Hand Rehabilitation In Burns

Introduction
Burns
Clinically Relevant Anatomy Of Hand
Common Hand Problems In Burns
Surgical Management
Evidence based Physical Therapy Rehabilitation
Outcome Measures
Summary
References

1. REVIEW OF LITERATURE

2. HAND REHABILITATION IN BURNS

3. CONTENTS Introduction Burns Clinically Relevant Anatomy O f Hand Common Hand Problems In Burns Surgical Management Evidence based Physical Therapy Rehabilitation Outcome Measures Summary References

4. INTRODUCTION   BURNS: tissue injury that results from exposure to heat (flames, steam, hot liquids etc .), chemicals, electricity or even radiation. In India, over 10,00,000 people are moderately or severely burnt every year ( WHO Jan , 2018) Even though hand burns are not life threatening or fatal, it has a detrimental effect on the functional and social aspects of an individual. In more than 80% of all burns, the hand is involved ( Kamolz LP et.al., 2009 ) The hand ranks as one of the 3 most frequent sites of burn, scar contracture and deformity which can interfere in the functional abilities of a person.

5. DEGREES OF BURNS Burns are classified by the depth of injury, which helps determine the appropriate treatment

6. Degree/Depth Mechanism of injury Layer of skin involved Appearance Pain Scar Healing time Superficial (1 st ) Sun exposure, hot liquids Epidermis only Pink-red, moist, no blisters Mod-severe None 3-7 days Superficial partial (2a) Hot liquids, chemical burns( weak acids..) Superficial (papillary) epidermis Blister, red moist, intact epidermal appendages, Severe Minimal 1-3 weeks Deep partial (2 b) Flame, electrical, hot liquid Deep layer (reticular) Dry, white, non-blanching Minimal High risk scarring and contractures 3-6 weeks with scars Deep (3 rd ) Flame, electrical, chemical, blast self immolation Full thickness of skin and into sub cut. Fat or deeper Leathery, dry, white or red with thrombosed vessels Painful at surrounding tissue Severe risk scarring and contractures Deal not heal by primary intervention, requires skin graft 4 th Prolonged exposure to flame, chemical… Extends through skin, sub cu. Fat, under ly . ms and bone Black, charred with eschar, dry Painful a surrounding tissue Definite scars and contractures Requires excision

7. 1st Degree — Epidermis

8. 2nd Degree — Dermis Partial thickness damage Skin damage ( blisters) Vascular layer Collagen strands with nerve endings Hair follicles, oil & sweat glands Lymph spaces

9. 3rd Degree — Subcutaneous tissue Full thickness skin damage skin is white and leathery Adipose tissue damaged Fibrous connective tissue damaged

10. 4th Degree — Muscle or bone

11. Zones of Injury The local effect involves three burn zones: (Hettiaratchy and Dziewulski 2004 ) Zone of Coagulation :  T he point of maximum damage  Irreversible tissue loss due to coagulation of constituent proteins

12. Zone of Stasis :  Characterised by decreased tissue perfusion  Potential to rescue the tissue in this zone  Problems such as prolonged hypotension , infection or oedema can convert this area into one of complete tissue loss Zone of Hyperaemia :  The tissue here will invariably recover unless there is severe sepsis or prolonged hypo perfusion

13. STAGE TIMESCALE PROCESS SIGNS AND SYMPTOMS TREATMENT Inflammation 0-5 days Vasoconstriction followed by vasodilatation and influx of inflammatory mediators and WBCs. Increased capillary permeability. Exudate leaks into tissues. Pus may be produced Redness, Heat, Swelling, Pain Reduce heat and oedema and pain. Prevent infection and disruption of wound. (immobilisation, positioning, splinting) Proliferation (fibroplasia) Begins day 3-5. Lasts 2-6 weeks. Fibroblasts synthesize collagen. Laid down haphazardly. Angiogenesis continues. Moist red raised tissue over wound Early: positioning and immobilisation Later: gentle stress (splinting, exercise) Reduce oedema and prevent contracture Remodelling (maturation) Begins week 4-6. Lasts up to 2 years. Synthesis of collagen balanced by degradation. Organisation of collagen fibres along lines of stress. Wound closure Scar red and raised progresses to flat pale and pliable. Scar tissue tightens. Optimise function Splinting Positioning Exercise Stretching Strengthening.

14. COMPLICATIONS OF BURN More commonly encountered hand complications after burn include: Post burn edema Hypertrophic scarring Scar contracture Joint deformities Sensory impairment Loss of skin stability Restricted functional use of the hand

15. Post Burn Edema In superficial partial-thickness burns, minimal fluid is leaked into the extravascular space, and edema is minor and transient. In deep partial-thickness and full thickness burns, edema is more severe and prolonged . Witte CL, Witte MH, Dumont AE. Significance of protein in edema fluid. Lymphology 1971;4:29–31 Oedema in the hand results in the position of intrinsic minus ( Kamolz et al 2009)

16. Hypertrophic scarring Hypertrophic scars are a common complication of burn injuries. A healing wound requires a balance of several opposing reactions Degradation of necrotic tissue/proliferation of new cells Building up/ breaking down of collagen Creating/controlling of new blood supplies (Linares et al 1996).

17. Disequilibrium of any of these processes may result in abnormal scarring and it is accompanied by : (Procter 2010). Exaggerated angiogenesis with high blood flow Increased deposition of collagen High rates of contraction Pruritus (Itch) Dryness Lack of pliability.

18. BURN CONTRACTURES & DEFORMITIES OF HAND Brown N and Chung K conducted a study on post-burn contractures of the hand i n 2017 which stated that burn contractures present as a spectrum of deformities that significantly limit hand function. T he common hand deformities which are seen after burn are Burn claw deformity Flexion contractures Boutonniere deformity Thumb adduction contracture Burn syndactyly MCP joint contractures Brown M, Chung KC. Post-burn Contractures of the Hand. Hand clinics. 2017 May 1;33(2):317-31.

19. EVIDENCE A study was done by Alexander and Lasgeear post-burn contractures of the hand in 2016 , which reported that the common hand deformities seen after burn are : Claw hand deformity MCP hyper extension contractures Flattened hand/loss of arches Boutonniere deformities Swan neck deformities Mallet deformities Web space contractures/Syndactyly

20. CLAW HAND DEFORMITY Can occur in the early post injury period as a result of edema, tendon injury , or scar contracture. Post burn edema causes hyperextension of the MCP joints and flexion of the IP joints, (claw hand deformity). MCP Hyperextension occurs as the dorsal skin is drawn taut by the fluid shift into the extravascular tissues and as the palmar arches flatten. PIP Flexion occurs due to edema -imposed tension on the common digital extensor tendon system and concurrent MCP hyperextension.

21. Boutonniere Deformities Involves the extensor apparatus at the PIP joint level. R esult of direct thermal injury or of tendon ischemia. Tendon ischemia can result when the injured tendon is compressed between the eschar and the head of the proximal phalanx as the PIP joint is flexed.

22. Palmar Cupping Deformity Exaggerated concavity of the hand’s transverse and longitudinal palmar arches. Associated with hyperextension of the MP joint of the thumb sensory deficits loss of the stable grasping surface of the palm Palmar burns often require extensive therapy and multiple reconstructive efforts to yield functional results.

23. Mallet Deformity Thermal injury to the terminal slip of the extensor tendon Loss of DIP joint extension (mallet deformity). Injury to the terminal slip can be a result of tendon ischemia induced as the injured tendon is compressed between the eschar and the base of the distal phalanx as the DIP joint is flexed.

24. Swan Neck Deformity: PIP hyperextension deformity and flexion of the DIP joint Incidence is common in middle finger (Howell J et. al) C ommon causes (Howell J et. al) include: Extensor communis tendon adherence Ischemic contracture of intrinsic muscle Joint stiffness from improper immobilization Burn scar contracture

25. Wound Management The use of negative pressure dressings to treat burn wounds and to assist with skin graft adherence is a common treatment approach in burn care.

26. Surgical Management Escharotomy Fasciotomy

27. REHABILITATION Hand and wrist rehabilitation after a burn depends on the severity of the burn. Varies from oedema control to outcome assessment Includes wound management, splints, ROM exercise, positioning and scar control. Burn rehabilitation should be initiated within the first 24 hours of admission of a burn patient to establish an individualized positioning, splinting, exercise, and functional activity plan. Moore M et.al in 2009 stated that most of the complications can be minimized with early and ongoing therapy.

28. Aims and principles of treatment Prevention of additional/deeper injuries Preservation of active and passive ROM Early functional rehabilitation Prevention of adherent scar formation Prevention of infection ( Kamolz et al 2009)

29. MAJOR CONSIDERATIONS IN HAND REHABILITATION Chronic edema ROM/Strength Skin integrity Scar characteristics Orthosis Intervention Physical Agents Deformity/contracture Return to work/school Functional use ADL participation and modifications

30. General guidelines for burn therapy approaches are outlined in the following Sections: Positioning Edema management Tendon integrity Anti-contracture positioning Neuropathy prevention

31. Positioning Specific positioning of the burned hand is crucial healing with optimal results. Key components of positioning include elevating the distal extremity to facilitate venous blood flow placing an elongation force on healing tissue protecting viable joint and soft tissue structures from additional trauma such as rupture or excessive pressure.

32. Edema Management Elevation of the hand and upper extremity above heart level is crucial to absorption of developing edema fluid ( Kamolz 2009). It is also critical to extend the elbow sufficiently to promote venous drainage. Elevation of the upper extremity by pillows, foam wedges/ troughs, or slings supported on bedside attachments, Bradford sling. Active exercise to activate the muscle pump to decrease edema. The technique used to reduce edema should be selected carefully to avoid potential injury of fragile tissues.

33. COBAN WRAP to decrease hand oedema. Advantage: does not stick to underlying tissue, making it suitable for use in the acute stages of burns (Lowell 2003 ). There is currently limited quantity of evidence to support the use of Coban wrap in the treatment of Oedema .

34. EVIDENCE Author, year: Lowell et.al, 2003 Case study : 59 year old male with 46% TBSA thermal burn. Bilateral dorsal hand burns included. Intervention: Day 3 post skin grafting left hand wrapped in standard gauze dressing, right hand wrapped in coban self-adherent wrap. On post-op day 11 coban wrap applied to both hands Outcome measures: 1) Circumferential of oedema measurement at level of MCP, DIP and PIP 2) Range of motion 3) Grip Strength 4) Nine hole peg dexterity test Results: Significantly decreased oedema in the right hand versus control hand at 11 days post op. Decreased oedema bilaterally post op day 17. Improved grip strength in right hand versus control hand 17 days post op. Improved dexterity and ROM in right hand versus control hand 21 days post op Limitations: Hand dominance not established, single subject study

35. Oedema Glove/Digi Sleeve H and specific oedema management products. Currently no specifc evidence available to support its efficacy for oedema reduction. However it is common practice of hospitals in Ireland, India, china etc. to provide these products to patients with excessive hand and finger oedema. Principle: compression to reduce oedema which is heavily supported by evidence (Latham and Radomski 2008).

36. Tendon integrity Continual wound assessment/inspection for exposed tendons Most common locations for extensor tendon exposure : PIP joint, dorsal hand Treat deep dorsal wound as if exposed until confirmed otherwise, skin healed or tissue covered Extensor tendon rupture – Delayed healing of dorsal digital wounds

37. Fibrosis + thickened eschar can lead to delayed tissue death , “crushing effect” on extensor mechanism Treatment options/combinations – Fluff wrap, Coban , gloves – AROM, functional use

38. Anti-contracture Positioning Moore ML et.al in 2009 stated that with any burned body part, the position of comfort for the patient becomes the position of contracture formation due to edema organization, wound bed contraction, and ultimate scar formation. If wrist ROM becomes limited in a specific direction, splinting the wrist in the opposite direction would be indicated. Apfel LM et.al in 1994 investigated different approaches for positioning the burn patient and stated that generally the anti-deformity position of the hand with a dorsal burn is an intrinsic plus position, consisting of wrist extension, MP joint flexion, PIP and DIP joint extension, and thumb palmar abduction.

39. With deep palmar burns, the hand is usually positioned with all the finger joints extended and the volar thumb web space under stress to preserve finger extension and thumb radial abduction, respectively. These palmar burns need to be positioned by a splint. Following re-epithelialization, silicone elastomer may be added to the splint to provide positioning and scar management.

40. Hand Splinting: Dynamic and static splinting provide this prolonged low stretching force (Kwan 2002). A systematic review carried out in ( Esselman in 2006 concluded that there are no studies examining the effectiveness of hand splinting for hand burns, but rather studies describing types of hand splint interventions. Literature in the area suggests the use of splinting in the initial inflammatory phase to promote a position of safe immobilisation.

41. MOVEMENT • Minimise scar contraction, promote function • Daily monitoring for loss of motion or limitations, initial deformity, maladaptive positioning • Challenges in acute phase : pain, fibrous oedema, increasing tautness, inelastic eschar • What is limiting AROM? functional use? • Disruption of the coordinated interplay of intrinsic and extrinsic muscles , tendons and joint is the underlying cause of most post-burn functional disturbances.

42. Active ROM G entle active ROM exercises preferred treatment during the acute stage of injury most effective means of reducing oedema by means of active muscle contraction ( Glassey, 2004 ). If this is not possible due to sedation, surgical intervention etc. then positioning the patient is the next best alternative. Passive ROM Passive ROM exercises in the acute stage are contraindicated as applying passive stretching forces may result in future damage to the burned structures ( Boscheinen-Morrin ; 2004) .

43. Another study by Cooper et al. in 2007 stated that applying passive manoeuvres in the acute stage will result in increased oedema, haemorrhage and fibrosis of the burned tissues Boscheinen-Morrin and Connolly in 2001 recommended passive joint mobilisations can begin during the scar maturation phase once the scar tissue has adequate tensile strength to tolerate friction caused by mobilisation techniques.

44. Evidence for hand mobilisation: Author ; year: Okhovation et al; 2007 Study type: randomized controlled trial Subjects: 30 burn admissions to Tehran Hospital in 2005. Matched in pairs based on clinical details (sex, age, TBSA, depth of burn). Randomly assigned into two groups Intervention: Routine rehabilitation protocol: chest physiotherapy and active/passive movements 15-20 minutes daily commenced 2/52 post admission. Burn rehabilitation protocol : routine protocol plus targeted stretching program to contracture risk areas for 30-45min 2-3times daily commenced on day 1 of admission .

45. Outcome measures: Outcome measures used were Presence of burn contracture (goniometry) Occurrence of thrombosis Length of Hospital Stay Skin grafting requirement . Results : Development of post burn contractures on discharge from hospital was 6% in the burn rehabilitation group versus 73% in the routine rehabilitation group. No significant difference regarding thrombosis, duration of stay and number of skin grafts

46. Scar Management Abnormal scarring is the most common complication of burn injuries, with the estimated prevalence of > 70% of those who suffer burn injuries ( Anzarut et al, 2009) They may also be painful, pruritic, and they may limit range of motion where they occur on or near a joint ( Morien et al 2009; Polotto 2011 ). The evidence and recommendations for use in the most common of these, including silicone gel, pressure garment therapy, massage, laser therapy, matrix therapy etc.

47. silicone gel or sheeting Author; year: Momeni et al 2009 Study type: RCT, double blind placebo controlled trial Subjects : N=38, with hypertrophic scars post thermal burn. All were 2-4 months post burn, with areas including upper limb (n=14) lower limb (n=8) trunk (n=3) and face (n=9). Intervention : Patients acted as their own control, with the scar area being randomly divided into two sections: one received silicone sheets, and the other a placebo. Both were applied for 4hrs/day initially, with this incrementally increased to 24 hrs/day over the course of the study, for a four month period.

48. Outcome measures : assessed at one and four months, by a blinded assessor using the Vancouver Scar Scale and by Clinical Appearance. Results : No significant differences in baseline characteristics. At one month the silicone group had lower scar scores than the placebo group, however they were not statistically significant . At four months, the silicone group had significantly lower scores on VSS for all dimensions except pain compared to placebo.

49. Studies Included: 15 RCTs, n=615, only 3 studies specific to burn patients. 12 compared silicone to no treatment, and the remainder silicone was compared to placebo or laser treatment. Outcome Measures: Primary outcome measures included scar length, width and thickness; secondary outcomes include scar appearance, colour, elasticity, relief of itching/pain Results: No significant difference between silicone gel sheeting and control in reducing scar length and width. Significant results for reducing scar thickness, though these were thought not to be clinically relevant. No statistically significant difference between silicone gel and controls in secondary outcomes. Brien and Pandit 2008: Cochrane Systematic Review Investigating the Efficacy of Silicone Gel Sheeting in Preventing and Treating Hypertrophic and Keloid Scars

50. Pressure Garment Therapy (PGT ) In a study by Procter et. al in 2010 stated that effectiveness of PGT has never been proven, it is a common treatment modality for reducing oedema and managing hypertrophic scars. The exact physiological effects of how pressure positively influences the maturation of hypertrophic scars remain unclear . MacIntyre & Baird in 2006 suggested possible physiological effct of PGT : Hydration effect Blood flow Prostaglandin E2 release

51. EVIDENCE Author; year: Engrav et al ; 2010. RCT Subjects: 54 patients recruited over 12 years. Forearm burn requiring >3 weeks to heal/skin grafting. Mean age, 36 yrs , mean length of follow up, 9.5 months Intervention: Randomised normal compression (17- 25mmHg) and low compression (<5 mmHg) to proximal/distal area of scar. 23 hrs/ day to wound maturity, or up to 1 yr Outcome measures: Durometry (hardness ), colorimetry (colour ), ultrasonography (thickness ), Clinical appearance: judged by a panel of 11 experts in burn care Results : decrease in scar hardness and thickness. The authors concluded by recommending that PGT should continue to be used.

52. Massage According to a study by Glassey in 2004 - Five principles of scar massage 1. Prevent adherence 2. Reduce redness 3. Reduce elevation of scar tissue 4. Relieve pruritus 5. Moisturise

53. EVIDENCE Author; year: Field et al; 2000 . RCT Subjects: 20 subjects in remodelling phase of wound healing. Randomly assigned into 2 groups-Massage Vs Control Intervention: Massage Therapy Group: 30minutes massage with cocoa butter twice weekly for 5 weeks. Control Group: Standard Treatment Outcome measures: Itching: VAS, Pain: McGill Pain Questionnaire, Anxiety: State Trait Anxiety Inventory & Mood: Profile of Mood States Results: Massage Therapy Group Reported: decreased itching, pain, anxiety and increased mood Ratings improved from the 1st -last day of the study

54. Laser Therapy A study was conducted by Gaida K et.al in 2004 to study the effect of low level laser therapy for burn scar. 19 subjects with burn scars were treated with a 400mW 670 nm Soft laser twice a week over 8 weeks. The Vancouver Scar Scale (VSS) for macroscopic evaluation and the Visual Analogue Scale (VAS) for pruritus and pain were used for assessment. The result of the study showed that 17 out of 19 subjects exhibited an improvement after treatment and the study concluded that LLLT is an effective modality for the scar management.

55. Matrix Rhythm Therapy A study was conducted by Sarı Z et.al in 2014 to investigate the application of matrix rhythm therapy as a new clinical electrotherapeutic modality in burn physiotherapy programmes Intervention : 12 subjects with upper extremity burn were treated using whirlpool, MRT and exercise therapy. Result : there was no significant difference in values of pain, muscle strength and flexibility between pre- and post-treatment assessments. A significant increase was found in the range of motion and sensory function at pre-treatment according to post-treatment.

56. Transcutaneous Electrical Nerve Stimulation (TENS) Author; year : Hettrick H et.al; 2004 Study type : pilot study to investigate the effect of Transcutaneous Electrical Nerve stimulation for the management of burn pruritus. Intervention : Thirty outpatient subjects were included in the study and were randomly assigned into a control group or a treatment group. The subjects in the control group received the standard of care for burn-related itching, which involved the daily use of pressure garments, skin and scar lubrication, soft tissue mobilization, physical or occupational therapy, and anti-itching medication.

57. The treatment group continued to receive the standard of care in addition to their assigned TENS parameter for 1 hour a day, 7 days a week for 3 weeks. The treatment group received TENS using the high-frequency, low-intensity mode Results: the VAS scores differed significantly between the control and treatment group and it concluded that TENS is an effective non invasive, nonmedicinal modality that significantly reduces burn pruritus.

58. OUTCOME MEASURES The Hand Burn Severity (HABS) score Burn Specific Health Scale (BSHS)

59. SUMMARY

60. REFERENCES Glassey N. Physiotherapy for burns and plastic reconstruction of the hand. London/Philadelphia: Whurr publishers ; 2004 . Gaida K, Koller R, Isler C, Aytekin O, Al- Awami M, Meissl G, Frey M. Low level laser therapy—a conservative approach to the burn scar?. Burns. 2004 Jun 1;30(4):362-7 . Sarı Z, Polat MG, Özgül B, Aydoğdu O, Camcıoğlu B, Acar AH, Yurdalan SU. The application of matrix rhythm therapy as a new clinical modality in burn physiotherapy programmes. Burns. 2014 Aug 1;40(5):909-14 . Hettrick H, O'Brien K, Laznick H, Sanchez J, Gorga D, Nagler W, Yurt R. Effect of transcutaneous electrical nerve stimulation for the management of burn pruritus: a pilot study. The Journal of burn care & rehabilitation. 2004 May 1;25(3):236-40 . Kamolz LP, Kitzinger HB, Karle B, Frey M. The treatment of hand burns. Burns. 2009 May 1;35(3):327-37 .

61. Bhattacharya V, Purwar S, Joshi D, Kumar M, Mandal S, Chaudhuri GR, Bhattacharya S. Electrophysiological and histological changes in extrinsic muscles proximal to post burn contractures of hand. burns. 2011 Jun 1;37(4):692-7 . Procter F. Rehabilitation of the burn patient. Indian journal of plastic surgery: official publication of the Association of Plastic Surgeons of India. 2010 Sep;43( Suppl ):S101 . Moore ML, Dewey WS, Richard RL. Rehabilitation of the burned hand. Hand clinics. 2009 Nov 1;25(4):529-41 . Richard R, Baryza MJ, Carr JA, Dewey WS, Dougherty ME, Forbes- Duchart L, Franzen BJ, Healey T, Lester ME, Li SK, Moore M. Burn rehabilitation and research: proceedings of a consensus summit. Journal of Burn Care & Research. 2009 Jul 1;30(4):543-73 . Aoife Hale, Rhona O’Donovan, Sarah Diskin , Sarah McEvoy , Claire Keohane , Geraldine Gormley . Physiotherapy in Burns, Plastics and Reconstructive Surgery:Impairment and Disability.Short Course. 2013; April 19

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