Burns - types, evaluation and occupational therapy

The role of occupational therapist in burns

1. BURNS P. GRIZELDA EVANGELINE BOT- INTERN

2. SKIN AND ITS LAYERS The SKIN is the body’s largest organ of the body and primarily serves as an environmental barrier. The functions of the skin are Sensation Thermoregulation Protection from chemical or bacterial invasion and ultraviolet rays Prevention of loss of body fluids When the skin is damaged a myriad of systemic, physiological and functional problems can occur.

3. LAYERS OF THE SKIN Epidermis Top outermost layer of the skin. Non vascular layer made up of epidermal cells. Dermis Middle layer of the skin. Makes up 80 percent of skin’s thickness. A network of capillaries, sweat glands, sebaceous glands, nerve endings and hair follicles. Hypodermis Bottom or fatty layer of the skin. Has connective tissues and helps nerves and blood vessels. Also called as subcutaneous fat.

4. BURNS A burn is an injury to the skin or other organic tissue primarily caused by heat. Common sources of heat: Thermal – Hot liquids (scalds), Hot solids (contact burns), Flames (flame burns) Chemicals – Strong acids, paint thinner or gasoline, acid attack (abuse) Radiation – X-rays, Ultraviolet radiation (sunlight) Electrical – electrical current shock, either AC or DC

5. CLASSIFICATION OF BURNS

6. Superficial Partial Thickness Burn (1 st and 2 nd Degree burn) Appearance: Red or Bright pink Blistered Texture wet and soft. Areas of destruction: Epidermal layer and possibly portions of the upper dermal layer. Sensation: Intact Exposed nerve endings make wound painful. Extremely sensitive to change in temperature, exposure to air and light touch. Blanching: Present and pronounced Wound closure: Spontaneous re epithelialization in 14 days or less. Grafting is not necessary.

7. Superficial Partial Thickness Burn (1 st and 2 nd Degree burn)

8. Deep Partial Thickness Burn (Deep 2 nd Degree Burn): Appearance: Mottled red or waxy white Wet looking Wound is soft and elastic Areas of destruction: Epidermis and greater portions of dermal layer (hair follicles, sweat glands, epitherlial elements intact) Sensation: May be intact with areas of diminished sensation. Sensitive to pressure, insensitive to pinprick and light touch Blanching: Present but diminished Wound closure: Re epithelialization from the epithelial bed in 3-6 weeks

9. Deep Partial Thickness Burn (Deep 2 nd Degree burn)

10. Full Thickness Burn (3 rd Degree Burn) Appearance: White or tan Waxy or thrombosed veins Dry, leathery texture Wound rigid, non elastic Areas of destruction: Entire epidermis and dermal layers Hair follicles, nerve endings, epithelial elements, sweat glands if fat layer is involved Sensation: Wound initially painless Blanching: Absent Wound closure: Skin grafts required, spontaneous re epithelialization impossible due to destruction of epithelial elements.

11. Full Thickness Burn (3 rd Degree Burn)

12. Classical Electrical Burn (4 th Degree Burn) Appearance: Entry wound charred and depressed. Exit wound dry with depressed edges, “explosive” appearance. Areas of destruction: Deep soft tissue damage to fat, muscle and bone (not always apparent immediately). Blood vessels thrombosed. Nerves along path of electricity. Note: Fractures or dislocations may occur if current was strong enough to cause tetanic muscle contractions of dominant muscle group. Sensation: Absent at entry and exit sites. Blanching: Absent. Wound closure: Extensive surgical excision of necrotic tissue followed by skin grafts. Possible amputation.

13. Classical Electrical Burn (4 th Degree burn)

14. SYMPTOMS I˚ degree burn Painful burn Redness swelling II˚ degree burn Scarring Painful, redness Sensation problem Loss of temperature control Pigment changes Dependent edema (gravity related swelling) III˚ degree burn Same as II˚ degree burn symptoms More sensory loss Numb sensation No hair growth after graft IV˚ degree burn Affects Functional performance

15. Methods to calculate the percentage of body burned WALLACE’S RULE OF NINE Head and neck = 9% (4.5% for anterior and 4.5% for posterior) Trunk = Anterior 18%, Posterior 18% Arms = 18% (9% for one arm – 4.5% for anterior and 4.5% for posterior) Legs = 36% (18% for one leg – 9% for anterior and 9% for posterior) Genitals and perineum = 1%

16. Severity is measured by % of TBSA burned Small = 15% of TBSA Moderate = 15% to 49% of TBSA Large = 50% to 69% of TBSA Massive = more than 70% of TBSA Depth is measured by the number of layers of skin burned I degree = superficial or partial thickness of epidermis II degree = deep partial thickness of epidermis and varying depths of dermis III degree = Full thickness of epidermis, dermis and subcutaneous tissues, tendons/muscle, hair follicles.

17. Scar formation After initial healing, most burn wounds have an erythematous , flat appearance. As the healing process continues, the wound’s appearance may change as a result of scar hypertrophy and contraction . The amount of time needed to achieve wound closure is a strong determinant - Age, race, and burn depth are other variables. Bacterial infections in the wound increase the inflammatory response, which can delay wound healing and contribute to scar formation. However, any factor that delays healing will increase the potential for scarring.

18. Hypertrophic scars are thick, rigid, erythematous scars that become apparent 6 to 8 weeks after wound closure. Superficial burns that heal in less than 2 weeks will not generally form a hypertrophic scar. Deeper burns that take longer than 2 weeks to heal have a greater potential to form hypertrophic scars. Although most hypertrophic scars mature in 1 to 2 years.

19. Hypertrophic scars Keloid scars Appear as a red raised scar tissue Often appear as shiny rounded protuberances Colour ranges from pink to purple Scarring does not extend beyond boundary of original wound Scarring extends beyond boundaries of original wound Promote scar contracture Do not promote scar contracture Can regress with time Do not regress with time Nodular structures containing α -SMA producing myofibroblasts. Rarely nodular, no α -SMA producing myofibroblasts.

20. OT ASSESSMENT Burned areas Skin and scar condition Scar measurement Pain ROM -PROM -AROM Contracture Edema Hand functions In hand manipulation Precision handling Non prehensile functions

21. Muscle strength Sensory testing Functional Mobility Ambulation ADL Self care Productivity Leisure Psychosocial Affect Mood Coping skills Home and work environment evaluation

22. Problems relevant to OT Self care is affected Loss of performance due to burned hands/arms or legs Guarding position: Flexion and adduction Difficulty in dressing and other activities (unable to extend) Productivity is affected Leisure is affected Due to burns in lower limbs – unable to do outdoor activities or sports and burns in upper limb – unable to perform fine and gross motor activities

23. Sensorimotor Decreased ROM Muscle weakness Muscle atrophy Loss of grip and pinch strength Poor posture Contracture Deformity Mobility and ambulation is affected Severe pain Edema Loss of energy endurance Loss of sensory Tactile Proprioceptive Temperature Pressure sores Psychosocial Loss of self esteem Loss of self confidence Helplessness Loss of interest and motivation

24. CONTRACTURES: Contractures occur when the burn scar matures, thickens, and tightens. This can prevent movement. It usually occurs when a burn occurs over a joint. A contracture is a serious complication of a burn. Face Oral commissures of mouth Anterior neck Axilla Elbow Wrist Interphalangeal (IP) joints Fist web space of hand Knee

25. DEFORMITIES Burn deformities occur secondary to skin loss. But, deformity correction involves not only correcting the skin loss but also the secondary changes that have occurred in the musculotendinous units and joints. The most common deformities resulting from severe burns are contractures and the scarring or sticking together of skin around joints. Post burn deformities most often require plastic or reconstructive surgery for treatment. Face Mouth microstomia Closure of nares Loss of ear cartilage Neck Flexion Lateral scar banding

26. Shoulder Elevation Protraction Adduction, Internal rotation Elbow Flexion with pronation Hand Claw hand (MCP hyperextension) PIP and DIP flexion Flattened palmar arch Trunk Scoliosis Kyphosis

27. Hip Flexion Adduction Knee Flexion Hyperextension Ankle Equinovarus Plantarflexion Eversion Foot MTP hyperextension

28. OT INTERVENTION Acute care phase Surgical and postoperative phase Rehabilitation phase: inpatient Rehabilitation phase: outpatient ACUTE CARE PHASE Preventive Positioning The purpose of preventive positioning is to reduce edema and maintain the involved extremities in an antideformity position. The typical position of comfort consists of adduction and flexion of the UEs, flexion of the hips and knees, and plantar flexion of the ankles. The toes are generally pulled dorsally.

29. Splinting Splinting is initiated to maintain correct positioning and protect compromised tissues. It is not necessary for splints to be worn at all times to prevent contractures. When a splint is used during the acute phase, it is generally static in design and applied when at rest, with activity and exercise being emphasized during waking hours.

30. NECK

31. Axilla

32. Elbow

33. Knee

34. Ankle

35. Classic burn palmar pan splint Burn palmar pan splint Variation Palmar wrist cockup splint

36. Palmar wrist cockup with thumb component Dorsal pan splint

37. Therapeutic Exercise and Activity Tolerance These activities are initiated as soon as the client is medically cleared to get out of bed and bear weight on his or her LEs. Sitting tolerance Transfers Ambulation If the client has burns on the LEs, elastic wraps should be applied before the client sits up and the feet become dependent. When the client is sitting in a chair, the LEs should be kept elevated . Any time spent dangling the feet or standing statically should be limited to prevent distal venous congestion and unnecessary discomfort.

38. In addition to functional activities, active exercise is a primary component in every burn treatment plan Active exercises Active assisted exercises Passive exercises The focus of exercise in acute care is to preserve ROM and functional strength, build cardiopulmonary endurance, and decrease edema. Strengthening activities are introduced into the acute care intervention program as soon as the patient’s condition allows. Active movement activities Resistive activities

39. Hand exercises

40. Axilla stretch minimal banding or pull Neck stretch (mouth and teeth closed) Neck stretch with assistance Hand exercises – full flexion Axilla stretch with banding

41. ADL Make temporary use of adaptive equipment necessary. This equipment may include built-up or extended handles on utensils, a plate guard , or an insulated travel mug with a lid and straw . Hair grooming and shaving are other self-care activities to initiate early, depending on the client’s strength and activity tolerance. Modifications in the client’s environment , equipment, or previous performance patterns may be necessary to support independence.

42. SURGICAL AND POSTOPERATIVE PHASE Positioning and Postoperative Splinting Therapeutic Exercise and Activity Activities of Daily Living and Client Education Positioning and postoperative splinting: postoperative immobilization to allow adherence and vascularization of the grafted skin. postoperative immobilization is often achieved through the use of bulky restrictive dressings and standard positioning equipment , splints are frequently needed to maintain the position. Most splints are typically made with plaster bandages or thermoplastic materials.

43. Therapeutic Exercise and Activity Throughout the postoperative phase of care, active and resistive exercise of the uninvolved extremities should be continued when possible to prevent loss of ROM and strength. The average period of immobilization is 3 to 5 days, Exercises can be resumed as soon as graft adherence is confirmed. Gentle AROM Active exercise of a body area with a donor site is generally permitted after 2 to 3 days if no active bleeding is present Standard treatment for LEs involves elevation and wrapping with elastic bandage . Ambulation following excision and grafting of the LEs is not usually resumed until 5 to 7 days after surgery. With the physician’s consent, the client is encouraged and assisted to ambulate for short distances and then slowly increase the distance . When the client is able to walk, exercise on a stationary cycle ergometer is beneficial for increasing activity tolerance.

44. Activities of Daily Living and Client Education Self-care and leisure-promoting activities should be continued and increased in a way that is commensurate with the demands of the activity, the client’s physical abilities, and the client’s tolerance of activity If a UE is immobilized, creative ADL adaptations may be needed to allow clients continued involvement in their care and control over their environment. Though only temporary, simple techniques such as universal cuffs strapped over splints or extended handle utensils help preserve newly reacquired independence and foster confidence and feelings of self-actualization. Continued psychosocial support and burn care education are also essential to ensure understanding of post-surgical precautions and procedures .

45. REHABILITATION PHASE: INPATIENT Skin Conditioning and Scar Massage Compression Therapy Therapeutic Exercise and Activity Edema Management Activities of Daily Living Splinting

46. Skin Conditioning and Scar Massage Skin-conditioning techniques are used to improve scar integrity and durability against minor trauma caused by pressure or shearing forces, decrease hypersensitivity, and moisturize dry, newly healed skin. Lubrication and massage with a water-based cream or lotion should be performed three to four times a day or whenever the skin feels excessively dry, tight, or itchy. Massage should be performed in a circular motion, with more pressure applied gradually as tolerated over time. Because of damaged or lost skin Precautions , including the use of sunblock and avoidance of prolonged sun exposure, are taught before the client is discharged.

47. Compression Therapy Compression therapy should be initiated early in the inpatient rehabilitation phase, as soon as most of the larger wounds are closed. Temporary interim pressure bandages or garments assist in general skin desensitization, edema control, and early scar compression. Elastic bandage wraps, self-adherent elastic wraps, tubular elastic support bandages, pre-sized elastic pressure garments, and commercial or custom-made elastic garments are all commonly used. Approximately 5 to 7 days after removal of the postoperative dressings Temporary compression dressings and garments are taken off only for bathing, dressing changes, skin care, and garment laundering. Independent donning and doffing of interim garments are incorporated into the client’s ADL training.

48. Therapeutic exercise and activity Once the scars are moisturized and lubricated, stretching is performed to increase the flexibility and fluidity of movement. Stretches should be slow and sustained , and forceful dynamic stretching should be avoided. Stretching in front of a mirror provides positive visual feedback for the patient and is helpful in correcting abnormal posturing. AROM exercises, strengthening , and tasks to increase activity tolerance should follow stretching exercises. During the rehabilitation phase, emphasis is placed on flexibility exercises using complex motions that require the movement of several joints simultaneously. Most ADLs require complex motions, and exercise programs should emphasize not just individual joint ROM but also combined joint mobility in functional patterns of movement.

49. Strengthening activities use of cuff weights Dumbbells resistive exercise bands work simulation equipment Activities for hand strengthening and coordination may include using exercise putty hand manipulation boards work simulators and work samples crafts, and meaningful activities typing on a computer dialing a cell phone playing cards or board games with visitors.

50. Edema Management To treat edema of an extremity, elevation, progressive compression, and activity are recommended. It is applied in a spiral fashion , from distal to proximal , with the previous lap overlapped by a half overlap starting on each digit and continuing in this manner across the hand or foot and onto the wrist or ankle. Strips are also applied to each web space The distal tips of digits are left open to monitor color, which should be rosy and not blanched or bluish. The wrapped hand should be used during ADLs and other functional motions and elevated just above heart level when the client is resting. For edema of the LEs, use of a double layer of elastic wrap when ambulating , elevation when resting , active ankle exercises , and avoidance of static standing are recommended.

51. Whenever compression therapy is used to treat edema of the hands or feet, before and after circumferential or volumetric measurements are recommended to monitor the effectiveness of the treatment. Self-adherent elastic bandage material (Coban or Co-Wrap) is often used as an early form of compression for the digits, hands, and feet.

52. ADL and Client’s education Eating, dressing, grooming, and bathing skills should be emphasized as part of the normal daily routine to increase independence and activity tolerance. Early identification of abnormal movements helps patients understand and relearn normal movement patterns before the abnormal patterns become habitual. Practicing ADLs with personal care items and supplies from home helps foster self-confidence in functional performance skills before hospital discharge. In addition to basic ADL and self-care tasks, IADL tasks such as home management responsibilities should be practiced before discharge. Prevention techniques taught as part of the inpatient treatment program should also be part of the home program.

53. Before discharge from the hospital or transfer to an inpatient rehabilitation facility, the client and family should receive a comprehensive home care education review.

54. REHABILITATION PHASE: OUTPATIENT Therapeutic Exercise and Activity Scar Management Activities of Daily Living Community Re-entry Psychologic Adjustment Discharge from Treatment Therapeutic Exercise and Activity Inpatient rehabilitation techniques, equipment, and therapeutic activities continue to be appropriate during outpatient therapy Skin lubrication, massage, and stretching should precede progressive strengthening exercises and activities.

55. Scar management Use of compression garments is indicated for all donor sites, graft sites, and burn wounds that take more than 2 weeks to heal spontaneously They should be worn 23 hours a day and be removed only for bathing, massage, skin care, or sexual activity. Face masks and gloves may also be removed for meals. Compression therapy should be applied to the burned area for approximately 12 to 18 months or until scar maturation is complete . It is recommended that the client possess a minimum of two sets of garments at any time to allow both around-the-clock compression therapy and laundering. Because of the elastic construction of the fabric, clients should hand-wash the garments with mild soap and allow them to air-dry unless otherwise advised by the manufacturer. If they are properly cared for, most garments will last approximately 2 to 3 months before replacements are needed.

56. Because of body contours, bony prominences, and postural adjustments, flexible inserts or pressure-adapting conformers are often needed under the garments to distribute the pressure more evenly . Silicone gel pads, Silastic elastomer, Otoform -K, Plastazote , and Velfoam are useful for hand scars . Sixteenth-inch Aquaplast and Silastic elastomer work well on face scars Velfoam and silicone gel pads are effective at the flexion creases of the knees , elbows, and anterior aspect of the ankle to equalize pressure and prevent discomfort during activities.

57. Activities of Daily Living Activities performed during therapy should not only promote strength, activity tolerance, and functional ROM to counteract the effects of scarring but also preserve independence in performance of occupations related to clients’ personal contexts and interests. Community Re-entry Correspondence sent to the community setting before the client’s return helps educate employers, teachers, and peers about burn injuries and what the client has experienced. This correspondence should explain the purpose of compression garments , splints , exercise , and skin care precautions ; digital photos are helpful. The goal of a re-entry program is to reduce restrictions in the client’s activities and ease the transition of returning to previous areas of occupation.

58. Strength, activity tolerance, and flexibility , often identified as work tolerances, are obvious goals of burn rehabilitation. Physical demands of jobs, as described in the Dictionary of Occupational Titles, are also components of functional skills; lifting, stooping, pushing, pulling, handling, and manipulating activities can be given. A job analysis interview , performed as part of the activity needs analysis, will provide the type of information needed to integrate activities into the intervention plan, which should not only improve functional ability but also provide reconditioning for returning to work. Education regarding the body’s response to variations in temperature and precautions for dealing with extremes of temperature are necessary for the patient to plan for anticipated temperature tolerance problems.

59. Psychologic Adjustment Apathy, avoidance of pain, scar tightness, and hypersensitivity all contribute to noncompliance and subsequent dysfunction after injury. Counseling, support, and training in pain management and relaxation techniques , visits from a recovered burn survivor to a new patient are often of great benefit. Attending a burn support group can also help the burn survivor and family members in psychologic adjustment. Group discussions among burn survivors promote acceptance of what they have already experienced and realistic expectations of what they still need to accomplish. Discharge from treatment The outpatient therapy program should be re-evaluated periodically to determine whether the frequency of treatment, program progression, or professional or educational status should be changed (e.g., return to work or school). When clients have resumed their preinjury activities, outpatient therapy may be discontinued.

60. Complications of burns Heterotopic Ossification Heterotopic ossification (HO) is formation of bone in locations that normally do not contain bone tissue. It typically develops either in the soft tissue around the joint or in the joint capsule and ligaments, and it often forms a bony bridge across the joint, thereby resulting in a fused joint. Frequently found in the posterior aspect of the elbow, it may occur in other joint areas such as the shoulder, wrist, hand, hip, knee, and ankle. Treatment: Frequent AROM exercise of the joint should be carried out within the pain-free range.

61. Neuromuscular Complications Peripheral neuropathic conditions are the most common neurologic disorder observed in burn patients. They usually occur with high-voltage electrical burns or burns involving greater than 20% TBSA. Localized compression or stretch injuries of nerves are encountered during burn recovery. Treatment: To implement more effective prevention and intervention techniques, therapists should be aware of the causes and symptoms of various nerve injuries The therapist should be attentive to any developing symptoms of sensory or motor dysfunction in a client who was initially

62. Facial Disfigurement Facial scars can be devastating, both functionally and psychologically. Tight or hypertrophic scars not only distort the smooth contours of the cheeks and forehead but can also flatten the nasal contours, evert the eyelids and lips, and constrict the optic and oral commissures. Vision, speech, feeding, and dental hygiene can be adversely affected by oral and eye contractures. Treatment: Two main compression therapy methods are used to prevent or manage hypertrophic facial scars. An elastic face mask can be worn with underlying flexible thermoplastic conformers. The other option is a rigid, total-contact transparent facial orthosis.

63. Infection Pulmonary Complications Metabolic Complications Cardiovascular Complications Pathological Scars Other complications

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