burn rehablitation

1. Physiotherapy in the rehabilitation
of burn injury

2. Outline
Introduction to burns
Prognosis of burn patients
Classification of burns
Mechanism of injuries
First aid and prevention
Prognosis
Management
Rehabilitation of burn patients

3. Introduction to burns
• A burn is an injury to the skin or other organic
tissue primarily caused by heat or due to radiation,
electricity, friction or contact with chemicals. WHO
A burn is an injury to the skin or other organic tissue primarily caused by
exposure to heat or other causative agents (radiation, electricity, chemicals)

4. The problem
• Burns are a global public health problem, accounting
for an estimated 180,000 deaths annually.
• The majority of these occur in low- and middle-
income countries
• Almost two thirds occur in the African and South-
East Asia regions. WHO
• In 2004, nearly 11 million people worldwide were
burned severely enough to require medical attention.
• In India, over 1,000,000 people are moderately or
severely burnt every year.

5. Skin anatomy
 Largest organ and 15% of body wt. the body's
largest organ
 At 44°C longer exposure , 50 ° C short exposure, and
at 55 ° C & > brief exposure causes tissue damage

6. What does the epidermis (top layer of skin) do?
• Acts as a protective barrier: The epidermis keeps
bacteria and germs from entering your body and
bloodstream and causing infections.
• Protects your body: Langerhans cells in the
epidermis are part of the body’s immune system. They
help fight off germs and infections.
• Makes new skin: The epidermis continually makes
new skin cells.
• Provides skin color: The epidermis contains melanin,
the pigment that gives skin its color. The amount of
melanin you have determines the color of your skin

7. What does the dermis (middle layer of skin) do?
• The dermis makes up 90% of skin’s thickness.
• Has collagen and elastin: Collagen is a protein that makes
skin cells strong and resilient. Another protein found in the
dermis, elastin, keeps skin flexible.
• Grows hair: The roots of hair follicles attach to the dermis.
• Keeps you in touch: Nerves in the dermis tell you when
something is too hot to touch. These nerve receptors also
help you feel pain.
• Produces sweat: Sweat glands in the dermis
release sweat through skin pores. Sweat helps regulate your
body temperature.
• Supplies blood: Blood vessels in the dermis provide
nutrients to the epidermis, keeping the skin layers healthy

8. What does the hypodermis (bottom layer of skin) do?
• Cushions muscles and bones: Fat in the hypodermis
protects muscles and bones from injuries when you fall
or are in an accident.
• Has connective tissue: This tissue connects layers of
skin to muscles and bones.
• Helps the nerves and blood vessels: Nerves and
blood vessels in the dermis (middle layer) get larger in
the hypodermis. These nerves and blood vessels branch
out to connect the hypodermis to the rest of the body.
• Regulates body temperature: Fat in the hypodermis
keeps you from getting too cold or hot.

9. Classification of burn
Degree
o Depending on how deeply and severely they
penetrate the skin's surface
– 1st, 2nd (Superficial partial thickness and Deep partial
thickness) 3rd and 4th
Extensiveness
– Total body surface area (TBSA)
Localization

10. Burn classification
Little blistering, no scarring
Intact blister, Minimal scarring
Broken blisters, Scar formation
No blistering, hard scar

11. Burn classification
4th degree electrical burn
 Affects epidermis, dermis, and bone
 Presence of entrance and exit wounds
 Skin appears yellow and ischemic
 May cause spinal cord damage and arrhythmia

12. Burn wound zones
 Zone of coagulation (irreversible damage)
 Zone of stasis (injured tissue may die)
 Zone of hyperemia (minimal cell damage)

13. Location of burn
 Some locations are more severe than others
Face, possibly in combination with burning of the
airways
Joints
Hands

14. How we determine percentage of burn
 Body surface is divided in parts of 9%
 Fairly accurate for adults but not usable for
children
 More than 15% is a severe burn

15. Role of 9 Children (Age 1-14 years)
Rule of 9 Adults (Age ≥ 14 years)

16. Rule of 9 for Infant (Age < 1 year)

17. Palmer Method
• Utilize the patient's palm size not your
own.
• The patient’s palmar surface including
their fingers = 1% TBSA

18. Mechanism of injury
• Thermal injuries
– Scalds—About 70% of burns in children are caused by
scalds.
– spilling hot drinks or liquids or
– being exposed to hot bathing water.
– Scalds tend to cause superficial to superficial dermal
burns
• Flame—Flame burns comprise 50% of adult
burns.
– They are often associated with inhalational injury and
– other concomitant trauma.
– Flame burns tend to be deep dermal or full thickness

19. • Contact—In order to get a burn from direct
contact
– the object touched must either have been
extremely hot or
– the contact was abnormally long.
– epilepsy or those who misuse alcohol or drugs

20. • Electrical burn
– An electric current will travel through the body from
one point to another, creating ‘’entry’’ and ‘’exit’’
points.
– The tissue between these two points can be damaged by
the current
• Chemical burn
– Chemical injuries are usually as a result of industrial
accidents but may occur with household chemical
products

21. First aid and measures
• Move the victim from the accident place to avoid
further injury;
• If the victim is burned with fire apply cool
applications, immerse the burned area in cool
water
• Role the burned person on the ground, or cover
with water socked thick cloth or blanket and put
out the fire.
• If the accident is of electric source, quickly
disconnect at the electric meter or check point,
or use rope wooden stick, dried cloth etc. to
disconnect;

22. Modern burns care
1st Phase:
Initial evaluation, resuscitation [1-3 days] post
Burn and fluid resuscitation, asmt of associated
injuries and comorbidities.
Infection control + Nutritional support
2nd Phase:
Wound excision
Wound closure [biological skin/artificial skin]

23. 3rd Phase:
Final wound closure, definitive covers,
reconstruction [face & hand]
Final Phase: [3 R ‘s]
Rehabilitation, reconstruction, and reintegration.

24. Burn
injury
Primary injury
Immediate damage by burn little can be
done.
Removal heat source
Rapid cooling
Secondary injury
Loss of fluid
Fluid shift
Secondary infection
Tissue coagulation

25. Prevention of burn
• kettles and hot pans are out of the reach of children
• Supervise children’s activities, never leave children
alone with open flame
• Move open fire from central area to a corner
• Elevate the fire or erect a barrier
• Educate children about the dangers of fire
• Electrical sockets have shutters, and electrical cables
are secure with the insulation intact
• Matches and cigarette lighters are stored safely

26. Prognosis of burn patients
Age
o Burns in people aged over 60 years or under 5
years carry a poor prognosis.
 Inhalation burns
o A high percentage of patients with facial burns
develop pneumonia. Where there are inhalation
burns as well, the mortality rate is very high.

28. Prognosis of burn patients
Total burn surface area (TBSA)
o The greater the total burn surface area, the
poorer the prognosis.
o Percentage chance of survival = [100 - (age in years +
%TBSA)
• For example
– A 60-year-old with 30% TBSA has a 10% chance of survival
[100 - (60 + 30)]=10
– A 30-year-old with the same TBSA has a chance of
survival of [100 - (30 + 30)], or 40%.

29. IMPORTANT
• Tomorrow might be too late !
– Patients may want to delay their
rehabilitation until they feel
better
– Joint stiffness likely and soft-
tissue glide reduced
– Quick wound healing prevents
hypertrophic scarring

30. Anticipated Goals and Expected Outcomes
It is difficult to list specific goals and outcomes
because of the varied nature of each burn injury.
Suggested goals and PT POC for burns
o Wound healing
o Reduce complication
o Maximize ROM
o Restore cardiovascular level
o Good to normal strength is achieved
o Independent ambulation
o Minimize scar, education, aerobic capacity, self
management.

31. Positioning and splinting
• Aims-Positioning
– Immobilize skin grafts Protect
– Minimize edema
– Maintain elongation of tissues
– Preserve function
• Aims-splinting (anti deformity positioning)
– Reduce pain prevent or manage contracture
– Maintain ROM
• Splint caring- ensure no pressure points,
check routinely, proper fit, revise if needed

32. Cont …
• The position of comfort for the patient is
usually that of joint flexion. Unfortunately this
allows scar tissue to contract and cause
deformities.
• Therefore, it is essential that joints be held in
the correct position during recovery

33. Head and neck
• A small roll (towel) behind the neck and/or a pillow
under the shoulders will help to maintain extension of
the cervical spine. The patient may be in lying (chest
and leg burns) or in half-lying with facial burns
(because of facial oedema)

34.  Upper limbs
o The upper limbs should be elevated on pillows with
the shoulder in abduction and slight flexion, the
elbows and wrists in extension, and the hands with
MCP joints in flexion, IP joints in extension, and
thumb in palmar abduction.
 Lower limbs
o The lower limbs are rested with the hip joints in
extension and slight abduction, knees in extension
and ankles in 90-degree dorsiflexion (in a foot drop
splint). Elevation is obtained by raising the end of
the bed, not by placing pillows under the legs,
which would put the hips into flexion.

35. Splinting
• Splints may be static or dynamic
• Static splints have no moving components and
provide support and immobilization
• Dynamic splints employ traction devices such
as rubber bands, springs, cords, or Velcro strips
to alter the range of passive motion of a joint or
joints

37. Effect of strap placement on a resting hand
splint.
A. Improper wrist strap placement
resulting in wrist flexion.
B. Proper wrist strap placement
providing relative wrist
extension.
C. Improper digital strap
placement facilitating proximal
interphalangeal (PIP) flexion
and MCP joint flexion.
D. Proper digital strap placement
over proximal phalanx
promoting MCP joint flexion
and PIP joint extension.

38. Pain control
Characteristics of pain:
• Most severe in case of partial thickness wounds
• Initially intense sometimes moderates with time
• Intensifies when manipulated.
• Most patients may need supplementary
analgesics for wound dressing changes, physical
therapy, and sleep.

40. Reference
• Tidy's physiotherapy,13th edition

41. Reading assignment
1. INTRODUCTION TO PLASTIC SURGERY
o Tidy's physiotherapy,13th edition