This presentation provides an overview of 1) burns- introduction and types of burns physiotherapy assessment and management of burns types of skin graft and rehab following reconstructive surgeries 2) Cancer- introduction Types of cancer Cancer-related fatigue and its management ACSM guidelines

1. BURNS AND CANCER
REHABILITATION
PROTOCOL
SURUCHI.V.RAO, PT

2. Introduction of burns
2
 A burn is defined as a traumatic injury to the
skin or other organic tissue primarily caused
by thermal trauma.
 It results when some or all of the cells in the
skin or other tissues are destroyed by heat,
cold, electricity, radiation, or caustic chemicals

3. 3
 Skin is the largest organ of the body and a
cutaneous membrane which covers the entire
body
 Consists of dermis and epidermis
 Epidermis is the superficial layer and dermis is
the deep layer

4. 4
EPIDERMIS DERMIS SUBCUTANEOUS
Composed of epithelial
tissue
Capable of regeneration
Deeper, thicker layer
Areolar and adipose
tissue
Avascular Connective tissue Storage for fat/
insulation
Deepest layer (Stratum
Basale) contains ‘Stem
cells’
Contains blood vessels,
nerves, glands and hair
follicles
Contains large blood
vessels
New skin cannot
regenerate if injury
destroys a large portion
of this layer
Attaches to underlying
facia and overlies
muscle and bone

5. 5

6. Types of burns
6
 Thermal
 Chemical
 Electric burns
 Radiation burns

7. Depth of burns
7
Depth characteristics cause
First degree burn Erythema
Pain
Absence of blisters
Superficial burns(sunburn)
Second degree burn Red or mottled
Flash burns
Hot steam, hot fluids
Third degree burn Dark and leathery
Dry
Fire
Electricity or lightning
Prolonged exposure to hot
liquids/ objects

8. Physiology of burns
8

There are 3 zones of injury and healing

The 3 zones are
1.
Zone of Coagulation
2.
Zone of Stasis
3.
Zone of Hyperaemia

9. 9
Zone of Coagulation:
 The point of maximum damage
 Irreversible tissue loss due to coagulation of
constituent proteins.

10. 10
Zone of Stasis:
1.Characterised by decreased tissue perfusion
2. Potential to rescue the tissue in this zone
3. Problems such as prolonged hypotension,
infection or oedema can convert this area into
one of complete tissue loss

11. 11
Zone of Hyperaemia:
1. The tissue here will invariably recover unless
there is severe sepsis or prolonged
hypoperfusion.

12. 12

13. Tissue healing
13
STAGE TIMESCA
LE
PROCESS SIGNS AND
SYMPTOMS
TREATMENT
Inflammation
.
0-5 days •Vasoconstriction
followed by
vasodilatation
•influx of
inflammatory
mediators and
WBCs.
• Increased capillary
permeability.
Redness,
Heat,
Swelling,
Pain
Prevent infection
and disruption of
wound.
(immobilisation,
positioning,
splinting)
Reduce heat and
oedema and pain
Proliferation
(fibroplasia).
Moist red
raised tissue
over wound
3- 5 days
to 2-6
weeks
Fibroblasts
synthesize collagen.
Angiogenesis
continues.
Early: positioning
and immobilisation
Later: gentle stress
(splinting, exercise)
Reduce oedema
and prevent
contracture

14. 14
STAGE TIMESCALE PROCESS SIGNS AND
SYMPTOMS
TREATMENT
Remodelling
(maturation).
Begins week
4-6. Lasts up
to 2 years
Synthesis of
collagen
balanced by
degradation.
Organisation
of collagen
fibres along
lines of
stress.
Wound
closure Scar
red and
raised
progresses to
flat pale and
pliable. Scar
tissue
tightens.
Optimise
function
Splinting
Positioning
Exercise
Stretching
Strengthening

15. Complications
15
 Edema
 Vascular insufficiency
 Joint contractures
 Hypertrophic scarring
 Pain

16. Physiotherapy assessment of
pain
16
Physiotherapy aims
1. Prevent respiratory complications
2. Control Oedema
3. Maintain Joint ROM
4. Maintain Strength
5. Prevent Excessive Scarring

17. Subjective assessment
17
 Presenting complaint
 History of Presenting Complaint – consider the
history of the incident with mechanism of injury
and any falls and the type of burn
 Medical and Surgical History - any surgical or
medical management like debridement
escharectomy, flaps/grafts

18. Objective assessment
18
Pain Intensity Assessment
 Observational behavioural pain assessment
scales should be used
 Eg- FLACC scale , Wong-baker pain rating
scale VAS can be used in children aged 12
years and older and adults.

19. 19
Inhalation Assessment Physical signs are
 Hoarse vocal quality
 Oedema
 Erythema (Superficial reddening of the skin,
usually in patches, as a result of injury or
irritation causing dilatation of the blood
capillaries)
 Soot stained sputum
 crackles on auscultation and chest x-ray
changes

20. Oedema Assessment
20
Stage of Oedema Appearance of Oedema
Stage 1 Soft, may pit on pressure
Stage 2 Firm, rubbery, non-pitting
Stage 3 Hard, fibrosed

21. Mobility assessment
21
The assessment and treatment of mobility can
be separated into two aspects
 Limb and trunk- Assessment of limbs and trunk
should include joint ROM and strength. limiting
factors may include pain, muscle length, trans-
articular burns, scar contracture and the
individual specificity of the burn.

22. 22
General Functional Mobility
 All functional transfers, gait, endurance and
balance should be assessed
 Consider posture, demands of vocational
roles and ADLs, cardiovascular response to
mobilisation and Pain
 The outcome measure used is BHSS(burn
specific health scale)

23. 23

24. Management of burns
24
 Assess airway
 Breathing: check for inhalation injury
 Circulation: fluid replacement
 Disability: compartment syndrome –
 Exposure: percentage area of burn by Rule
of 9’s

25. 25
 The “Rule of 9’s” is commonly used to
estimate the burned surface area in adults.
 The body is divided into anatomical regions
that represent 9% of the total body surface
 The outstretched palm and fingers
approximates to 1% of the body surface area.

26. 26

27. Physical therapy intervention
27
 Positioning and splinting
 Therapeutic exercises- Active and passive
exercises
 Resistive and conditioning exercises
 Ambulation
 Scar management
 Pressure dressing

28. Aims in each phase
Acute phase
 Prevent deformities
 Maintenance of
range of motion
 Promote Healing
Subacute
 Maintenance of
range of motion
 Regain range of
motion
28

29. Positioning techniques
29
Common contractures Positioning
Hip flexion contracture Prone lying, legs extended, no pillow under knees in
supine, limit sitting/side lying
Knee flexion contracture Long sitting/ supine lying, no pillow beneath knees
Neck flexion contracture Neck in extension. If head needs to be raised, do not
use pillows.
Neck extension contracture Head in flexion. Sitting or lying with a pillow behind the
head.

30. Immobilisation of the hand
30
 The most common deformity associated with
burns is the ‘claw’ deformity.
 It involves extension of the MCP joints, flexion
of the PIP joints, adduction of the thumb and
flexion of the wrist
 This position is referred to as the intrinsic
minus position.

31. 31
Splinting position involves 20-30 wrist
extension, 80-90 degrees flexion MCP joints,
full extension PIP and DIP joints and palmar
abduction of the thumb

32. 32

33. Splinting position
33
 Static splinting – To stretch contractures
through the application of incrementally
adjusted static force to promote lengthening of
contracted tissue
Eg- finger flexion strap splint

34. 34
 dynamic splinting- aids in initiating and
performing movements by controlling the
plane and range of motion of the injured part. It
applies a mobile force in one direction while
allowing active motion in the opposite
direction. This mobile force is usually applied
with rubber bands, elastics and springs

35. Examples of splints
35

36. Edema management
36
 Elevation of the extremity with appropriate
slings
 Coban wraps - used to decrease hand
oedema and does not stick to underlying
tissue, making it suitable for use in the acute
stages of burns

37. Subacute stage
37
 The main aims are mobilization and scar
management
 Burns patients should be mobilised as early as
possible to avoid deconditioning and possible
respiratory complications associated with
prolonged bed rest

38. 38
Rationale followed before mobilization is
 ROM exercises which includes both active
and passive based on the status of the patient
 Passive stretching which produces
lengthening of the tissues
 Passive joint mobilizations can be started
once the scar tissue has adequate tensile
strength to tolerate friction caused by
mobilisation techniques

39. Contraindications/ Precautions
39
 Active or Passive range of motion exercises
should not be carried out if there is suspected
damage to extensor tendons
 Flexion of the PIP joints should be avoided to
prevent extensor tendon rupture.

40. 40
 The hand should be splinted in the position of
safe immobilisation or alternatively a volar PIP
extension splint until surgical intervention
 Range of motion exercises are also
contraindicated post skin grafting as a period
of 3-5 days immobilisation is required to
enable graft healing

41. Scar management
41
 Pressure therapy is still the first-line treatment
for scars, especially for those with deep burns
 It can relieve edema, inhibit growth of
hypertrophic scars, promote scar maturation,
protect the newly healed skin, and relieve
itching and pain

42. 42
Pressure therapy is recommended for areas
that healed 2–3 weeks post burn to prevent
and inhibit scar formation. Areas healed over
3 weeks post burn, grafted, and donor sites of
split-thickness skin grafts should receive
pressure therapy.

43. 43
 It should be carried out progressively to reduce
the chances of skin breakdown caused by
friction or high pressure on newly healed,
fragile skin, and to improve patients’ tolerance
and compliance.

44. Scar massage
44
 Scar massage increases the pliability of the
skin and helps in relieving itching and pain.
 The tightness of scar might be due to
excessive fluid retained inside and deep and
firm massage can help to resolve this problem
 Deep and circular massage can also help re-
alignment of collagen fibers during scar
formation.

45. Surgical management
45
 Primary excision - surgical removal of eschar
and burn wound is closed by graft after
primary excision
 There are 3 types of grafts which are allograft,
autograft and xenograft

46. Skin grafting procedure
46
 Removal of skin along with dermatome to graft
on a burn wound is called skin grafting
 It includes 2 types which is split skin grafting
and full skin thickness graft
 Split skin grafting consists of epidermis and
superficial part of dermis
 Full skin thickness graft consists of full dermal
thickness

47. 47
 Graft can either be a sheet graft or mesh graft
 Sheet graft is a skin graft applied to a recipient
bed without alteration following harvesting
from a donor site
 Mesh graft consists of device that makes tiny
parallel incision in a linear arrangement which
will permit the graft to be expanded

48. Physiotherapy after
reconstructive injuries
48
 Performed on abnormal structures of the body
to improve function or approximate normal
appearance.
 Abnormalities can be congenital or due to
external factors
 General rule is to know when and how should
mobilisation be introduced

49. 49  Strengthening: specific to the impaired
structures and general to the limb/body
 ROM: passive and active
 Flexibility: of the soft tissues and scar
 Proprioception: to minimise risk of re-injury and
return to higher level activity/sport
 Circulatory exercises (anti-DVT exercises)
 Mobility and balance
 Postural exercises
 Donor site
 Exercise prescription

50. 50
 Initially after grafting or reconstructive
surgeries, affected part is immobilized
 After the immobilization phase, if the graft is
healed , start with active ROM exercises only,
PROM and stretching to be avoided
 Based on the grafting , PT intervention is
decided

51. Reconstruction
51

52. EVIDENCES
52

53. 53
TITLE YEAR
EFFECTIVENESS
OF EARLY
STRETCHING
EXERCISES FOR
RANGE OF MOTION
IN THE SHOULDER
JOINT AND QUALITY
OF FUNCTIONAL
RECOVERY IN
PATIENTS WITH
BURNS - A
RANDOMIZED
CONTROL TRIAL
2017 Active and passive stretching for the involvement of
the shoulder joint with axilla as a result of the burn
injury
Control group- active mobilization exercises, active
assisted exercises, muscle strengthening exercises
and activities of daily living.
Experiment group-
1)Passive stretching exercises in supine position and
the patient’s shoulder was abducted and flexed till the
limit and held in that position for 1 minute.
2) Active stretching exercises •-The patient was
instructed to hold the bed head bar in supine lying and
the side railing in sitting position
 Sustained stretching protocol which has significant
benefits with regard to improving the range of
movements of the shoulder joint, functional activities
of a shoulder joint of burnt victims

54. 54
TITLE YEAR Procedure
Clinical Effect of
Comprehensive
Rehabilitation
Treatment for Deep
Burns in Different
Functional Joint
Areas
2019 To analyse the clinical effect of comprehensive
rehabilitation therapy in patients with deep burns at
different functional joint areas
 the conventional group carried out normal routine
and the experimental group went early PT intervention
 posture position was placed in in an anti-collapse
position
 For neck burns- occipital posture, and fully recline
the head
Ankle and its upper limbs of the burn patients- To
position the upper limbs at an angle about 90°,
straighten the elbow joint, and select the wrist joint to
take the middle position, flexing the
metacarpophalangeal joint about 60° to 70°, while
extending the interphalangeal joint or flexing the
interphalangeal joint 5° to 10°.

55. 55
CANCER
REHABILITATION
PROTOCOL

56. Introduction
56
 According to WHO, cancer is defined as the
uncontrolled growth and spread of cells.
 It can affect almost any part of the body. The
growths often invade surrounding tissue and
can metastasize to distant sites.

57. 57
 It is known that cancer treatment is associated
with adverse physical and physiological
changes leading to metabolic and functional
modifications, inducing pathologies of the
cardiac, pulmonary, neural, bone and
skeletomuscular systems
 These alterations affect cardiorespiratory
capacity (fitness), strength, body composition,
and physical function including immune
system integrity, peripheral neuropathy, and
quality of life

58. 58

59. Cancer grading
59
T (tumour) N (lymph nodes) M (metastasis)
•
TX: Unable to measure
tumour.
•T0:No evidence of
tumour.
•Tis: Tumour hasn't
grown into nearby
tissue.
•T1 toT4: Tumour has
grown into nearby
tissue (numbers 1–4
describe how much the
tumour has grown).
•
NX: Unable to evaluate
lymph nodes.
•N0: No cancer found in
lymph nodes.
•N1to N3: Cancer has
spread into lymph
nodes. (Numbers 1–3
are based on how many
nodes are involved and
how much cancer is
found in them.)
•
M0:Cancer hasn't
spread to other parts of
the body.
•M1:Cancer has spread
to other parts of the
body.

60. Cancer rehabilitation
60
“Medical care that should be integrated
throughout the oncology care continuum and
delivered by trained rehabilitation
professionals who have it within their scope of
practice to diagnose and treat patients’
physical, psychological and cognitive
impairments in an effort to maintain or restore
function, reduce symptom burden, maximize
independence and improve quality of life in
this medically complex population”
Silver et al;2015

61. 61
 Comprehensive, interdisciplinary rehabilitation
services (physiatry, physical therapy, occupational
therapy, speech language pathology)
 Individualized treatment plans
 Pretreatment assessments (if indicated) and patient
education
 Post-treatment assessment and follow up
 Lymphedema (swelling) management services
 Exercise and fitness programs
 Pain management
 Nutrition counseling
 Prosthetics and orthotics

62. Clinical models of rehabilitation
62
Postacute cancer rehabilitation
 Inpatient rehabilitation facilities, skilled
nursing facilities, long-term care hospitals
 The rehabilitation service conducts a formal
functional assessment to identify impairments
and provides a range of services (eg,
physiatry, physical therapy, occupational
therapy, speech therapy, nutrition, psychology,
nursing) to assist in optimizing an individual’s
function

63. 63
Home care model
 Home-based care models include multiple
medical and rehabilitative disciplines and are
typically nurse-driven, with nursing staff
providing initial assessment and treatment
planning.
 This model focus on the consistent use of
screening tools and clearly defined
recommendations for interventions or referral
especially dietician, PT/ OT

64. Ambulatory care
64
 Comprehensive care in the outpatient setting
is a logical extension of the postacute model
and complements the delivery of outpatient
ambulatory oncology care through functional
screening and monitoring for late effects and
providing interdisciplinary intervention to
alleviate functional deficits

65. 65
 Multidimensional rehabilitation program
models strive to address both physical and
emotional needs of patients. A
multidimensional approach is more likely to
help patients cope with their physical needs.
 Multidimensional rehabilitation program
models involve interval face-to-face and phone
contact between a patient and a rehabilitation
health professional

66. 66
 The main features of this model, is attention to
interdisciplinary input, the inclusion of
nonmedical domains (eg, caregiver status,
home environment assessment), and the
emphasis on functional capacity and quality of
life, for a holistic approach that contributes to
the overall functioning

67. Clinical objectives measures
67
1. Physical performance- Karnofsky
Performance Scale is a predictor of overall
survival and geriatric assessment
2. Cognitive performance- prehabilitation or
pretreatment assessment to establish a
cognitive baseline to optimize proactive
screening.
3. Functional mobility- Gait and balance tests

68. Breast cancer
68

69. 69
 Day 1-7
1. Deep breathing exercises- As a part of
relaxation and to increase the chest
expansion
2. Hand pumps- to reduce swelling
3. Shoulder shrugs and retractors activation

70. 70
 Active stretching exercises can begin week 1
after surgery, or when the drain is removed,
and should be continued for 6 to 8 weeks or
until full range of motion is achieved in the
affected upper extremity.
 Scar management should be done and
educated

71. 71
 Progressive resistive exercises, can begin with
light weights (1-2 pounds) within 4 to 6 weeks
after surgery.
 All kinds of electrical modalities are
contraindicated in cases of metastasis

72. ACSM guidelines
72
 Warm up: 5-10 minutes to raise heart rate
 Aerobic Exercise:
Frequency: 3 -5 times per week
 Intensity: 50-70% of max. heart rate
 Type: walking cycling aerobic activity
 Time: 30 minutes maintaining as a long term routine
 Resistance Training:
- Frequency: 2/3 times a week
 Intensity: 12/15 reps of 60 % of 1RM
 Type: Supervised resistance program of major muscle
groups
 Time: 6 weeks

73. Lymphedema management
73
 Pre- and postoperative measurements of both
arms are useful in the assessment and
diagnosis of lymphedema.
 Circumferential measurements should be
taken at 4 points: the metacarpal-phalangeal
joints, the wrists, 10 cm distal to the lateral
epicondyles, and 12 cm proximal to the lateral
epicondyles

74. 74
 A difference of more than 2.0 cm at any of the
4 measurement points may warrant treatment
of the lymphedema

75. Management
75
 Compression garments is advised to be worn
continously except during night
 Manual lymph drainage, compression and
massage therapy are associated with volume
reductions.
 Pneumatic compressions are effective in
reduced edema

76. Pain management
76
 Usually associated post – surgery
 Acupuncture TENS can be used for pain relief
 Proper positioning is required
 Patient education to be given

77. Cancer related fatigue
77
 Fatigue is common in cancer patients
especially who undergo radiation
 Fatigue management is tailored made based
on the specific patient
 Generally fatigue is managed by low-
moderate level of aerobic activity for 30
minutes like walking, jogging, cycling

78. ACSM GUIDELINES FOR
CANCER REHAB
78
AEROBIC RESISTANCE FLEXIBILITY
Breast
cancer
150 min/week of
moderate-intensity or 75
min/week of vigorous-
intensity activity, or an
equivalent combination.
It is supervised and
progressed slowly
Major muscles
and tendons
involved are
stretched
Prostate
cancer
150 min/week of
moderate-intensity or 75
min/week of vigorous-
intensity activity, or an
equivalent combination
Muscle-strengthening
activities of at least
moderate intensity at
least 2 days/week for
each major muscle
group.
Colon 150 min/week of
moderate-intensity or 75
min/week of vigorous-
intensity activity, or an
equivalent combination
Progressions are
slowed and supervised
as vigorous training can
lead to herniation
Precautions to
be taken while
stretching

79. Bone and soft tissue tumors
79
 Rehabilitation is based on the tumor
morphology and the surgery performed
Types of
surgeries
Limb salvages
Bone grafting
and cementing
Endoprosthetic
replacement
arthodesis
Amputation

80. 80
 In bone grafting and cementing, ROM exs will
be based on whether the limb or joint is
cemented or uncemented
 Usually in uncemented cases, assisted range
with active
 In cases of amputations, stump exercises are
followed along with edema prevention

81. Summary of cancer rehab
81
 Provide rehabilitation screening and assessment
as a part of a comprehensive cancer care plan,
from the time of diagnosis throughout the course
of illness and recovery, to address the functional
needs of patients.
 Incorporate objective assessment of a patient’s
functional status before active cancer treatment
begins, at regular intervals during treatment, and
during survivorship to preserve and optimize
function
 Conduct a thorough assessment regarding
standard functional measures specific to different
cancer populations.

82. 82

83. References
83
 Physiotherapy in Burns, Plastics and
Reconstructive Surgery ; University of Limerk
 Stout, N. L., Silver, J. K., Raj(2016). Toward a
National Initiative in Cancer Rehabilitation:
Recommendations From a Subject Matter
Expert Group. Archives of Physical Medicine
and Rehabilitation
 Beverly S. Reigle. Cancer Rehabilitation and
the Role of the Rehabilitation Nurse; 2017

84. 84
 Laura Stefani; Clinical Implementation of
Exercise Guidelines for Cancer Patients:
Adaptation of ACSM’s Guidelines to the Italian
Model :2016
 Physical Rehabilitation Services in Disasters
and Emergencies: A Systematic Review

85. 85