MES 1 | BURN REHABILITATION

WEEK 9
SY 2020-2021

BURN REHABILITATION
- recovery is a long process, starts in the acute phase and goes on even if the pt has returned to previous
function.

BURN
 4th most common type of trauma worldwide
- following traffic accidents, falls, and
intrapersonal violence
 most commonly occurs at home, with cooking
as the most common activity
 pediatric burns occur at home unsupervised
 adults are equally likely to sustain a burn at
home, outdoors or at work
 elderly are most likely to sustain a burn in the
bathroom followed by the kitchen
Burn is an acute wound because we expect it to heal
at reasonable period depending on the depth. But if
there is an infection, the timeline would be much
longer.
BURN WOUND ZONE
 Zone of coagulation
- inner zone
- area of cellular death (necrosis)
- composed of necrotic tissues
 Zone of stasis
- area surrounding zone of coagulation
- cellular injury: decreased blood flow
and inflammation
- potentially salvable; susceptible to
additional injury
 Zone of hyperemia
- peripheral area of burn
- area of least cellular injury &
decreased blood flow
- complete recovery of this tissue is
likely
TYPES OF BURN
CHEMICAL BURN
 causes injury d/t a wide range of caustic
reactions
- radical alteration of pH
- disruption of cellular mechanism
- direct toxic effects on metabolic
processes
 determinants of severity of injury
- duration of exposure (the longer the
skin is exposed, the higher is the risk
for severe injury, neutralization will
depend on that
- nature of agent
 consider systemic absorption of some
chemicals (thru skin, mucus membrane of
inhalation)
THERMAL BURN
 determinants of severity of injury
- temp: protein denaturation occurs at
40 deg C
- duration of contact
- thickness of skin
 depth of injury determines healing potential
and needs for surgical intervention
FROSTBITE
 damages the skin and underlying tissues when
ice crystals puncture the cells or when they
create a hypertonic tissue environment
 can interrupt blood flow (increased blood
viscosity)  hemoconcentration 
intravascular thrombosis  tissue hypoxia
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MES 1 | BURN REHABILITATION

 frostnip or whitening of exposed area does not
appear to cause damage but may increase risk
of frostbite on future exposure
ELECTRICAL BURN
 causes damage as electrical energy is
transformed into thermal energy as the current
passes through poorly conducting body tissues
 also, injury to cell membranes disrupts
membrane potential and function
 ex: electrical burn  heart rhythm can be
affected  arrythmia
 cross-sectional area critical
- as the area of exposure decreases,
the current density decreases,
generating greater heat
- if entry point has a small cross-
sectional area = high risk of sever
injury
- ex: entry point = finger
 low tension injuries occur at less than 500
volts; high tension injuries occur above 500
volts
 cutaneous injury does not reflect extent of
injury
- iceberg effect
 severity depends on
- voltage of source
- amperage of current passing thru
tissues
- resistance of tissues
- duration of exposure
- pathway of current
 current traversing the most resistant tissue
produces the greatest heat, the nearby tissue
can also get affected
 least conductive tissue and most resistant is
the bone  cartilage  tendon  skin  mm
 blood  nerve
 partial (2nd degree) thickness burns that heals
spontaneously without surgery within 2-3
weeks usually resolves without hypertrophic
scarring or functional impairment (ex. sunburn
or minor scald burns)
 wound that takes longer than 3 weeks to heal
o hypertrophic scarring
o cause functional impairment
o provides only thin layer of epithelial
covering that remains fragile for weeks
to months
 appearance of wounds and apparent burn
depth changes within 7-10 days
o due to thrombosis of dermal blood
vessels and death of thermally injured
skin cells
o superficial burns may convert to
deeper wounds d/t infection,
dessication of wounds or use of
vasoactive agents during resuscitation
Immediately after burn, priority is for the vital function
to be stable.
1. Superficial
a. 1st degree
2. Superficial partial thickness
a. 2nd degree
3. Deep partial thickness
a. 2nd degree
4. Full thickness
a. 3rd and 4th degree

BURN DEPTH AND CLASSIFICATION

 burn depth is:
o significant determinant of mortality
o primary determinant of pt.’s long-term
appearance and functional outcome
 deeper wounds means destroyed dermal
appendages  longer healing and more
scarring

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MES 1 | BURN REHABILITATION

Total Body Surface Area

 Ave area of skin in adults in 1.82m2; in neonates only 0.25m2

 Only partial and full thickness burns are included in the calculation of TBSA burned
 Surface area determined most accurately by charts that are specific to pt.’s age (Lund and Browder(
 In adults = Rule of Nines

Rule of Nines in children not encouraged in clinical practice.

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MES 1 | BURN REHABILITATION

Lund and Browder Chart SEVERITY OF INJURY

 Age
 Associated injuries (inhalational injury and
head injury particularly important)
 Existing co-morbidities
 TBSA injured
 Depth of injury
 Body part injured

LOCAL RESPONSE TO BURN INJURY

 Local edema d/t
- vasodilation
- Increased extravascular osmotic
Parkland Formula activity
- Impaired cell membrane function
- for calculating amt of fluid for - Microvascular permeability
resuscitation  If >30%TBSA is involved, edema is seen in
non-burned areas

In extensive burn injuries, vasodilation can lead to

hypovolemia  shock

 Heterogenous reduction in perfusion creates

local ischemia and necrosis
 Endothelial cells, platelets, leukocytes migrate
injured area; platelets contribute to hemostasis
and thrombosis

GENERAL RESPONSE TO BURN

 Hypovolemia is a major problem
 Systemic hemodynamic changes include initial
depression of cardiac output
 Pulmonary function is near normal but
inhalational injury is the single most important
cause of mortality
 Disrupted thermoregulation

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MES 1 | BURN REHABILITATION

INHALATIONAL INJURY ACUTE BURN REHAB

 Risk factor for morbidity POSITIONING

 Reduction of available oxygen with toxic
smoke components such as carbon monoxide
and cyanide increases burn injury
 Increase risk for pneumonia, ARDS, and multi-
organ system dysfunction
 Proper positioning is fundamental to prevent
contractures and avoid compression
neuropathies
- keep tissue elongated
 Extension and abduction, but can be
individualized depending on needs

PHASES OF BURN MODERN BURN CARE

PT’s are rarely involved

GOAL: Pt should be stable

GOAL: Save burnt tissues

SPLINTING
Indications:

 maintain jt position
 correct/prevent deformities
 control edema
 complement pressure therapy

A good splint is:

 easy to don and doff

 avoid pressure over bony prominences
 made of moldable materials
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MES 1 | BURN REHABILITATION

 compatible with wound dressings and topical

medication

EXERCISE
 Initial goal: maintain ROM and strength
 Stretching is indicated when there is LOM
 Strengthening should begin as soon as
tolerated
 Precautions c post grafted patients (after skin
graft, mobilized once cleared by surgeon.

 pressure facilitates parallel orientation of

collagen during scar maturation
POST ACUTE BURN REHAB - custom fitted compression garment
SKIN CARE that provides at least 35mmHg of
pressure is worn 23h/day
- Custom made acrylic facemask
preserves facial contour
- for scars around the mouth,
microstomia can be used to maintain
normal aperture of the mouth and
stretch scar present

 rationale for the use of compression garment,

for overall flattening of the scar:
- decrease blood flow to the scar
- reorganization of collagen fibers
- decreases water content of scar
 Healed skin is fragile and easily abraded - provides actual pressure to the scar
 Sensitive to sun and chemicals
 Lacks lubricant
 Advise pt to:
- moisturize and sun block
- avoid prolonged water exposure
- avoid drying soap and detergent
- use mild soap
- massage skin often to stimulate blood
vessels

SCARRING NEUROMUSCULAR COMPLICATIONS IN

 Within 1-3 months, hypertrophic scarring
occurs irregular, raised and red scars BURN
- often regress spontaneously overtime PERIPHERAL NEUROPATHIES
- differentiate from keloid Focal neuropathies

 Commonly d/t faulty positioning, improperly

applied splints or bulky dressing

Multiple neuropathies

 Incidence of 2%
 M>F (4:1)
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MES 1 | BURN REHABILITATION

 Typically asymmetrical
 More likely in the UE
 Not always on the burned areas FUNCTIONAL TRAINING

Generalized peripheral neuropathy  Structured exercises combined with

 Incidence – 50%
 Correlates with amount of TBSA burned
- >20% TBSA in adults
- >30% TBSA in children
 Theoretical etiologies
- neurotoxicity from medications
- toxicity from circulating neurotoxin
from burn injury
HETROTOPIC OSSIFICATION
 Abnormal calcification of soft tissues
surrounding a jt
 Risk factors
- >20% TBSA
- open wounds
- Immobility
 Most common site: posterior elbow, then hip in
children and shoulder in adults
 Site doesn’t correlate with burned areas
 May be single or multiple
 S&Sx
- progressive loss of jt ROM
- Nerve entrapment mononeuropathy
 May resolve spontaneously
 Significantly interferes with function and is
unresponsive to non-surgical tx
 Surgery excision only when the bone is
matured to prevent risk of recurrence
therapeutic and fun activities
 May do ADLs appropriate for age and
development
 Play is considered an ADL and should be
encourage whenever possible
RETURN TO WORK
 TBSA injured correlates most strongly with the
length of time needed to return to work
 Other factors affecting RTW
- hand burn
- type of employment
- age
Ex: pt with hand involvement and work includes fine
motor activities may have a delay
The older the pt, less chance in RTW
 Overemphasis on ROM s adequate attn. to
endurance and strength and power required in
work may delay RTW
 IN severe injury, 20-50% of pt require change
in occupation
 Determining level of function after burn injury
should be considered to facilitate work
hardening/pre-vocational rehab

BURN-INDUCED AMPUTATION
 Electrical burn is the leading cause of
amputation
 UE>LE
 Additional issues in burn amputee
- skin fragility
- hypertrophic scarring
- burn contractures
- altered skin sensation
 Blistering and open sores can develop more
easily than wt other patients
 Higher rate of successful UE prosthesis use
when patients are fitted within 30 days of
amputation
 In LE, final prosthesis is fitted after 3 months
because the volume of the stump can still
change after 3 months
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