1. Acute care physical therapy for burns patients
By Juhi Gupta
University of South Florida
2. Depth of injury1
1) First degree burns: involves epidermis
only, appears as pink or red in color,
blanching is present and wound typically
heals within 3-5 days with no scarring.
2) Second degree (superficial partial
thickness): Involves with epidermis and
portion of dermis, appears as bright pink
or red, wet with blisters, blanching is
present, heals by re-epithelization in
10-14 days with no scarring or grafting
needed.
3. Depth of injury1
3) Second degree (deep partial thickness): involves epidermis and deeper
portion of dermis, appears mottled red and waxy white, blanching is absent,
heals by re-epithelization in 14- 21 days or longer.
4) Third degree (full thickness): involves entire epidermis and dermis, appears
white or tan, dry and leathery, blanching absent, skin graft required.
5) Fourth degree: involves deep tissue damage to fat, muscle, tendon, fascia,
nerve and/or bone, blanching absent, excision of necrotic tissue and skin graft
required, possible amputation.
4. Goals of acute rehabilitation for Patients with
burns 2,3
● Performing passive ROM and stretches
to prevent contracture
● Splinting and anti-contracture
positioning
● Minimize edema during ambulation
● Functional mobility
● Patient and family education
5. Stretching and early mobilization 2,3
● Joints affected by burns should be moved several times a day to prevent
joint contractures.
● Pain control through analgesic drugs is crucial to allow patients to
complete functional movements and activities of daily living.
● Patients who are unable to move should have passive ROM and stretches
completed to maintain ROM and to prevent joint stiffness.
● Therapeutic exercises include ambulation, balance and coordination,
muscle strength and endurance, AROM and PROM.
6. Scar Management 4
● There are higher chance of contractures and hypertrophic scars after the
burn injury.
● Anti-contracture positioning and splinting must start from day one
● Compression wraps prevent excessive scarring, assist in reducing edema
and helps with pain when extremity is in dependent position.
7. Anti-contracture positioning 4
Area Burnt Anti-contracture position
1) Front of the neck Neck in extension
2) Posterior neck Sitting with head in flexion and pillow behind neck
3) Axilla (A/P axillary fold) Lying or sitting with arm abducted to 90 degrees
4) Front of elbows Elbow extension
5) Back of the knees Legs extended in lying and sitting
6) Feet Ankles positioned at 90 degrees
10. Types of Skin grafts 1
1) Xenograft - use of animal tissue (temporary)
2) Allograft - Use of cadaver tissue (temporary)
3) Autograft - taken from patient’s own skin from uninvolved donor site
- full thickness
- Split thickness
11. PT protocols for skin grafts 5
● AUTOGRAFTS:
● Face and neck graft:
OOB: resume OOB activity on POD# 1 (keep head upright and neutral)
ROM: Hold ROM until POD#5; resume ROM to donor site areas on POD#1
● Axillary graft:
OOB: Resume PT/OT for OOB on POD# 3 with arm abducted at 90 degrees
ROM: Hold ROM to axilla until POD# 5. Resume ROM to donor site areas on POD#1.
● Upper extremity graft:
OOB: resume PT/OT for OOB POD#1 with splint in place
ROM: Hold UE ROM until POD#5 to all joints affected.
● Trunk and back graft:
OOB: Hold PT/OT for OOB until POD#3
ROM: Resume ROM on POD#5 (resume ROM to donor site areas on POD#1)
12. PT protocols for skin grafts 5
● Gluteal, hip and thigh graft:
OOB: Hold PT/OT for OOB until POD#5
ROM: Resume PT/OT for ROM to unaffected joints on POD#1 (resume ROM to donor sites area on POD#1)
* NO sitting for gluteal graft until cleared by MD
● Leg and foot graft:
OOB: Resume OOB to chair only, NWB to affected extremity with leg elevated and splint on at all time on POD#
1. Resume ambulation on POD#5
ROM: Resume PT/OT to unaffected joints, resume ROM to donor site on POD#1
● Xenograft:
○ Continue with OOB and ROM after xenograft is adhered or had sufficient time to dry
○ Continue with ROM to area not xenograft-covered
● Allograft:
○ Indication # 1: Biological dressing (temporary covering), Resume PT/OT OOB and ROM on POD# 1
○ Indication # 2: Diagnostic dressing (determine for autograft take), Resume PT/OT OOB and ROM on POD#5
13. References
1) Wright PC. Fundamentals of acute burn care and physical therapy management.
Phys Ther. 1984;64(8):1217-31.
2) Giuliani CA, Perry GA. Factors to consider in the rehabilitation aspect of burn care.
Phys Ther. 1985;65(5):619-23.
3) Sheridan RL. Burn rehabilitation. Emedicine.
http://emedicine.medscape.com/article/318436-overview. Accessed June 23th, 2014.
4) Procter F. Rehabilitation of the burn patient. Indian J Plast Surg.
2010;43(Suppl):S101-13.
5) TGH Protocol
