Burns Rehabilitation.pptx

Rehabilitation is an essential component in the management of patients with burns and should be commenced on the day of injury is sustained. In other words, oedema control, respiratory care, positioning, functional movements which are pertinent in burn cases must begin without delay[1]. The process of rehabilitation requires efforts from a multidisciplinary team of health professionals who specialise in burn care viz: physiotherapists, doctors, nurses, occupational therapists, dieticians, psychologists, plastic surgeons, psychologists, social workers etc. Family members and support groups should also be involved in the recovery process of these patients.

Therapeutic exercises to maintain and improve ROM as well as enhance muscle strength.
Transcutaneous Electrical Nerve Stimulation (TENS) to relieve pain and pruritus (itching).
Hydrotherapy to encourage ROM exercises especially when there is marked pain and patient is fearful to move limbs.
Paraffin wax therapy when applied to contractures in the extremities can improve ROM[7]
Extracorporeal shockwave therapy (ESWT). Low-energy ESWT along with traditional physiotherapy has been shown to relieve burn scar pain, pruritus and improve health-related quality of life[8][9]. It can also be used to improve scar appearance and functional mobility in patients with severe burns[10].
Scar tissue massage to improve the pliability of scars. The video below shows different scar tissue massage techniques.

1. Burns Rehabilitation Jebastin Immanuel PG Student Master of Physiotherapy in Neurological and Psychosomatic Disorders

2. Contents Introduction & Aims Classification of Burns Mechanism of Injury Early Stage of rehabilitation Late Stage of Rehabilitation Guidelines Recent Evidences/Advances

3. Introduction In India around 7 million people suffer from burn injuries each year with 1.4 lakh deaths and 2.4 lakh people suffer with disability Out of 5 burn victims 4 are women and children. Burns are also a leading cause of morbidity. Rehabilitation is an essential and integral part of burn treatment Burns rehabilitation should be a team approach. The term ‘Burns Rehabilitation’ incorporates the physical, psychological and social aspects of care.

4. Aims Of Burns Rehabilitation minimize the adverse effects caused by the injury in terms of maintaining range of movement, minimizing contracture development and impact of scarring, maximizing functional ability, maximizing psychological wellbeing, maximizing social integration

5. Classification https://youtu.be/UaCn15ei5Lo https://youtu.be/Up5z-e37v-A

6. Mechanism of Injury Heat burns   Hot liquids (scalds) . Hot solids (Contact burns):  Flames: Chemical burns Electrical burns Inhalational burns: Inhalational burns are the result of breathing in superheated gases, steam, hot liquids or noxious products of incomplete combustion

7. Early Stage Of Rehabilitation Critical Care Psychological Impact Anti-contracture positioning Splinting Stretching Early Mobilisation Activities of Daily Living Education

8. Critical Care Physical Rehabilitation should start from day 1 Postural management Elevation of all limbs Areas of potential pressure PROM C hange of dressings

9. Psychological Impact Initial and hospital experience Nightmares and flashback of events Comfort and reassurance

10. Anti-Contracture positioning From day 1 to Many months after discharge Positioning is important Tissue length Scar tissue ROM Patient rest in a comfort flexion position Wound Healing Burn wound not being nursed in anti contracture position with impending neck and axillary contracture

11. Area burnt Contracture/ difficulty experienced Anti-contracture position Front of neck Neck flexion. The chin is pulled towards the chest reducing neck movement. Contours of the neck are lost [ Figure 2 ] Neck in extension. No pillow behind head, roll behind neck. Head tilted back in sitting [ Graph 2 ]

12. Area burnt Contracture/ difficulty experienced Anti-contracture position Posterior neck Neck extension and other neck movements [ Figure 3 ] Sitting with head in flexion. Lying with pillows behind the head [ Graph 3 ]

13. Area burnt Contracture/ difficulty experienced Anti-contracture position Axillas or anterior and posterior axilliary fold Limited abduction, protraction when burns also to chest [ Figure 4 ] Lying and sitting - arms abducted to 90 degrees supported by pillows or foam blocks between chest and arms. Figure of eight bandaging or strapping to provide stretch across chest [ Graph 4 ].

14. Area burnt Contracture/ difficulty experienced Anti-contracture position Front of elbows Elbow flexion [ Figure 5 ] Elbow extension [ Graph 5 ]

15. Area burnt Contracture/ difficulty experienced Anti-contracture position Back of hands Metacarpalphalangeal (MCP) Wrist - 30–40 degrees extended, MCPs 60-70 degrees flexion, IP joints in extension, thumb mid-palmar radial abduction [ Graph 6 ] Hyperextension, interphalangeal (IP) Flexion Adduction of thumb Wrist flexed [ Figure 6 ]

16. Area burnt Contracture/ difficulty experienced Anti-contracture position Palm of hand Fingers adducted and flexed, palm pulled inwards [ Figure 7 ] Wrist extended, minimal MCP flexion, fingers extended and abducted. [ Graph 7 ]

17. Area burnt Contracture/ difficulty experienced Anti-contracture position Groin (hip) Hip flexion Lie in prone with legs extended. Limit sitting and side lying. Supine lying with legs extended, no pillow under knees [ Graph 8 ] Hip adduction [ Figure 8 ]

18. Area burnt Contracture/ difficulty experienced Anti-contracture position Back of knee Knee flexion [ Figure 9 ] Legs extended in lying and sitting [ Graph 9 ]

19. Area burnt Contracture/ difficulty experienced Anti-contracture position Feet Feet are complex structures and can be pulled in different directions by healing tissues preventing normal mobility [ Figure 10 ] [ Figure 11 ] Ankles at 90 degrees – use pillows to maintain position. Encourage sitting with feet flat on floor as long as no oedema present [ Graph 10 ].

20. Area burnt Contracture/ difficulty experienced Anti-contracture position Face The face can be effected in various different ways including inability to open or closer mouth fully and inability to close eyes fully Regular change of facial expression and stretching regime required. A well-padded tube can be inserted into the mouth to combat mouth contracture [ Graph 11 ]

21. Splinting Highly effective method Maintain Anti- contracture position Remodel scar tissue Application of controlled stretch Early application of Splints ( a,b ) Foam and blown polystyrene along with PVC pipes used to make hand splints

22. Materials Plaster of Paris Cardboard Foam and blown polystyrene PVC piping  (a) PVC pipes and elbows cut, (b) padded and (c) fabricated into axillary splints

23. Stretching & Early Mobilization Several times a day Therapists should use Clinical judgement. Incorporating Games in Peads Encouraging patients amidst pain Therapeutic Exercise Ambulation of joints Neurovascular integrity Cardio and resp Capacity Coordination Balance Strength Endurance

24. Before mobilizing Check for Recent surgery Vitals Building Patients confidence

25. Activities of Daily Living

26. Education Education is of paramount importance along with a consistent approach from all members of the multidisciplinary team Initial reluctance due to frustration, pain and fatigue is to be countered by encouragement and education.

27. Wound healing in Burns Wound healing has four phases: H emostasis, I nflammation, T issue proliferation and T issue maturation or remodeling

28. Pathological Changes Local Response Douglas Jackson has classified thermal injury into 3 zones. zone of coagulation zone of stasis zone of hyperemia

29. Stage of Shock This lasts for 2-3 days, longer in elderly There is increase capillary permeability with loss of protein and electrolyte from the blood The main changes are Reduced plasma volume Increased proportion of RBC to plasma into blood vessels- resulting in increased blood viscosity and slowing of circulation. Reduction of cardiac output Increased heart rate

30. Pathological Changes Can be seen in three stages Stage of Shock Stage of eschar (burned skin) removal Stage of Healing

31. Complications Primary Systemic Complications Pulmonary edema Occlusion of arteries Cardiac failure Renal failure Liver failure Permanent brain and vital organ damage

32. Secondary Systemic complications Infection Pulmonary Complications Metabolic Complications Cardio vascular complications Heterotopic ossification Neuropathy

33. Late Stage of Rehabilitation Psychological Impact Scar Management Positioning Splinting Stretching and exercise Massage Pressure Therapy Silicone Activities of daily Living Social Rehabilitation

34. Summary Rehabilitation from a burn injury is a lengthy process, which starts on day one and involves a continuum of care through to scar maturation and beyond. It involves a dedicated multidisciplinary team of professionals and the full participation of the patient. Sustaining a burn injury, however big or small can have a dramatic affect on the individual’s physical and psychological well-being and requires teamwork and commitment to help each individual overcome the difficulties they may encounter. While the path is not always easy, with the right support and therapeutic intervention, the commitment of the team to not accept even one contracture, and provide understanding of the psychological and social challenges, the patient can reach their maximum physical, psychological and functional outcome.

35. References Rehabilitation of the burn patient https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3038404/# https://www.nhp.gov.in/disease/skin/burns