Current Concepts Burn Rehabilitation, Part II

This article summarizes current interventions for several of the most common challenges faced by patients during their rehabilitation from burn injury. These challenges include range of motion preservation through scar contracture management, achieving maximal independence through exercise and activities of daily living training, and psychological recovery through nonpharmacologic approaches pain and anxiety.

Key points

  • Range of motion can be preserved through splinting and scar contracture management.

  • Maximal independence after burn injury can be gained through exercise and activities of daily living training.

  • Child life specialists and recreation therapists specialize in nonpharmacologic management of pain and anxiety to aid in psychosocial recovery following burn injury.

Outpatient management of scar contractures

Rehabilitation from a burn injury begins acutely within minutes of admission to the hospital but can continue for weeks, months, and years. Outpatient care is essential to the success of burn survivors. Studies show that the prevalence of scar contracture at discharge is high, around 40% to 55%, thus showing a need for optimal continued rehabilitation and reconstructive care. The focus of care continues on minimizing hypertrophic scar and contracture formation; improving flexibility, strength, and endurance; ensuring proper skin and scar management techniques; and promoting independence in normal daily activities, including self-care and social and recreational pursuits. This long-term rehabilitation phase may include reconstructive surgeries and lifelong services for contractures being exacerbated by patients’ growth and aging. Outpatient therapy services, including occupational, physical, and recreational therapy (RT) aid in the continuum of care that patients need to succeed and return to their life goals.

Outpatient management of scar contractures

Rehabilitation from a burn injury begins acutely within minutes of admission to the hospital but can continue for weeks, months, and years. Outpatient care is essential to the success of burn survivors. Studies show that the prevalence of scar contracture at discharge is high, around 40% to 55%, thus showing a need for optimal continued rehabilitation and reconstructive care. The focus of care continues on minimizing hypertrophic scar and contracture formation; improving flexibility, strength, and endurance; ensuring proper skin and scar management techniques; and promoting independence in normal daily activities, including self-care and social and recreational pursuits. This long-term rehabilitation phase may include reconstructive surgeries and lifelong services for contractures being exacerbated by patients’ growth and aging. Outpatient therapy services, including occupational, physical, and recreational therapy (RT) aid in the continuum of care that patients need to succeed and return to their life goals.

Hypertrophic scars

From the time of wound closure, clinicians can often predict the potential for hypertrophic scarring. Family genetics increase the likelihood of developing hypertrophic scarring but not as much as the overall time of wound healing. Literature indicates that the time to heal directly correlates to the propensity to form hypertrophic scars (HSs), with those healing in 14 to 21 days having a 30% incidence of HSs and those more than 21 days with a 78% incidence. HSs can affect people’s ability to fully engage in their days. Neuropathic pain, itching, pruritus, and stiffness create barriers in burn patients’ levels of function, including work and recreational activities. Therapy services can offer scar modalities and pressure garment therapy to help in decreasing these symptomatic restraints.

Through the use of manual scar management or compression garment therapy, 2 main goals are achieved: restricting the flow of blood to the scar area and inhibiting growth of the HSs by controlling collagen synthesis by limiting access to blood supply, oxygen, and nutrients. Scars create increased tension and restriction for passive or active movement, which influences the patient’s ability to resume preburn activities. The burn rehabilitation team can manage all the components of so-called scar wars by introducing, educating, and providing the tools needed to enhance patients’ quality of life.

Scar management

Pressure Garment Therapy

Literature continues to question the efficacy of pressure garment therapy in treating HSs ( Fig. 1 ). Although used as long ago as the early 1800s, pressure garments were not used prophylactically or to treat HSs until the early 1970s, based on observed increase rate of maturation. The use of compression garments is currently standard among burn centers to treat HSs because of its “non-invasive characteristics and presumed desirable treatment effects with few associated complications.”

Fig. 1
Hypertrophic scarring following a burn to the dorsal left hand. The efficacy of pressure garment therapy for treating hypertrophic scar has been questioned.

As wound size decreases and tensile strength of the graft or conservative healed skin wounds occur, pressure to the hands can progress from Coban wrap to temporary pressure gloves, with a recommended pressure of 15 to 20 mm Hg. Upper and lower extremity compression can progress from Ace wraps to the use of commercial Tubigrip or Demigrip, which also tend to vary in pressure from 15 to 20 mm Hg. Once a patient’s wounds are well healed, and no dressings are needed, other commercial garments may be measured and fitted to the patient by the therapy team. These products have a high-grade compression of about 30 to 45 mm Hg and can be used for longer durations because the products are of higher quality (ie, Mediven, Jobst, Bioconcept). It has been noted by patient reports that there is a significant improvement in erythema when placed in higher mercury garments, such as 25 to 45 mm Hg, as opposed to the lower-level compression, as their wounds progress in healing. Depending on the funding source of the patient, custom burn garments for any part of the body can be measured by the outpatient therapists and obtained through a company specializing in burn-specific garments. If funding is not available for custom burn garments, consider the use of more affordable garments for the trunk or extremities, such as athletic-style garments ( Table 1 ).

Table 1
Affordable options for compression garments should be considered when funding for custom burn garments is not available
Trunk Garment Options Corsets/Spanx/girdle Abdominal binders 15 cm (6”) Ace wrapping
Upper and Lower Extremity Compression Sliders/biker shorts/compression shorts Basketball/football sleeves Weight-lifting/golf gloves

Assessment tools such as the Vancouver Scar Scale, which is a clinician’s tool to examine pigmentation, pliability, vascularity, and height of scarring, or the Patient and Observer Scar Assessment Scale can aid in understanding the positive results the use of pressure garment therapy can provide. Having patients’ personal input on their progress or personal assessment of their pain, stiffness, and pruritus of their HSs can guide clinicians in altering the use of or need for change in mercury pressure of the garments. Studies have shown that with the use of compression, the height of the HSs can flatten and improve by 92%.

For burn wounds that are deeper or those that require autografting, scar tissue may require 9 to 18 months to reach full maturation. The use of pressure garments decreases the hydration of the scar, reducing the neovascularization and accelerates the remission phase of the postburn reparative process. With the use of pressure garment therapy until this scar tissue maturity is achieved, it minimizes edema, provides a method of scar tissue pliability, and assists with reeducation of abnormal sensory responses.

Patients with burns may require the use of compression garments for 2 years or more, depending on the depth of the injury and the vascular symptoms, which may fluctuate throughout the rehabilitation and maturation phases. Some burn centers recommend wearing compression garments as much as 23 hours a day for 12 months. It is important that patients have continued contact with the therapy team to reassess and monitor potential need for changes to the garments. Family and patient education is essential regarding the rationale for the use of pressure during the acute phase of the burn, as well as frequently throughout the rehabilitation phase, to ensure compliance.

Clinicians should take into consideration both the pros and cons of pressure garments ( Table 2 ) when assessing patients and their primary needs. Although pressure garment therapy has been shown to aid in reducing HSs, other aspects of outpatient therapy, such as exercise, splinting, and reconstructive surgery, allow an optimal level of function and cosmesis to be achieved.

Table 2
Clinicians should consider the pros and cons of the use of pressure garment therapy when addressing a patient’s rehabilitation needs
Pros Cons
Decreased edema Costly
Decreased neuropathic pain Overheating
Increased pliability Unattractive
Flattening of HSs/increased tissue aesthetics Wound breakdown/blistering
Increased psychosocial health Family compliance/adherence

Scar Massage

The use of scar massage in addition to pressure garment therapy can effectively increase the aesthetic appearance of HSs, increase movement of scar contractures, and decrease hypersensitivity and neuropathic pain. The use of massage therapy or therapist-assisted manual elongation techniques has frequently been used in individuals with firm, nonelastic scar tissue or scar bands. A literature review of numerous studies found some evidence for the benefit of massage therapy. Studies show that daily scar massage may prevent and improve HSs by improving scar-related pain, pruritus, pliability, and thickness. Therapists should include education of scar management techniques as soon as burn wounds are closed and not at risk for skin breakdown or abrasion. A thick moisturizing cream, such as Eucerin or Cetaphil, helps to softening the skin before direct manual massage. The technique of scar massage should be to apply a slow, prolonged pressure to areas of tension or thickness, emphasizing areas of a potential or contracted joint. It is suggested that patients complete massage 3 times a day for 5 minutes, especially in an area of HSs, while the joint is in full extension and the scar contracture is at its fullest pull or tension. Massage techniques create a force and mechanical change in the direction and pull of the scar tissue that seems to create a disruption of the fibroblasts. Patients report a decrease of pain and pruritus with the use of massage techniques. A reduction of pain with the use of massage techniques could be attributed to the release of dopamine, which is obtained through firm pressure. Often patients are hypersensitive to deep scar massage so techniques of desensitization should also be introduced. Simple techniques such as touching or rubbing areas with different textures ranging from cotton balls to terry cloth towels, as well as just having the patient touch the newly healed skin, can aid in sensitivity and normalizing touch.

Silicone

Scar tissue can be further influenced by the therapist with the use of silicone gel or silicone gel sheets. In the current practice guidelines for the use of silicone, it is recommended for use with immature scars that have a high potential of developing HSs. The process of positive scar influence through the application of silicone has been described as hydration and occlusion, which seems to reduce the activity of fibroblasts and collagen development. Silicone can be used under an Ace wrap or pressure garment. Guidelines recommend that the silicone extends 5 mm beyond the margins of the scar. The silicone wearing time should begin at 1 to 2 hours, and, if there is no development of skin reaction or pruritus, then should increase daily until 23 hours a day is reached. To further minimize skin problems, the silicone must be removed, with the area of application and the silicone washed and dried thoroughly several times a day. For selected patients, the ability to tolerate the silicone is poor if their home environment or work place has high temperatures and humidity; for these patients it may be limited to a few hours daily. The incidence of skin maceration and contact dermatitis increases in this type of environment and should be monitored.

Silicone products come as a gel or hydrogel sheet and also as a silicone spray, which can be more costly. There are also over-the-counter options of silicone that can be purchased by patients who are not able to purchase because of financial strain ( Box 1 ). Most insurance companies do not cover the expense of silicone and this becomes an out-of-pocket expense for the patient and family.

Box 1

  • Swimmer’s ear wax

  • Nipple pads for breast-feeding mothers

  • Prosthetic liners

  • Over-the-counter (drug store) silicone Band-Aids

Affordable silicone options should be considered when gel sheet, hydrogel sheet, or silicone spray are not available to the patient

Studies show that the use of silicone gel sheet or spray with compression garments and pressure garment therapy alone for 1 year were associated with significant improvement of the Vancouver Scar Score and the subscores for pliability, height, pruritus, and vascularity at the 18-month end point. If patients can be provided with scar management tools, such as compression therapy, scar massage, and silicone, there is an increased likelihood of returning back to their normal lives at a quicker rate.

Therapeutic exercise in the long-term rehabilitation phase

During the outpatient rehabilitation phase of recovery, patients with burns may go through countless physical and emotional changes. Once home, patients begin to experience both functional and social consequences from the burn injury, all of which have a direct effect on the motivation to remain compliant with therapy recommendations. Before discharge from the acute setting, a patient’s strength and endurance may be adequate for independence in daily living. Once home, fatigue may be a major barrier to success. Because of this a continued rehabilitation program and open communication with the therapy team must continue after discharge.

Patients who sustain burn injuries can experience diminished activity performance caused by the sequelae of immobilization, ventilator dependence, and the burn-related catabolic response. Hypermetabolism following a burn injury can result in loss of muscle mass, leading to rapid-onset muscle fatigue. During this phase, individuals attempting to complete activities of daily living (ADL) must perform at a higher percentage of their maximal effort. The predicted age-appropriate resting energy expenditure following a burn injury remain increased by 20% to 100% for months to years. The burn-induced catabolic response can persist from 9 months to 3 years after the burn, resulting in an impaired ability of the individual to effectively resume preburn activities.

Burn injury causes protein synthesis and muscle atrophy to occur at the site of the injury as well as distant to the injury. A 2016 survey of individuals with larger percentage burns found that more than 30% identified muscle weakness and more than 50% reported fatigue. In addition, patients with an average length of stay of 15 days, indicating small percentage burns, also had muscle weakness greater than the matched controls. Pulmonary function following a burn injury has been identified as being decreased compared with the patients’ age-related peers. Pulmonary function has been found to remain decreased for months to years following a burn, regardless of the presence of an inhalation injury. During the first 2 years following the burn injury pulmonary change may be identified as having an obstructive pattern, and later develops into a restrictive pattern.

In recent years, an effort has been made to determine whether a structured resistive exercise program could benefit patients who have sustained a burn injury. From the work and research completed to date, it is recommended that individuals more than 7 years of age should be evaluated for strength and cardiovascular performance. When assessments indicate the individual is below norms for the individual’s age group, a structured, supervised resistance and/or aerobic program should be implemented. Following participation in a structured supervised resistive exercise program, individuals reported an improvement in health-related quality of life equal to their noninjured counterparts. Although Storch and Kruszynski did not specifically study the effects of an exercise program on individuals following a burn, they focused on individuals admitted to an intensive care unit (ICU) and found similar positive effects of psychosocial improvements. Storch and Kruszynski indicated that physical exercise programs can contribute to improvements in cognitive function; specifically, memory, concentration, and focus. With a structured resistive exercise program for individuals with burn injury, an increase in protein synthesis also produced an increase in muscle size and lean body mass, regardless of age or gender.

In the first 6 to 8 weeks of an exercise program, improved efficiency in neural recruitment patterns, which contributes to increase in muscle power, was observed. Muscle hypertrophy occurs during the 12 to 16 weeks of the resistive program.

The use of propranolol in children resulted in improved maximal oxygen uptake (V o 2 ) compared with a group that received only a resistive-only program. However, the use of this beta-blockade with adults is associated with negative outcomes. For children and adults, more improvements were noted when an anabolic agent, such as oxandrolone, was used in conjunction with the exercise program.

In “Practice Guidelines for Cardiovascular Fitness and Strengthening Exercises Prescription after Burn Injury,” it is recommended that children to receive a structured exercise program for up to 12 weeks and adults from 6 to 12 weeks. However, current research has not extended beyond 12 weeks and the potential for benefits remains unknown. For children less than 7 years of age, an increase in movement of elbows and knees was recorded when their programs included both music exercise and rehabilitation compared with rehabilitation only. Both programs resulted in greater improvements than no structured therapy.

For patients with less than 15% total burn surface area (TBSA) with unhealed burn wounds, participation in an exercise program produced positive effects on pain reduction, muscle strength, and movement without harm to the healing process. With the use of handheld dynamometry, the greatest minimal detectable difference in muscle strength was with static grip strength and the least was in the deltoids. The study reported that the biceps and quadriceps strength increased in a linear trajectory with biceps at 0.1 kg/d and quadriceps at 0.18 kg/d. Static hand grip strength decreased between day 1 and 3 by 1.76 kg/d; however, between day 4 and 6 it increased by 1.13 kg/d.

Research work performed to date has shown that patients involved in a structured exercise resistive program versus those who are not require fewer invasive surgical procedures; at 6 months they have greater aerobic capacity, muscle strength, and lean body mass, and return to work sooner. Resistive programs could begin on an inpatient basis, although many are established after discharge. A work-to-tolerance program for 12 weeks is suggested by de Lateur and colleagues, whereas Porter and colleagues provide a 6-week program for those with less than 60% TBSA and a 12-weeks program for those with more than 60% TBSA. Although most of the outpatient resistive exercises programs are 3 days a week for 30 minutes, the length of the session is influenced by the patient’s deconditioned status. For patients transferred to an inpatient rehabilitation program, portions of the resistive exercise program can be initiated if active movement of the body area is within functional limits. The author’s program places patients in an elongation, movement, endurance, and progressive resistive program within 24 to 48 hours following burn hospital discharge for 2 to 4 hours, 3 days a week, with no harmful events occurring. The length of the program is based on the patient’s s preburn activity level; for those needing to return to competitive employment/work, the program may be up to 12 to 16 weeks.

Outpatient treatment activities are similar to those used during the inpatient rehabilitation phase, but their intensity and frequency increase. Scar management techniques such as massage and elongation continue but there is a greater focus on strengthening, and ADL independence is essential as well. Because scar management is more successful during the early stages of wound maturation, limitation in self-care ability can be resolved if appropriate treatments are implemented. Performing basic self-care activities, such as donning compression garments or working on applying lower body clothing, can also be an effective and meaningful way to increase strength, endurance, and coordination. It is important not to introduce adaptation tools early, such as ergoreachers or built-up handles, without first applying compensatory techniques because burn patients’ scar contractures are relative to the amount of accommodation that is provided to the pattern of scar.

Positioning/Splinting

Once scars mature in the rehabilitation phase, the need for splinting and preventive positioning decrease but there are times when a scar contracture is so advanced that prevention of further loss of motion is the next therapy goal. When a patient is compliant with postdischarge management and has access to the use of preventive tools such as splints, further surgical reconstruction can often be avoided. During the long-term phase of rehabilitation, scar maturation occurs but range of motion gains can still be achieved with the use of home exercise program (HEP) and progressive splinting ; research has shown that splinting alone can be more effective in reversing scar contractures more rapidly than all other interventions in this phase.

Static and/or dynamic splinting can be effective as a corrective force to exert or stretch the tight tissue or correct an existing contracture. Static splints can be used during rest or sleep to maintain the range of motion that is achieved throughout the day with dynamic splinting and the HEP. Splints should be fabricated to have the wrist in a neutral 10° to 15° of extension, metacarpophalangeal (MCP) joints at 70° to 90° of flexion, and the thumb in a combination of radial and palmar abduction at the carpometacarpal, and MCPs at full neutral extension (very similar to positioning in the acute phase).

Dynamic splinting works on the biomechanical principle of increasing tissue creep by applying a constant force to progressively lengthen the tissue over time using rubber bands or pulleys ( Fig. 2 ). Studies show that increased tissue length occurs in a manner similar to the increase that occurs during the use of tissue expanders in burn reconstruction. Although custom dynamic splinting may be time consuming, this is preferred compared with static splints to enhance functional gains.

Nov 21, 2017 | Posted by in Dental Materials | Comments Off on Current Concepts Burn Rehabilitation, Part II
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