Burn rehabilitation specialists evaluate the burn victim as soon as it is feasible to see what kinds of intervention may be necessary. Therapists need to know the mechanism injury, the premorbid state of the patient and the total body surface area involved. If there are other injuries, these need to be known about as well. The rehabilitation specialist will then get an idea of what the body's range of motion is and how well the patient can perform activities of daily living. Finally, short and long-term treatment goals are determined and documented so a treatment plan can begin. Reassessment is done on a regular basis.
The goal of burn rehabilitation is to restore the patient's quality of life as quickly and effectively as possible. In severe burn victims, this restoration is painful, difficult, and time-consuming. Burn rehabilitation focuses on a holistic physical, mental, and emotional treatment plan. In addition to therapy, burn wound management should continue to minimize scarring and functional issues that can result.
Physiotherapy: Physiotherapy will often depend on the size of the burn injuries and whether or not they span across joints. This consideration is important because healed skin often contracts, or pulls together. When this occurs over joints, the patient will often experience a decrease in mobility. Physiotherapy aims to maintain and restore the joint's range of motion.
Occupational Therapy: Occupational therapy helps burn patients to recover, maintain life skills, and return to daily life with minimal changes or issues. Occupational therapy encourages burn victims to participate in daily living activities. In the early stages of burn rehabilitation, these activities may involve eating and bathing. During later burn rehabilitation stages, these activities may involve work-related tasks. The goal of occupational therapy is to encourage the patient to become as independent and self-sufficient as possible. This helps with both physical and psychiatric recovery from the burn injury.
Psychiatric Therapy: In addition to severe pain during the treatment and recovery process, burn victims may also face psychological trauma. Conditions such as post-traumatic stress disorder (PTSD), anxiety, and depression may have a significant impact on the patient's quality of life. Additionally, severe burn scarring and disfigurement may negatively impact the patient's ability to cope and reintegrate back into society.
There are challenges when a burn victim is bed-bound with large total body surface area burns. The rehabilitation specialist helps position the victim and develops a positioning program so that the badly burned areas don't have too much pressure on them for long periods of time. The rehabilitation team works with splints, cut-out troughs, pillows and the bed itself in order to have the best possible chance of healing burned areas. For example, some patients with back wounds need to be positioned on their stomach to prevent shearing off of the grafts of human skin placed on the back.
Other purposes of victim positioning include the following:
Wedges made of foam or wood can be placed beneath the mattress to allow the patient to comfortably lie on one side or another. Prone positioning is considered a measure of last resort because it can compromise the patient's airway and is uncomfortable for some patients.
Positioning the Head and Neck: Ideally, the head and upper torso should be placed at a 30-45 degree angle from the horizontal part of the bed. If the hips are burned (or buttocks), the entire bed can be placed in a slanted position to take the pressure off the sacrum. Ear cups may need to be placed on the victim's ears if they are burned so they don't come in contact with the bed or bedding materials. Mouth and nose splints are available to keep these areas from contracting. Face masks may need to be used to protect facial burns and to decrease scarring.
The neck is generally placed in a neutral position or in slight extension. Collars can be fabricated in order to keep the neck from contracting in a forward position. A head strap or special splint can prevent the neck from healing to one side. The back may be placed in a neutral position in order to prevent scoliosis.
Upper Arm Positioning: The upper extremities need to be placed in such a way so as to prevent swelling. There are splints available for keeping the shoulder joint abducted, meaning it is away from the body. If the swelling is not prevented in the first 3 days following the injury, there will be a permanent deformity of the arm and hands. The elbow joint can be placed in full extension in order to prevent the elbow from permanent contracture. Measures must be taken so that the forearm can be rotated palm up and palm down without much difficulty.
Lower Extremity Positioning: If there are burns of the abdomen that extend down to the thigh, it is natural to hold the hips slightly flexed for comfort. Unfortunately, this is not a good way to prevent permanent back and hip problems later. Ideally, the hips should be neutral with a slight 15-20 degree abduction of the hip so the legs are slightly apart. The knee should be splinted in full extension in order to prevent contractures of the knees. Finally, the foot should be placed at a 90-degree angle to the rest of the body so that the foot doesn't end up in a permanently flexed position.
The rehabilitation specialists need to take part in the management of the burn scar. Scars, by their very nature, contract the skin and this cannot happen for the best in functional recovery of the joints. In addition, it would be ideal to do whatever it takes to prevent the scar from becoming hypertrophic and, therefore, not cosmetically acceptable. Hypertrophic scars are difficult to manage and care needs to be taken early on in the course of healing in order to prevent them. One of the best ways to prevent hypertrophic scars is to use pressure garments that slightly decrease the circulation to the scar and can, therefore, keep less collagen from forming on the scar.
Eventually, the burn victim will be able to ambulate and exercise to some degree. The exercise program must be done gradually, beginning with stretching exercises and ending with aerobic exercise and weightlifting. This is a slow process—one that can take months to years to complete. The success of an exercise program depends on the patient's age, the degree of burn, and on the motivation of both the patient and his or her occupational and physical therapists.
Intensive burn rehabilitation is particularly important in children due to their increased physical and psychological vulnerability. Physiotherapy is crucial, as the growth of a child demands elasticity and health of the skin. Children with skin contractures may require several surgeries to transplant additional skin so that the child can maintain normal movement. Children with burn scarring or disfigurement may also have increased difficulty with self-esteem, self-acceptance, and social integration with peers.
Crystal Hospital Building, Maratha Colony,
Wamanrao Sawant Road,
Dahisar (East), Mumbai-400068, India.