A brief outline of how to go about the rehabilitation for post burn patients

1. Review Of Literature

2. Burn Rehabilitation
By:
Radhika Chintamani
Orthopedic Manual Therapy
Under the guidance of
Dr. Santosh Metgud

3. Contents
1. Definitions
2. Skin Anatomy
3. Classification of burn
4. Pathological changes: Local and Systemic
effects
5. Assessment of burns
6. Outcome measures
7. Treatment phases

4. Definitions and Epidemiology.
• A burn is an injury to the skin or other organic tissue primarily
caused by heat or due to radiation, radioactivity, electricity,
friction or contact with chemicals. (WHO, September 2016)
• Epidemiology:
A five year epidemiological study done by Goswami et al.
collected retrospective data of all the burn patients admitted to
the BCU in Tata Main Hospital, Jamshedpur, Jharkhand, India
from January 2009 to December 2013 were collected and were
analyzed. The number of admission from 2009-2013 were
variable, ranging from 326-436 and the overall male to female
ratio was 1:1.05, with most common etiology to be Flame
burn (65.16%).
HyperlinksIndianJBurns24141-1241573_032655.pdf

5. Skin Anatomy

6. Classification of Burns 4
On the basis of skin
thickness
On the basis of
etiology
1. Superficial thickness
burn
2. Superficial Partial
thickness burn
3. Deep Partial
thickness burn
4. Full thickness burn
5. Subdermal burn
1. Thermal burn
2. Chemical burn
3. Electrical burn
4. Inhalation burn
5. Friction burn
6. Radiation burn

7. On the basis of skin thickness
CHARACTERS: 1. Surface thickness of burn 2. Color. 3.
Surface Appearance. 4. Pain. 5. Edema. 6. Healing. 7. Scarring

8. On the basis of etiology
Thermal Burn:
•Types of
mechanism:
Conduction and
radiation.
Pathological mechanism is temperature-time relation.

9. Ref: Carrougher G.J. Burn Care AND Therapy. 1998: pg No.: 1-34,
133-166.

10. Chemical burns

11. Chemical burns
Agent Common source Mechanism of action
Alkalis Lime
Potassium hydroxide
Sodium hydroxide
Cement
Household cleaners
Cell dehydration
Liquifaction necrosis.
Acids Industrial cleaners
Household rust removers
Oxidation
Hydrocarbons Industrial cleaners
Solvents and degreasing
agents
gasoline
Protoplasmic toxicity
Ref: Carrougher. G. J. Burn care and therapy. Mosby Inc.(1998).pg no:6

12. Electrical burns
Hyperlinks[Macedonian Journal of Medical Sciences] Electrical Injuries Etiology
Pathophysiology and Mechanism of Injury.pdf
Voltage Effect
1 mAmp Threshold of perception
5-10mAmp Maximum harmless
current
16-
20mAmp
Tetany of skeletal muscles
20-
50mAmp
Paralysis of respiratory
muscles (respiratory arrest)
100mAmp Threshold for ventricular
fibrillation
2-5Amp Asystolia

13. • Two types: Direct inhalation burns and indirect
burns.
• Direct burns: Enclosed space.
• Indirect Inhalation burns: concomitant to neck and
facial burns.

14. Friction burn
HyperlinksFriction Burns.pdf

15. Radiation burns
Minimum radiation required
to cause burn is greater than
25rads.
Radiations greater than 100
rads cause acute radiation
syndrome. (3types)
Ref: Kelleher D: Acute effects of radiation. In United States Navy/Royal
Navy workshop on nuclear warfare combat casualty care, US Navy, 1983,
US Govt Prnt Offc

16. Radiation burn
Acute skin effect Dosage in
Gy
Early transient erythema 2
Faint erythema: Epilation 6-10
Definite erythema:
Hyperpigmentation
12-20
Dry desquamation 20-25
Moist desquamation 30-40
Ulceration >40
Ref:Hyperlinksinonizing burn.pdf

17. Skin exposed to high temperature
Breakdown of proteins of skin
Cell and tissue damage
Loss of barrier function of the skin
Massive fluid loss from water evaporation
Inability to control body’s temperature due to loss of body
heat occurring due to excessive evaporation
Loss of proteins, potassium and sodium
Pathology of burn injury (common pathology)

18. Burn Injury
Increased fluid
leakage from
capillaries
Tissue edema
Loss of blood or
any fluid due to
imbalance
poor blood visceral
supply
Stomach ulcer and
renal failure
Increased level
of
catecholamine
Inflammatory
response
Hypermetabolic
state (causing
decrease in body
wt)

19. The local effect involves three burn zones:
www.vicburns.org
The depth of the wound develops over time: The burn process
peaks at approximately three days. Progression is 3D- zone of
coagulation both increases in depth and width.

20. Pathological changes
1. Local changes:
a. Severity of burn.
b. Three zones of burn
c. Vascular changes: due to circulatory disruption, third
spacing, fluid remobilization.
2. Systemic changes:
a) Shock: lasts for 12-24 hrs
b) Biochemical changes: electrolyte imbalance, blood urea.
c) Blood changes: increased breakdown of RBC’s.
d) Metabolic changes: The greater the TBSA, the greater the
risk and impact of hyper metabolism.

21. Evidence
Author
name
Title and year Parameters Conclusion
William DW.
Long. J.
Mason. A.D
Skreen. R.W
Pruitt. B.A
Catecholamines
Mediator of the
Hypermetabolic
Response to
Thermal Injury
[1974]
Energy Expenditure
Interaction with
Metabolic Rate, Body
and Skin Temperatures.
The injury stimulates the
hypothalamic reset of the
internal thermostat due to
which burn patient strive
to maintain a core body
temperature about 10-20
greater than normal.
Goran M.
Peters EJ.
Herndon DN.
Wlofe. R. R.
Total energy
expenditure in
burned children
using the doubly
labeled water
technique.
[1990]
Resting energy
expenditure in burned
children
Total energy
expenditure in burned
children
REE is 1.2times greater
than that of normal
TEE 1.3 times greater
than that of normal
children

22. Stages of burns
Stage of Shock
Stage of Eschar
Stage of Healing and Reconstruction
Phases of burn
1. Emergent phase:24-48hrs.
2. Acute phase: 48hrs-wound closure.
3. Chronic phase: wound closure-functional ADL
regainment.

23. Complications of healing in burn2
i. Pain: Background pain, pain due to anxiety,
Procedural, Break-through pain.
ii. Edema.
iii. Inflammatory Response.
iv. Compartment syndrome.
v. Hypertrophic scarring.
vi. Keloid.
vii. Toxic Epidermal Necrolysis.
viii.Reduced ROM.
ix. Impaired functional capacity.
x. Psychological problems.

24. Assessment2
Primary assessment
• Airway.
• Breathing.
• Circulation.
• Neurologic status.
Secondary assessment
• Type and Mechanism of
injury
• Severity and extent of
burn
• Depth of burn

25. Wallace Rule Of Nine

26. Lund Browder Chart

27. Physiotherapy Assessment
• On observation: degree of burn, severity of burn,
extent of burn, edema,etc.
• Edema assessment: site, pitting, non-pitting.
• Burn wound area assessment: Laser dopler
flowmetry, clock method.
• On palpation: Area to be palpated burnt area with
sterile methods and the area beside it to assess for
assessment of perception of sensation.
• Range of motion assessment: after advised period
of immobilization.

28. Outcome measures 2
HyperlinksBURN SPECIFIC HEALTH
SURVEY.docx
HyperlinksBSHS-B.pdf
Scar Outcome Measures:
HyperlinksBurn scar scales.pdf

29. • Evidence:
• When the BSHS – B is used in comparison
with the SF -36 health questionnaire, the
BSHS – B was seen to provide more useful
information with fear avoidance and post-
traumatic stress disorder in relation to
returning to work (McMahon 2008).
• HyperlinksBurn Centre Referral Criteria.docx

30. Hydrotherapy
for cleansing
30 minutes
Adequate
cleansing is
achieved by mild
soap.
Mechanical
debridement
Chemical
debridement
Surgical
debridement
Wet dressing,
Wet-to-dry
dressing,
Wet-to-moist
dressing.
Accuzyme,
Collagenase
Santyl,
Elase.
Tangential
excision.
Fascial
excision.
Cleansing 1
Debridement of
wound 1
Treatment of burns:
I. Emergent Phase: 2

31. Wound covering1
Biological
wound
dressings
Biosynthetic
wound dressings
Synthetic wound
dressings
1. Xenograft
2. Allograft
1. Biobrane
2. Calcium
alginate
1. Thin film
dressing
2. Composite
dressing

32. Formula name Recommended
solutions
Formula for
estimating fluid needs
EVANS 0.9% of NS +
Colloid solution
1ml/kg/%TBSA +
1ml/kg/%TBSA
Brooke Lactated Ringer’s
solution + Colloid
solution
1.5mlkg/%TBSA +
0.5ml/kg/%TBSA
Hypertonic saline Na+ 250mEq/liter Volume to maintain
urine output at
30ml/hr
Modified Brooke Lactated ringer’s
solution
2ml/kg/%TBSA
Parkland Lactated Ringer’s
Solution
4ml/kg/%TBSA
Common fluid resuscitation used in emergent phase of burn
are: Adult burn resuscitation formula: Initial 24hr post injury

33. Formula
Name
Recommended
solutions
Formula for existing fluid needs
EVANS 0.9% NS +
5% Dextrose in water
50% of first 24hrrequiremnt +
2000ml
Brooke Lactated ringer’s
solution+
5% dextrose in water
50% to75% of first
24hrrequiremnt +2000ml
Hypertonic
saline
33% isotonic salt
solution
0.6ml/kg/%TBSA burn +
Replacement of insensible losses
Modified
Brooke
Colloid solution +
5% dextrose in water
0.3-0.5ml/kg/%TBSA +
Volume to maintain desired urine
output
Parkland 25% albumin +
5% dextrose
20-60% of calculated plasma vol
+
Volume to maintain desired urine
output
Second 24hrs post injury 2

34. Acute Phase
Aims:
• Protect/promote healing.
• If can not be managed with conservative
treatment then surgery specified.
• Reduce pain and edema.
• Reduce risk of complications by maintaining
immobilization.
• Optimize scar appearance.
• Decrease complications of scar /prolonged
positioning on range of motion and function.
• Prevent contractures
• Prevent deformities/loss of range

35. Type of
treatment
Dosage Duration Effects
HyperlinksIont
ophoresis and
Low level
LASER1.pdf
Continuous
frequency
modulation=500
Hz.
10min Acceleration of
messenger RNA
transcription rate of
collagen gene,
Increased fibroblast
activity, increased
concentration of
inhibitory
neurotransmitters.
HyperlinksDer
mapulse
Stimulator.pdf
0-5.6mA Increases TGFβ
Physical therapy intervention to promote healing in acute phase:

36. Hyperlinks
hyperbaric_
oxygen_ther
apy_for_the
rmal_burns.
pdf
100%
oxygen at 2
ATA
90 minutes
every 8 hours
for 24 hours,
then every 12
hours until
healed
mean healing
times were
significantly
shorter in patients
exposed to HBOT
and that fluid
requirements
were also smaller
in the HBOT
group
Hyperlinks
ECSWT.pdf
100
impulses/cm2
20 seconds/cm2 accelerated
epithelialization

37. Reconstructive Ladder
Dermal replacements
Primary intention, delayed primary intention
Secondary intention
Skin grafts
Local flaps
Regional flaps
Distant
flaps
Free
Flaps

38. Surgical Procedures Immobilization Time
Biological dressing <24hrs
Autografts 24-48hrs
STSG 3-5days
FTSG 5-7days
The following is the recommended immobilization times for
the various skin grafts
Ref: ANZBA 2007; Edgar and Brereton 2004
Rationale for immobilization

39. I. Pain:
• Physiotherapy management: TENS, cognitive behavioral
therapy, music therapy, Virtual reality.
Modality Dosage Duration Effect
HyperlinksTENS
effective at reducing
pain in patients with
severe burn
injuries.pdf
pulse width of
80-85msec,
rate of 75-
90pps
Reduction in pain after
a Traverse
(enzymatic
debridement) procedure
HyperlinksVR in
burns.pdf
Water friendly
VR
3min along
with physical
therapy
Reduction in
procedural pain and
pain related to anxiety
Hyperlinksmusic
therapy in burns.pdf
MBI
MAR
MAE
Relaxation induced
pain relief
Cognitive
behavioural therapy

40. II. Healing:
Relaxation, Massage, ESCWT.
III. Edema:
Bradford Sling
Edema glove and digi sleeve

41. Positioning in acute stage

42. Static splint
Dynamic splint
Splinting

43. Supportive splint
Corrective splint

44. Types of Splints used in Hand and
forearm burns

46. Skeletal supension Traction

47. SCAR MANAGEMENT
HyperlinksLaser treatment for
burn scar.pdf
Pressure garments
Silicone sheets

48. Range of motion:
a. Mobilisation- both mobility and specific joint
mobilisation:
Frequency:
- Twice daily, with 10 repetitions with frequent
active exercises between sessions.
- For sedated patients: gentle passive range of
motion exercises done thrice daily.
Ref: Hale. A, O’Donovan. R, Diskin. S, McEvoy. S,
Keohane,Gormley G. Physiotherapy in Burns, Plastics and
Reconstructive Surgery. 2013. pg no: 3-25, 37-67.

49. Chronic Phase
• Aims:
i. Early functional rehabilitation
ii. Attainment of activities of daily life
HyperlinksBurn_Exercise_Fact_Sheet_508.pdf
Circuit Training for Inpatient and outpatient
aerobic and resistance training.docx

50. Reference
1. Carrougher G.J. Burn Care AND Therapy. 1998: pg No.: 1-
34, 133-166.
2. Hale. A, O’Donovan. R, Diskin. S, McEvoy. S,
Keohane,Gormley G. Physiotherapy in Burns, Plastics and
Reconstructive Surgery. 2013. pg no: 3-25, 37-67.
3. O’ Sullivan. Schmitz T. Physical Rehabilitation. JAYPEE
BROTHERS. 2007. ed(5th):pg. no: 1091-1116
4. Goswami P., Singodia P, Sinha A, Tudu A. Five-year
epidemiological study of burn patients admitted in burns care
unit, Tata Main Hospital, Jamshedpur, Jharkhand, India. Indian
Journal of Burns. 2016: 24: pg no:41-46.
5. Moritzz. A. R. Henrique. F. C. STUDIES OF THERMAL
INJURY II. THE RELATIVE IMPORTANCE OF TIME AND
SURFACE TEMPERATURE IN THE CAUSATION OF
CUTANEOUS BUBTNS. 1946: pg no.: 695-720.

51. 6. Gjorgje Dzhokic, Jasmina Jovchevska, Artan Dika. Electrical
Injuries: Etiology, Pathophysiology and Mechanism of Injury.
Macedonian Journal of Medical Sciences. 2008 Dec 15; 1(2):54-
58.
7. Kelleher D: Acute effects of radiation. In United States
Navy/Royal Navy workshop on nuclear warfare combat casualty
care, US Navy, 1983, US Govt Prnt Offc.
8. Rayan. J.L .Ionizing Radiation: The Good, the Bad, and the
Ugly. Journal of Investigative Dermatology (2012) 132, 985–993;
doi:10.1038/ jid.2011.411; published online 5 January 2012.
9. http://:www.vicburns.org
10. Goran M. Peters EJ. Herndon DN. Wlofe. R. R. Total energy
expenditure in burned children using the doubly labeled water
technique. The American Physiological Soceity.1990:pg no.:
E576-E585.
11. William DW. Long. J. Mason. A.D Skreen. R.W Pruitt. B.A.

52. 12. Belli. M, Fernandes C, Neves L, Mourão V, Barbieri R,
Esquisatto M, Amaral M, Santos G and Mendonça F. Application
of 670nm InGaP Laser and microcurrent favours the healing of
second degree burns in wistar rats. Laser Phys. 25 (2015).
13. Cianci P. Lee L. Shapiro R. William. C. Green B. Adjunctive
Hyperbaric Oxygen reduces the need for surgery in 40-80%
BURNS. Journal of Hyperbaric medicine. 1988. (3):pg. no: 97-
101.
14. Ghetti C. Music Therapy and Music-based Interventions for
Surgery, Medical Procedures and Examinations. Journal Medical
Music Therapy. 2014 (7). Pg no: 1-10.
15. Sharar S, Miller W, Soltani M, Hoffman H, Jensen M, Patterson
D. Applications of virtual reality for pain management in burn-
injured patient. NIH Public Access. (2008).pg no: 1-14
16. Osborne C. Is Transcutaneous Electrical Nerve Stimulation
(TENS) effective as a modality to reduce pain and pruritus in
patients with burn injuries. 2015.

53. Thank