Goals of Burn Rehabilitation Overall Goal Short Term Goals Return to pre- injury • Assist Wound Healing Level of function with • Prevent ComplicationsBest possible cosmoses (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. Prevents Controls Edema Prevent Localized Maintain elongatedContracture Neuropathies 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 or Asymmetrical neck Head Burn that Posterior neck BurnCircumferential burn Includes the ear Ear not involvd burns
NECK BURNS Burn types Expected Position HOW to Maintain? Deformity Anterior or Flexion Extension/ - Towel under shoulders orCircumferential Contracture Hyperextension between scapulae burns - Foam cervical collarAsymmetrical Lat. Fl. Mid line --Towel roll, sand bag, neck burn Towards Or rotated away wedges on affected side. burned side - Prone lying head rotated opposite side.Head burns that Folding of the Avoid any - Foam or gel filled bag isinclude the ear Helix and pressure over used to elevate the ear condritis the ear from the bed.Posterior neck Hyperextension Head in midline - Pillows are used toburns- Ear not of the neck elevate the head and involved lengthen posterior tissues.
Trunk burns Burn types Expected Position HOW to Maintain? Deformity Clavicular & shoulder girdle - A square towel or pectoral protraction and shoulder retraction blanket between glenohumeral scapulae. adduction - Fig. of 8 wrapping From pectoral same as above Same as aboveregion to below plus Same as above with upper with towel extended umblicus kyphosis Back hyperextension downwards. Burns of the Exaggerated Using pillows under lower back lordosis Midline position knee to flatten back Lateral trunk Scoliosis concave Towel roll, sand burn to burned side Maintain trunk straight bag, wedges on affected side
Shoulder Burn types Expected Position HOW to Maintain? DeformityAnterior axilla Shoulder Shoulder Abd. / Ext. Rot. / Adduction & Flexion. - Towel roll, sand bag, Int. Rotation 90 Abd. /15- 20 horizontal wedges between Add. affected axilla and side. Above 90 Abd. And Ext. - Wrist cuff hanged or Rot. Should be attempted stockinet to I.V. pole temporary. (Murphy splint) - Aero plane splintAnterior chest Fl. / Add. Ext. & Abd. Shoulder.and anterior Arm. Ext. of dorsal spine - Towel roll, sand bag,arm. kyphosis wedges between scapulae for dorsal Ext. - Same as above for Ext. Abd. Shoulder.
ELBOW Burn types Expected Position HOW to Maintain? DeformityAnticubital or Elbow fl. Elbow extension Arm troughs are usedcircumferential Forearm Supination or neutral to maintain elbow pronation position. extension over bed table can be used if patient can voluntarily extend his elbow. Elbow splints can be used in positioningPosterior extension Elbow semiflexion same as above.surfaces of the deformity Supination or neutralupper position.extremities (not common)
Forearm And Wrist Burn types Expected Position HOW to Maintain? DeformityVolar surface Forearm wrist in functional Wrist splint pronation position (from neutral to 30 Towel or gauze Wrist degree extension. placed in the hand while flexion Forearm supinated or forearm supinated. neutral.Dorsal surface Wrist ext. Functional position of the Wrist splint contracture wristCircumferential Wrist wrist in functional Wrist splintburns flexion. position (from neutral to 30 Towel or gauze Forearm degree extension. placed in the hand while pronation Forearm supinated or forearm supinated. neutral.
Hands Burn types Expected Position HOW to Maintain? DeformityPalmar surface MCP hand positioned with In acute palmer burn flexion/ IP all fingers extended cases use dorsal splints. extension and the thumb web when healing progress Thumb space on a slight use silicone pad to opposition. stretch provide both positioning & pressure.Dorsal surface MCP hyper Wrist extension A gauze roll is extension MCP flexion. wrapped into the palm IP flexion IP extension. extending into the thumb web space. Thumb Thumb palmer Hand splint (Volar) adduction abduction or oppositionCircumferential contracture wrist in functional Wrist splintburns towards the position (from neutral Towel or gauze placed most deeply to 30 degree in the hand while burned side. extension. forearm supinated. Forearm supinated/ neutral.
HIP Anterior or Posterior Hip Burns Deformity PositionFlexion/ External Maintaining position • Slight Abduction Rotation • Mid rotationAnd or Adduction Towel roll or sand ▲ foam wedge bag lat. To Thigh Blanket between legs For neutral rotation For hip abduction Prone lying Knee ext. splint minimize Reduce hip flexion Hip flexion With prone lying
KNEE Burn Expected Position HOW to Maintain? types DeformityAnterior RarelyBurns causes extension contaracturePosterior Flexion Extension position bulky dressing toburns contracture impede knee flexion knee extension splints. Prone lying bed outside bed (Prone hang) achieve full extension.
Ankle & Foot Burn types Expected Position HOW to Maintain? DeformityPosterior or Plantar Neutral or dorsiflexion but use foot boardCircumferential flexion neutral is optimal Sponge booties or contracture custom splints with a (heel cord cut out heel. tightness)Isolated Rarely Plantarflexion position patient in prone lyinganterior causes with foot outside thesurface dorsiflexion bed, will rest on slight Contracture. 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 rehabilitationAcute Phase Wound Healing Rehabilitation Reconstruction phase Phase Phase
Acute Phase N.B. Uses of Splints Because of fluctuating edema atProphylactic role if tendons & This phase, splints should be joint damage is suspected • MOdulable • Not Constrictive
Wound Healing Phase Uses N.B. Avoid interference with healing• prevent development of by proper Fitting Contractures • Proper Length • Protect newly applied •Edges rolled and flared away Skin grafts From skin
Rehabilitation Phase Uses • Reduce contracture non surgically N.B. • prevent deformities If Scar tissue tensile strength is poor• provide sustained stretching of Monitor for wound break down Scar tissues. • Maintain gained ROM
Reconstructive Phase Uses• For fixation following release of N.B. Contractures or reconstruction Monitor for wound Maceration surgery
Examples Of Splints In Use Region SplintsCervical Soft neck collar (foam) Philadelphia collar Molded neck splint Watusi collar (plastic tubes) Halo- neck collarEar Semi- rigid oxygen maskMouth mouth spreader External traction hookAxilla and anterior chest Axilla air plane splint Clavicle figure of eight splint
Region SplintsElbow And Knee Gutter or trough splint AirslpintHip hip spica Abduction splint Spreader BarAnkle Posterior foot drop High top gym shoe Anterior & posterior ankle conformerWrist & 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
Application Parameters Intensity Rate setting Electrodes Treatment TimeAccording to Continuous • Active (Usually Time of treatmentpatient tolerance. • Surged Pulse Anode) cover 20-30 minutes. rate 80 pulse/sec. treatment area. • Dispersive (~ Cathode.) on the back
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 SUB- AQUATIC• Using coupling media as • Using suitably sized waterParaffin oil, aquassonic gel, container and previouslyOr aquasonic gel pad. boiled water.• Usually applied at wound • Usually applied to wound bed.edges • Distance 1-5 cm from skin .
ULTRAVIOLET RADIATIONS UVR1- 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 Increase Prostaglandins Enhance Quicken CollagenFibroplasia Synthesis EFFECTS “ Bio-stimulation” Enhance immune Increase ATP Cells to attack Synthesis Pathogens
Types Of Laser In Use For Wound Healing TypesHelium- Neon Galium- Aresnide Argon Carbon Dioxide (He-Ne) (Ga As) (Ar) (CO2) 632.8 nm Or Infrared Laser 488 – 514 nm 10.6 nm (IR) 904 nm