Rehabilitation in the Acute Versus Outpatient Setting

Rehabilitation of patients with burn injuries aims to restore strength, coordination, and mobility as closely to normal as possible and should begin immediately after initial admission. In the acute phase, baseline assessments are made against which all subsequent rehabilitation success is held. In the intermediate phase, active, full range-of-motion movement, ambulation of steadily increasing distances, and resistive exercise and stretching aid in the prevention of muscle and bone atrophy and preserve muscle memory and coordination. In the long-term outpatient rehabilitation phase, individualized patient-centered exercise programs can be advantageous in achieving measurable and lasting positive rehabilitation outcomes.

Key points

  • Rehabilitation of patients with burn injuries aims to restore strength, coordination, and mobility.

  • Occupational and physical therapy should begin immediately after admission.

  • A defined combination of aerobic and resistive exercise is helpful to enable a physical transition toward independent living and performance of activities of daily life as well as return to work.

Introduction

Medical and technical advancements over the last decades have greatly improved survival of acute thermal injury. With an increasing percentage of patients surviving severe and even massive burns, a paradigm shift is underway to accommodate for the specific acute, midterm, and long-term medical needs of an increasing number of patients who simply did not exist in the past.

Rehabilitation of thermally injured patients is defined as the part of specialized health care that focuses primarily on regaining and improving strength, cognition, and mobility following the injury. The overarching goal in doing so is to approach the degree of preinjury abilities as closely as possible.

The challenges in the rehabilitation of patients with burn injuries are on one hand similar to those in other critically ill patients and on the other hand unique in regard to burn injury and its sequelae. Generally, prolonged immobility during intensive care, resulting in muscle and bone wasting, loss of strength and coordination, as well as complications arising from secondary infection are common problems in all critically ill patients. Specifically in patients with severe burn injury, factors such as periodically recurring operations, delayed closure and secondary infection of dermal wounds, pulmonary dysfunction resulting from inhalation injury, and the need for specific positioning of patients in order to protect skin-grafted areas or donor sites represent serious challenges to early rehabilitation. Later in the course of hospitalization and outpatient treatment, challenges arise mostly from the formation of scar contractures over joints, cardiopulmonary dysfunction, the long-term consequences of major amputations, and psychosocial successions of a burn.

In any case, the rehabilitation efforts necessary to reach the full potential of recovery correlate with the extent of burn injury, the age of patients, the presence of concomitant injury or comorbidities, and the individual capacity of patients to perform the necessary tasks.

The main goals of burn-related rehabilitation are to maximize functional and cosmetic outcomes. Important short-term objectives focus on the preservation and improvement of range of motion (ROM) and functional ability. The most important long-term target is to facilitate return to independent living and working and to compensate functional losses. An accepted approach toward the conceptualization of burn rehabilitation is the subdivision into its phases and their specific priorities.

Introduction

Medical and technical advancements over the last decades have greatly improved survival of acute thermal injury. With an increasing percentage of patients surviving severe and even massive burns, a paradigm shift is underway to accommodate for the specific acute, midterm, and long-term medical needs of an increasing number of patients who simply did not exist in the past.

Rehabilitation of thermally injured patients is defined as the part of specialized health care that focuses primarily on regaining and improving strength, cognition, and mobility following the injury. The overarching goal in doing so is to approach the degree of preinjury abilities as closely as possible.

The challenges in the rehabilitation of patients with burn injuries are on one hand similar to those in other critically ill patients and on the other hand unique in regard to burn injury and its sequelae. Generally, prolonged immobility during intensive care, resulting in muscle and bone wasting, loss of strength and coordination, as well as complications arising from secondary infection are common problems in all critically ill patients. Specifically in patients with severe burn injury, factors such as periodically recurring operations, delayed closure and secondary infection of dermal wounds, pulmonary dysfunction resulting from inhalation injury, and the need for specific positioning of patients in order to protect skin-grafted areas or donor sites represent serious challenges to early rehabilitation. Later in the course of hospitalization and outpatient treatment, challenges arise mostly from the formation of scar contractures over joints, cardiopulmonary dysfunction, the long-term consequences of major amputations, and psychosocial successions of a burn.

In any case, the rehabilitation efforts necessary to reach the full potential of recovery correlate with the extent of burn injury, the age of patients, the presence of concomitant injury or comorbidities, and the individual capacity of patients to perform the necessary tasks.

The main goals of burn-related rehabilitation are to maximize functional and cosmetic outcomes. Important short-term objectives focus on the preservation and improvement of range of motion (ROM) and functional ability. The most important long-term target is to facilitate return to independent living and working and to compensate functional losses. An accepted approach toward the conceptualization of burn rehabilitation is the subdivision into its phases and their specific priorities.

Acute rehabilitation phase

Despite the vast challenges associated with it, there exists a broad consensus among experts that burn rehabilitation must start as early as possible. The acute phase of rehabilitation ranges from the patients’ admittance to the burn unit, over the days of early excision and skin grafting, to the beginning of wound healing.

Baseline Assessment

The first step in rehabilitation should be an initial assessment of patients’ status that includes general information regarding the mechanism and extent of the sustained injury as well as details that directly impact rehabilitation, such as exposed tendons, the presence of concomitant fractures, and inhalation injury. Next, baseline measurements of ROM, muscle strength, sensation, and a history and assessment of the ability to perform activities of daily life before and immediately after the injury are recorded and serve as reference for future rehabilitation improvement and success. Next, patient-centered short- and long-term rehabilitation goals are defined during the onset of early acute care.

Positioning and Splinting

The objectives of effective patient positioning and splinting are to minimize contractures and joint deformities, optimize joint alignment, maintain ROM and tissue elongation, facilitate remodeling of adhesions, prevent pressure points and sores, protect operated sites (skin grafts and flaps), assist weakened muscles, and reduce edema through elevation.

The therapeutic armamentarium ranges from splints, special mattresses, and cut-out-foam, serial casting and strapping to the surgical placement of pins to maintain certain joint positions.

Special splints can be used to optimally position and prevent early contracture of the mouth, ear, nostrils, neck, shoulder and axilla ( Fig. 1 ), elbow ( Fig. 2 ), hip, knee, ankle, and foot. The ankle equinus deformity develops earliest, is most resilient to treatment, and should be avoided whenever possible through proactive fixation of the joint as shown in Fig. 3 (Multi Podus Splint TBC 47.7, AliMed, Dedham, MA).

Fig. 1
Bilateral axillary splints to prevent formation of acute contracture.

Fig. 2
Severe elbow contracture and correct splinting of the elbow.

Fig. 3
Severe wrist and hand contracture and correct splint placement for prevention.

The wrist and hand are especially prone to early contracture and should be splinted into 0° to 30° extension within the first 24 to 72 hours to prevent claw hand. The authors recommend metacarpophalangeal (MCP) joints be splinted in 70° to 80° flexion and interphalangeal (IP) joints to full extension. The thumb is splinted in a combination of palmar and radial abduction, and the MCP and IP joints are slightly flexed ( Fig. 4 ).

Fig. 4
Multipodus foot and ankle splint to prevent contracture.
( From Serghiou MA, Ott S, Whitehead C, et al. Comprehensive rehabilitation of the burn patient. In: Herndon DN, editor. Total burn care. 4th edition. Philadelphia: Elsevier; 2012. p. 517–49; with permission.)

Patient positioning protocols that regulate frequent and defined position changes during extended periods of immobilization should be installed in every burn unit to prevent pressure points and ulcers. The supine patient position is preferred unless otherwise necessary.

Therapeutic Exercise

Early physical therapy preserves joint mobility, promotes edema resolution, and prevents muscle atrophy, disuse osteoporosis, as well as respiratory and cardiac complications while reducing functionally impairing scar contractures.

Exercise must be started immediately in any conservative and most operative patient management regimens. Procedures such as debridement and fasciotomy or the placement of heterografts or synthetic dressing materials are not contraindications for exercise. The placement of skin grafts over joints may warrant a discontinuation of physical therapy in the particular area for 4 to 5 days but may otherwise not halt exercise efforts.

During the early phase of exercise, short duration and high frequency are favorable; complete active ROM exercise, preferably performed independently by patients, is best. Patients move major joints according to their full ROM to maintain mobility. If patients are critically ill, intubated, medicated, or otherwise unable to move fully and actively, assisted active ROM exercises are the treatment of choice followed by passive complete ROM if no active movement is possible.

Resistive exercise prevents muscle and bone atrophy and increases strength and proprioception and coordination. During the early phase, isometric exercise with or without gentle manual resistance during bed rest has been shown to conserve muscle memory.

Ambulation should be initiated as soon as patients with burn injuries are medically stable to do so. Walking provides mild cardiovascular conditioning, prevents pressure sores, preserves muscle strength and function, and increases appetite. A systematic analysis by Smith demonstrated a lower incidence of pulmonary embolism and deep vein thrombosis as well as shorter duration of hospitalization when patients with lower extremity skin grafts ambulated immediately after surgery. The Unna Boot, an impregnated semirigid bandage, can be used in combination with lower extremity skin grafting, facilitates earlier ambulation, and can be left in place for up to 7 days after grafting.

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Nov 21, 2017 | Posted by in Dental Materials | Comments Off on Rehabilitation in the Acute Versus Outpatient Setting
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