning. Repositioning hand placement and altering the magnitude of elongation force can be uncomfortable and disruptive for the patient. Finally, when possible, a physical environment conducive to relaxation should be provided. the expertise of a recreation therapist or child life specialist should be used to assist with nonpharmacologic pain and anxiety management.
Preservation of range of motion through splinting
The use of splints to manage and prevent burn scar contractures remains ubiquitous throughout the burn care community in terms of effectiveness. Burn centers differ in how and when splints should be applied whether during the acute rehabilitation phase, postoperatively, or during the intermediate phase. Static splints have become universal to maintain the extremities in the antideformity position, often within the first 24 hours of sustaining a burn injury. Depending on the setting, burn therapists may splint any part of the body with the underlying purpose of maximizing function and integrity of movement. Splints may include hand, wrist, elbow, axilla, foot, knee, mouth, and neck, in a static splint or with a dynamic component.
Acute splinting for deep dorsal hand burns is essential to protect tendon exposure because they may quickly become denatured and may rupture. Also, when a deep burn occurs to the dorsal proximal interphalangeal joints, concern for extensor hood disruption and subsequent boutonniere deformity should be considered. Immobilization by the use of static splinting will allow the proximal interphalangeal joint to be protected or to heal if ultimately ruptured.
Edema management through positioning and compression
Regardless of the mode of burn injury, edema in the extremities can cause a patient to assume a “position of comfort.” These are often postures that can reinforce common burn scar contraction patterns. Edema will also contribute to limitations of blood flow and create the potential for greater scar tissue development. The therapist’s knowledge of how to prevent positions of comfort and initiate edema reduction techniques in the acute phase can help a patient to achieve functional goals in long-term rehabilitation phase.
Edema
Edema occurrence in the face, extremities, and even trunk can be noted during the first 24 hours after resuscitation. If continuous renal replacement therapy is implemented by the medical staff, edema reduction can be a positive result. However, the therapist should assess all extremities to determine if further edema reduction techniques should be implemented. Edema of the face may be managed through head of bed elevation. Avoidance of pillows behind the head minimizes neck flexion and shoulder internal rotation. Depending on the anatomy of the patient, posterior neck support for the cervical area may be initiated and can be done without the use of a pillow. Upper extremities edema reduction positioning techniques can include elevation with use of netting with elbow flexion of 40° or less, hand elevated, or hand elevation with minimal elbow flexion with use of wedges/pillows ( Fig. 3 ).
