(2) burn rehabilitation

Goals of Burn Rehabilitation

Overall GoalReturn to pre- injury Level of function with

Best possible cosmoses

Short Term Goals• Assist Wound Healing• Prevent Complications

(muscloskeletal)

I. Positioning By definition positioning is:

The proper alignment and adjustment of body parts.

Positioning is a fundamental portion of burn rehabilitation.

Benefits of Positioning in Burn Rehab.

PreventsContracture

Controls Edema Prevent Localized Neuropathies

Maintain elongated Position of soft

Tissues

Burn patient has tendency to assume flexed adducted position (Fetal position) most probably as a reaction to pain.

Positioning program is maintained and/ or modified according to: Patient medical condition. ROM Skin condition.

Positioning program should be individualized. However, generally speaking, body parts should be positioned as to maintain burned tissue in their elongated state.

Typically limbs should be positioned in extension- abduction alignments.

Positioning is maintained using splints, pillows, and/ or foam wedges.

Specific Burn Sites

Body Segment

Anterior orCircumferential

burns

Asymmetrical neck burn

Head Burn thatIncludes the ear

Posterior neck Burn Ear not involvd

NECK BURNS

Burn types Expected Deformity

Position HOW to Maintain?

Anterior orCircumferential

burns

Flexion Contracture

Extension/Hyperextension

- Towel under shoulders or between scapulae

- Foam cervical collar

Asymmetrical neck burn

Lat. Fl. Towards

burned side

Mid lineOr rotated away

--Towel roll, sand bag, wedges on affected side.- Prone lying head rotated

opposite side.

Head burns that include the ear

Folding of theHelix and condritis

Avoid any pressure over

the ear

- Foam or gel filled bag is used to elevate the ear

from the bed.

Posterior neck burns- Ear not

involved

Hyperextension of the neck

Head in midline - Pillows are used to elevate the head and

lengthen posterior tissues.

Trunk burns



Clavicular & pectoral

shoulder girdle protraction and glenohumeral

adduction shoulder retraction

- A square towel or blanket between

scapulae.- Fig. of 8 wrapping

From pectoral region to below

umblicus

same as above plus

kyphosis Same as above with upper Back hyperextension

Same as above with towel extended

downwards.

Burns of the lower back

Exaggerated lordosis Midline position

Using pillows under knee to flatten back

Lateral trunk burn

Scoliosis concave to burned side

Maintain trunk straight

Towel roll, sand bag, wedges on

affected side

Shoulder



Anterior axilla ShoulderAdduction & Int. Rotation

Shoulder Abd. / Ext. Rot. / Flexion. 90 Abd. /15- 20 horizontal Add. Above 90 Abd. And Ext. Rot. Should be attempted temporary.

- Towel roll, sand bag, wedges between affected axilla and side.- Wrist cuff hanged or stockinet to I.V. pole (Murphy splint)- Aero plane splint

Anterior chest and anterior arm.

Fl. / Add. Arm. kyphosis

Ext. & Abd. Shoulder. Ext. of dorsal spine - Towel roll, sand bag,

wedges between scapulae for dorsal Ext.- Same as above for Ext. Abd. Shoulder.

ELBOWBurn types Expected

DeformityPosition HOW to Maintain?

Anticubital or circumferential

Elbow fl.Forearm pronation

Elbow extension Supination or neutral position.

Arm troughs are used to maintain elbow extension over bed table can be used if patient can voluntarily extend his elbow. Elbow splints can be used in positioning

Posterior surfaces of the upper extremities

extension deformity(not common)

Elbow semiflexion Supination or neutral position.

same as above.

Forearm And Wrist



Volar surface Forearm pronation Wrist flexion

wrist in functional position (from neutral to 30 degree extension. Forearm supinated or neutral.

Wrist splint Towel or gauze placed in the hand while forearm supinated.

Dorsal surface Wrist ext. contracture

Functional position of the wrist

Wrist splint

Circumferential burns

Wrist flexion. Forearm pronation

wrist in functional position (from neutral to 30 degree extension. Forearm supinated or neutral.


HandsBurn types Expected

DeformityPosition HOW to Maintain?

Palmar surface MCP flexion/ IP extension Thumb opposition.

hand positioned with all fingers extended and the thumb web space on a slight stretch

In acute palmer burn cases use dorsal splints. when healing progress use silicone pad to provide both positioning & pressure.

Dorsal surface MCP hyperextension IP flexion Thumb adduction

Wrist extension MCP flexion. IP extension. Thumb palmer abduction or opposition

A gauze roll is wrapped into the palm extending into the thumb web space. Hand splint (Volar)

Circumferential burns

contracture towards the most deeply burned side.

wrist in functional position (from neutral to 30 degree extension. Forearm supinated/ neutral.


HIP

Anterior or PosteriorHip Burns

DeformityFlexion/ External

Rotation And or Adduction

Position• Slight Abduction

• Mid rotation

Maintaining position

Towel roll or sand bag lat. To ThighFor neutral rotation

▲ foam wedgeBlanket between legs

For hip abduction

Prone lying minimize Hip flexion

Knee ext. splint Reduce hip flexion

With prone lying

KNEE

Burn types

Expected Deformity


Anterior Burns

Rarely causes extension contaracture

Posterior burns

Flexion contracture

Extension position bulky dressing to impede knee flexion knee extension splints. Prone lying bed outside bed (Prone hang) achieve full extension.

Ankle & Foot



Posterior or Circumferential

Plantar flexion contracture(heel cord tightness)

Neutral or dorsiflexion but neutral is optimal

use foot board Sponge booties or custom splints with a cut out heel.

Isolated anterior surface

Rarely causes dorsiflexion Contracture.

Plantarflexion position patient in prone lying with foot outside the bed, will rest on slight plantarflexion.

II. SplintingBy Definition:

Tools to support burned area, maintain joint position and correct or prevent deformity.

Mostly in use are thermoplastic materials, still there are some other materials in use such as leather, fiberglass, and metals.

Indications

Indications differ with

different phases of rehabilitation

Acute Phase Wound Healing phase

Rehabilitation Phase

Reconstruction Phase

Acute Phase

Uses of SplintsProphylactic role if tendons & joint damage is suspected

N.B.Because of fluctuating edema atThis phase, splints should be

• MOdulable• Not Constrictive

Wound Healing Phase

Uses

• prevent development of Contractures

• Protect newly applied Skin grafts

N.B.Avoid interference with healing

by proper Fitting• Proper Length

•Edges rolled and flared awayFrom skin

Rehabilitation Phase

Uses• Reduce contracture non

surgically• prevent deformities

• provide sustained stretching ofScar tissues.

• Maintain gained ROM

N.B.If Scar tissue tensile strength is poor

Monitor for wound break down

Reconstructive Phase

Uses• For fixation following release of Contractures or reconstruction

surgery

N.B.Monitor for wound Maceration

Examples Of Splints In UseRegion Splints

Cervical Soft neck collar (foam) Philadelphia collar Molded neck splint Watusi collar (plastic tubes) Halo- neck collar

Ear Semi- rigid oxygen mask

Mouth mouth spreader External traction hook

Axilla and anterior chest Axilla air plane splint Clavicle figure of eight splint

Region Splints

Elbow And Knee Gutter or trough splint Airslpint

Hip hip spica Abduction splint Spreader Bar

Ankle Posterior foot drop High top gym shoe Anterior & posterior ankle conformer

Wrist & Hand Wrist splint Thumb spica Thumb web spacer

III. Electrotherapeutic Modalities Several electrotherapeutic modalities

provide assistance in wound healing process BASICALLY including: HVPGS. US THERAPY. ULTRAVIOLET RADIATIONS LASER

HVPGS

There are several possible explanations of its effect on wound healing:

1- Positive electrical stimulation stimulates repair process.

2- Negative pole stimulation will destroy any bacteria.

3- Increasing superficial circulation hastens healing

ApplicationParameters

IntensityAccording topatient tolerance.

Rate setting Continuous • Surged Pulse rate 80 pulse/sec.

Electrodes• Active (Usually Anode) covertreatment area.• Dispersive (~ Cathode.) on the back

Treatment TimeTime of treatment 20-30 minutes.

ULTRASOUND THERAPY

Effects of US on wound healing include:

1- Promotion of formation of granulation tissue.

2- Accelerated re- epithelization.

3- It reduces wound infection, through improving circulation (?!).

4- It improves scar pliability ( thus used in hypertrophic scars).

5- Phonophoresis can be used to introduce wound healing medications.

APPLICATION

IN CONTACT• Using coupling media asParaffin oil, aquassonic gel, Or aquasonic gel pad.• Usually applied at wound edges

SUB- AQUATIC• Using suitably sized watercontainer and previously boiled water.• Usually applied to wound bed.• Distance 1-5 cm from skin.

ULTRAVIOLET RADIATIONSUVR

1- Accelerates healing through facilitating mitosis in the germinal layers of the skin.

2- Help in maintaining sterility through destroying surface bacteria.

N.B.: High doses should be avoided at growing wound edges as it may induce more skin damage.

Application Apply sensory test for erythema (E) (?!!!!!!). Calculate Erythema dose (?!!!!!!). Apply 25% of (E1) then progress in the

same rate (25% of the preceding dose. Then shift to E2 (2.5 x E1) and progress by

50% of the preceding dose. Then shift to E3 (5 x E1) AND PROGRESS

BY 75% of the preceding dose.

Notice

When the main aim of treatment is to facilitate mitosis gradual progression from E1 doses through E3 can be afforded.

If the condition shows wound infection high exposure doses would be initially implemented.

Avoid UVR in early stages of burn rehabilitation (inflammatory stage of healing) as it may aggravate the burn insult

LASER

Enhance Fibroplasia

Enhance immuneCells to attack

Pathogens

Increase ATP Synthesis

Quicken Collagen Synthesis

Increase Prostaglandins

EFFECTS “ Bio-stimulation”

Types Of Laser In Use For Wound Healing

Types

Helium- Neon (He-Ne)

632.8 nm

Galium- Aresnide(Ga As)

Or Infrared Laser(IR)

904 nm

Argon (Ar)

488 – 514 nm

Carbon Dioxide(CO2)

10.6 nm

(2) burn rehabilitation

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