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Burn Rehabilitation—A Team Approach
r Symposium on Burns
Burn Rehabilitation-A Team Approach Ph ala A. Helm, M.D., * Marjorie D. Head, LP.T., t Gerry Pullium, O.T.R., t Maureen O'Brien, B.A., § and G. Fred Cromes, Jr., Ph.D.!/
The burned patient has multisystem involvement that requires treatment from various disciplines throughout the course of management. The burn rehabilitation team is an integral part of the multidisciplinary team approach in the total care ofthe burned patient. Physicians, physical therapists, occupational therapists, social workers, and psychologists make up the nucleus of a rehabilitation team. Individual team members have specialized roles that overlap and complement each other, resulting in better overall patient care. Each burned patient is automatically referred to the rehabilitation physician upon admission to the hospital. Thus, within 24 hours the physician evaluates the patient's condition, establishes rehabilitation goals, and initiates the treatment plan by requesting the services of the other team members as needed. Follow-up care is provided on weekly team rounds where goals of treatment are redefined to adjust the program plan to the patient's constantly changing condition. Early goals during the period of resuscitation may include only positioning of body parts and hand splints for 24-hour wear; as the patient's condition improves, goals change to increased mobilization, ambulation, and self-care activities. Primary in the delivery of optimal care utilizing the team approach is close communication between all disciplines. This ensures continuity of care, a better understanding of individual services, and the total program operation becomes more efficient; care is divided among several disciplines with confidence that all needs of the patient are met-physical, psychological, and social. One line of communication is regular conferences for the entire team, including surgeons, nursing staff, and all rehabilitation personnel. Open discussions are held, reviewing patient management, discharge planning, and personnel problems related to paFrom The University of Texas Health Science Center at Dallas, Southwestern Medical School, Department of Physical Medicine and Rehabilitation, Dallas, Texas ·Chairman and Associate Professor tClinicai Instructor : Clinical Instructor §Instructor /I Assistant Professor
Surgical Clinics of North America-Vol. 58, No.6, December 1978
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tient care. Team care and close communication are continued following patient discharge in a weekly outpatient follow-up clinic. In utilizing the team approach to burn care, four basic principles of management have proved effective. These are setting of priorities, proper timing ofvarious program components,jlexibility of the program, and total patient involvement. The first basic principle is setting of priorities. Obviously certain basic procedures in rendering patient care take precedence over others. This is al§lo true in the rehabilitation process with respect to what is best for the patient physically, emotionally, and socially. For example, a patient has both a flexion and extension contracture ofthe elbow. What kind of splint should be applied? Functionally, the patient would be much better off with increased elbow flexion; therefore a splint to obtain functional elbow flexion would be the priority before splinting for extension. In another case, a patient has been hospitalized for two months; he is stable, but very depressed and less motivated because he has not seen his family. If he goes home for a week, he will probably lose joint mobility; however, Table 1. Helpful Hints in the Treatment of Burns DON'TS
Give patient with anterior neck burn a pillow Forget proper positioning in a seated or standing position
WHY
Neck flexion contracture Achieved motion can be lost with positions of comfort in all positions
Statically position shoulders in abduction in prone position
Brachial plexus stretch injury with resultant flail or weak upper extremity
Allow prolonged elbow flexion
Tardy ulnar nerve palsy with resultant clawing of hand Peroneal nerve palsy with drop foot Peroneal nerve palsy
Allow frog-leg position with feet inverted Apply thick bulky pressure dressings over fibular head Give repeated injections in deltoid muscles Use hydrotherapy to increase joint mobility Apply moist heat packs to burned skin Exercise exposed tendons Just exercise individual joints Leave bandages in place while exercising burn wound Neglect ambulation
Small nerve fiber damage with resultant weak deltoid and tight shoulder Dries skin and potentiates contractures Can bum hypoesthetic skin May rupture tendon Does not allow for function as a body unit Can tear tissue without being aware resulting in increased scarring Increased risk of thrombophlebitis
DO'S
Position neck in extension or hyperextension Position to provide maximal stretch to bands of scar tissue while lying, sitting, or standing Frequently change position of shoulder from abducted to adducted position in prone lying Position elbow extended Position knees extended and feet dorsiflexed Window the dressing to prevent pressure on peroneal nerve Rotate intramuscular injections Discontinue hydrotherapy after burns heal Useparaffin(118°F.) for heat Immobilize exposed tendons Exercise entire band of scar tissue Remove bandages on parts exercising Ambulate when medically cleared
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upon returning to the hospital his increased motivational level may be more than adequate compensation for the loss of motion. Thus, decisions regarding priorities must be made and are based on what is in the best long-term interest of the patient. Proper timing for the delivery of various program components, such as exercise, splinting, psychological counseling, applying pressure garments, etc., can be critical in reducing complications common to the burned patient. Appropriate timing may also decrease the length ofhospital stay and reduce the time rehabilitation services are needed, enabling the patient to return to work, school, or household duties sooner, and thus decreasing the total cost of burn care. Goals outlined for each patient must be flexible, allowing for the extreme differences in patient motivation, emotional stability, pain tolerance, and many other factors that affect cooperation with the total treatment plan. A flexible program permits patients to pace themselves regarding frequency and duration of treatment periods each day with respect to how they feel physically and emotionally. The fourth basic principle, but by far the most important, is total patient involvement, that is, active participation by the patient in the treatment process. It is often more expedient to take care of the patient's needs than to allow him to do things for himself; however, it is more beneficial to the patient and hastens the rehabilitation process if he is independent in his care to the extent that he is able. Patient education should stress independence and imbue the individual with the understanding that his commitment to the treatment process is directly proportionate to his rehabilitation success.
ACUTE AND SUBACUTE PHASES Rehabilitation management in the acute and subacute phases of burn care will be briefly discussed since these phases of treatment are fairly consistent in most areas. General goals are wound healing, maintenance of range of motion, ambulation, and self-care. However, there are certain aspects in the early program that need to be emphasized in terms of priorities and proper timing so these goals can be reached as quickly as possible. In the first 24 hours after admission, positioning of all burned parts is stressed, and all burn personnel are aware of proper positions: shoulders in 90 degree abduction with elbows extended and supinated; hips and knees fully extended; and feet dorsiflexed to 90 degrees. An exercise program is initiated within the first 48 to 72 hours post burn and carried out two to four times daily. All involved joints receive active or active assistive exercises. Nonburned lower extremities are always exercised to help prevent venous stasis. Independent activities of daily living and early ambulation are an integral part of the early program. Hydrotherapy and wound care are begun immediately upon admission and are continued until the patient is auto grafted or homografted; exercise and hydrotherapy are resumed five days post graft to both the grafted areas and the donor sites. Patients with porcine heterografts continue to receive daily hydrotherapy and exercises.
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Overall, splinting is minimal during the acute and subacute phases and is used primarily in the post-healing stage. However, there are several instances when splinting is necessary. Volar positioning hand splints are applied early to burned hands for 24-hour wear over a 72-hour period until edema is decreased, and then are worn only at night. In children, a frequently used splint in this early phase is the knee extensiondorsiflexion splint for lower extremity burns. It is difficult to maintain proper alignment without splinting in children, whereas adults are able to cooperate in positioning. Early splinting is also necessary when joints or tendons are exposed; the part is immobilized by a splint that places the exposed tendon on a slack to p'revent possible rupture. The splint is applied for 24-hour wear until the area is covered by autograft. Exercises to areas with exposed tendons are discontinued. Other instances in the acute and subacute phases where positioning with splints is necessary is with neuropathic problems. Henderson et al. reported a 15 per cent incidence of peripheral polyneuropathy in acute burn patients; Helm, Johnson, and Carlton reported an incidence of 29 per cent. 3 , 4 Since peripheral polyneuropathy can cause a distal muscle weakness and this, combined with a burned extremity, can increase the potential for contractures, the need for additional splinting ofthe wrist and hands, and feet and ankles is indicated. Other common neuropathic problems that require early splinting to prevent deformities are peroneal nerve palsy with resultant drop foot, and tardy ulnar nerve palsy with clawing of the hand.
CONVALESCENT PHASE By the time the burns have healed, and the patient enters into the convalescent stage, many problems will have become apparent. Sequelae such as muscle weakness from nerve injuries, and established contractures from skin or joint tightness are obvious areas for concentrated treatment. However, due to the prolonged contractile nature of the burn wound, a patient who heals initially with full range of motion has the potential to develop severe deformities as the healed skin matures and hypertrophic scarring develops. For this reason special attention must be given to the condition of the healed skin. Skin problems such as blister formation, breakdown, excessive dryness and cracking, or the gradual buildup of hypertrophic scar tissue can lead to a rapid decrease in motion and functional ability. Major emphasis early in convalescence must necessarily be on wound care and control of current or potential skin and scarring problems. The goals of increasing motion, strength, and functional ability are then appro ached naturally in the rehabilitation program, utilizing various modalities, splinting, and exercise techniques in a properly timed sequence to produce the best results.
Wound Care Whirlpool is used in the care of open wounds only until the areas can be managed with local wound care. Prolonged use of whirlpool has a drying effect upon the healed areas leading to decreased motion and
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Fine mesh patches applied to open wounds.
increased cracking and breakdown of the skin. Local wound care consists of using a basin and sterile sponge, mesh, or wash cloth to gently cleanse each open area. Strong antiseptic soaps are not needed at this time, and indeed the continued use of such agents often leads to allergy, rash, and skin breakdown. A mild nonirritating soap such as white Dial or Ivory may be used if sud sing is needed to remove film, exudate, or topical agents. Otherwise, plain water and the mechanical action of washing the open area are sufficient to cleanse the wound. Whatever agent is used should be thoroughly removed by copious rinsing. Usually, a dry mesh dressing is sufficient to cover the open wound. However, ifthe areais fairly large and a dry dressing causes discomfort, wounds may be dressed with a topical agent such as silver sulfadiazine or neomycin. Coarse mesh patches stimulate the growth of granulation tissue in small deep areas. Fine mesh patches help to flatten areas of hypergranulation tissue. Patches are applied wet and allowed to dry on the wound and are changed two to four times daily (Fig. 1). Areas of hypergranulation tissue that cannot be adequately controlled with fine mesh patches are treated with one or two applications of silver nitrate. Blistering of the skin can be particularly trying for the patient. Very small blisters are opened with a sterile needle, drained, and flattened with a small dressing. These areas will usually dry, crust, and heal without further problems. Larger blisters may need to be removed, leaving open areas that require conservative treatment. Painting these areas with Mercurochrome speeds the drying and crusting process. It should be emphasized at this poin t that opposite to the philosophy in acute bum care of removing all dead and devitalized tissue, the crusts that form over blisters and small unhealed areas are better left alone as long as the areas are dry and clean. Repeated removal of scabs at this point is traumatic to new epithelium and prolongs the healing process. Gentle daily washing and dressing changes are sufficient.
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Skin Care, Scar Control, and Exercise Techniques The goal at this point is to keep the skin or scar as soft, pliable, and flat as possible. This is best achieved by proper timing in the use oflubrication, massage, and pressure as healing occurs and maturation of the skin takes place. All healed areas are kept lubricated with a mild nonirritating agent. Mineral oil and cocoa butter are examples of lubricants that have been used successfully. Patients respond differently to various lubricants and several may need to be tried to find one that gives the most relief from the itching and dryness. Lubricants are applied lightly and rubbed in gently up to and around open areas and are kept off of the open wounds. Heavy lubrication is avoided, as the grease and oil are hard to remove and build up on the skin, causing pimples and white heads. Lubricants are applied as often as needed to keep the patient comfortable and the skin oiled. Once all open areas are healed, another good lubricant is paraffin. A standard paraffin machine available in most physical therapy departments may be utilized. Paraffin with a melting point of 120°F. is mixed with heavy duty mineral oil in a ratio of2. 5 to 3 ounces of oil to each pound of paraffin. The thermostat on the machine is then adjusted to lower the mixture to 115 to 118°F. The patient is positioned comfortably with the scar tissue on maximum stretch and the paraffin is applied over the scar tissue until a thick coating is achieved. This area is then wrapped with plastic sheets and several layers of toweling to hold in the heat, and the paraffin is left in place for 20 to 30 minutes. This technique is well tolerated by patients and has the added benefit of combining sustained stretch to tight areas while providing moist heat to painful joints. When the paraffin is removed, an oily residue is left on the skin, leaving the scar softer and more pliable and easily stretched another few degrees. This softness and pliability often lasts for several hours, thereby making it easier for the patient to participate in normal daily activities. Gentle sustained stretching is an effective exercise technique for lengthening bands of scar tissue and increasing range of motion. 6 The paraffin application combined with positions of sustained stretch is an effective way to begin a treatment session. 2 When the wound involves a joint or several joints, the contractile nature of scar must be considered, and body positions devised that provide stretch along the length and width of the area involved. For example, a person who has burns involving the anterior chest, neck, and axillae is positioned supine with a pillow under his thoracic spine and shoulders are placed in maximum abduction (Fig. 2). This position stretches the width of the scars across the pectoral area from axilla to axilla and the length of the wound from the neck down the trunk. The paraffin is applied to the patient in this position and left in place for 20 to 30 minutes of sustained stretch. Following the removal of the paraffin, active assistive range of motion with the therapist applying mild manual stretching at the extremes of motion is well tolerated. A contract relax technique is also helpful with the therapist applying a gentle stretch during the relax phase. Massage of scar tissue after the skin is softened by the paraffin aids in maintaining pliability. Deep massage ofthe subcutaneous tissue is done
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Figure 2. A, Scarring involving anterior chest, neck, and axillas. B, Positioning for sustained stretch prior to application of paraffin.
with care to avoid friction to superficial layers of the skin that could cause blisters (Fig. 3). If the skin is stretched until it blanches, palpation of the band of scar tissue helps determine how much" give" the scar has and ifit will tolerate further stretching. Active programs can be devised for the patient that will allow him to continue from this point in the treatment plan with minimal assistance. Overhead pulleys are useful for increasing shoulder motion, and once adequate range is achieved the patient may be able to hang from stall bars or chinning bars using his own body weight to stretch shoulders, elbows, and trunk. Rolling over a large barrel or bolster pillow is useful for increasing trunk mobility and the patient should position himself over the barrel face lying, back lying, and side lying with his upper arm abducted over head. Following skin care, lubrication, paraffin, stretching, and general "loosening up" routines, treatment is then concentrated on areas of specific problems. Neuropathies require special attention for muscle
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Figure 3. Deep massage of the subcutaneous tissue.
reeducation and strengthening. Generalized strengthening is important for reconditioning and increasing endurance, as burned patients are often debilitated and weak. Strengthening to the muscle group opposing a contracture assists in increasing range. Refinement of normal body movements needs to be incorporated into the treatment program. Postural training and proper body mechanics emphasize normal rotational movements to avoid the robot-like motion that the patient tends to carry over into his daily activities.
Hypertrophic Scar Control The effectiveness of custom-made pressure garments for the control of hypertrophic scarring has been well documented. Prior to prescribing commercial garments, the newly healed sensitive skin is preconditioned to accept the stress and pressure exerted by the garments. Graduated gradient pressure, properly timed, promotes desensitization and increases the skin's tolerance to the shear force that is inherent in the wearing of the commercial garments. Initially, gentle elastic pressure (less than 15 mm per square inch) is applied using an Ace wrap, an elastic tubular bandage, or a Lycra spandex material used to fashion homemade garments, i.e., gloves, chin straps, and vests. As the skin toughens and becomes less fragile, pressure is increased an intermediate step (less than 25 mm per inch). This is accomplished by increasing the wrap tension of the Ace bandage, doubling the tubular bandage, or using greater wrap stretch spandex fabric for garments. As skin continues to toughen, a commercial garment is prescribed. After the garment is fitted it is usually necessary to pad some areas with foam to redistribute or apply extra pressure (Fig. 4). Anatomical bridging such as that created by the scapulae or nose produces gaps in pressure and requires foam padding or molded isoprene plates that are held in place by the garment. Areas susceptible to contracture such as finger web spaces, antecubital fossa, popliteal fossa, and axilla should also have additional foam pressure.
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Figure 4. A, Before foam padding. B, Foam pad held in place by garment. C, Twenty-four hours after application of foam.
Blistering may occur at any time, but pressure garments or wraps are not to be discontinued unless major skin breakdown occurs. Proper use of gradient pressure greatly increases the patient's comfort, which then enables him to perform daily activities in a more normal fashion.
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Orthotic Management The necessity for splinting during the post-healing stage of burn treatment is considerably reduced by utilizing specialized exercise techniques, sustained stretch, and early gradient pressure. Generally speaking, splinting is initiated for skin bands that bridge the joint and threaten to web, correction for neurological deficit, and hypertrophic scarring in an area difficult to control with gradient pressure. Specialized splinting, employed when these problems first become apparent, prevents deformity, decreases hypertrophic scarring, and precludes or minimizes the need for extensive reconstructive surgery. Criteria for splint application includes the following considerations: (1) Will the newly healed skin tolerate stress? If so, for how long? How much? (2) Would the scar respond best to constant pressure or dynamic stretch? (3) Are there conflicting deformities requiring equal attention? (4) Can the patient accept the restriction and cosmetic appearance of the device? The length of time a splint is to be worn each day is determined by the location of the scar, its malleability or density, the type of joint function, and the patient's physical and psychological tolerance. For example, to maintain contour in the neck and chin, a hard conforming collar is worn most of a 24-hour period, whereas a splint applied to the palmar surface of the hand to prevent contractures is worn at night. During the day, normal functional use plus exercise is encouraged to prevent gross muscle imbalance. Conforming splints are the most widely utilized forms of splinting in burn care. These types of splints are constructed from isoprene plastic, which is heated and then molded directly on the patient for maximum contact with the scar or band formation. Hard, nonyielding pressure provided by conforming splints quickly produces a softening and flattening effect on the scar which allows increased skin excursion and restores contour. Conforming splints are indicated in the following instances: when contracture begins to develop over the volar aspects of hand, wrist, elbow, and posterior knee; when contour is threatened in the face, neck, and chin; and when hard pressure is needed for resistant scarring or encroachment of areas such as the axilla or finger web spaces. In the event of existing deformity, serial or progressive splinting is utilized for nonsurgical correction of contracture. A dramatic application of this method is demonstrated with patients who have sustained burns to the dorsum of the ankle and foot and present the following complications: difficulty in plantar flexion due to hypertrophic scarring, tightness of grafted skin, and metatarsal subluxation caused by hyperextension of the toes. To correct this deformity an anterior, ankle-toe conforming shell with a counter-resistive metatarsal support is applied at night and high top surgical shoes are worn during the day (Fig. 5). Splint alteration for increased plantar flexion and toe flexion is made in two weeks with subsequent alteration as needed. In an average of 8 to 10 weeks the patient achieves maximum improvement in alignment of metatarsals and toes and increased plantar flexion with softening of grafted skin or hypertrophic scar tissue (Fig. 6). At this time, splinting is discontinued or held in reserve in the event of recurrence.
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Figure Figure5. 5.A ,A,Anterior Anteriorconforming conforming splint with metatarsal plates. B ,B, Anterior splint with metatarsal plates. Anterior conforming splint applied. conforming splint applied.
Burns challenges rehabilitaBumstotothe thehand handproduce producea amyriad myriadofof challengesforforboth both rehabilitative early tiveand andorthotic orthoticmanagement. management.ToTodemonstrate demonstratethe theimportance importanceofof early diagnosis diagnosiswith withspecific specificpreventive preventivesplinting splintingmeasures, measures,the thefollowing following example exampleisiscited. cited.The Thepatient patientsustained sustaineda apartial partialthickness thicknessburn bumononthe the dorsolateral the ulnar side ofof the wrist and hand. AsAs dorsolateralside sideofof thefifth fifthfinger fingerand and ulnar side the wrist and hand. healing early band formation, healingoccurs, occurs,slight slightblanching, blanching,indicative indicativeofof early band formation,apappears pears along alongthe thelateral lateralaspect aspectofofwrist wristand andhand, hand,but butthere thereis isnot not
Figure (above ) and Figure6. 6. Before Before (above) and after ) application ofof splint. after(below (below) application splint.
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Figure 7.
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Fifth finger deformity before (A) a nd after (B) splinting. C, Fifth fmger appli ed.
significant loss in range of motion. Failure to splint at this time allows band formation to progress, producing mechanical deformity of the fifth finger, metacarpophalangeal hyperextension-subluxation with external rotation, and flexion contracture of the proximal interphalangeal and distal interphalangeal joints (Fig. 7, A and B). Loss of this strong grasp component in hand function has a serious vocational impact. Splinting to prevent or correct this problem should position the metacarpophalangeal joint in slight flexion, and the proximal interphalangeal and distal interphalangeal joints in extension with lateral force applied in a radial direction (Fig. 7C). To correct existing contracture, serial adjustment is made daily. 9
Figure 8 . A , Circumferential bums to ha nds. B, Conforming splint provides h ard pressure for palmar surface. C, Wrist splint is eq uippe d with rubber bands, providing sustained stretch for dorsal surface.
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As a general rule, splinting for sustained stretch is provided for burns involving the extensor surfaces and constant hard pressure is used for those involving flexor surfaces. Limitation in finger flexion or loss of grasp produced by burns involving the dorsum of the hand responds to continuous sustained stretch provided by a wrist cock up splint equipped with rubber bands attached to finger cuffs or dress hooks that have been glued to the fingernails. Conversely, palmar burns require constant hard pressure along the entire surface to soften the band formation and to prevent or correct flexion contractures. This is best accomplished by positioning the affected areas on maximum stretch and then molding a conforming splint. Circumferential hand burns constitute conflicting problems which may require utilization of both of the above methods on an alternate wearing schedule (Fig. 8). It should be stressed that splinting is an adjunct to the total burn treatment program and is only effective when combined with good skin care, exercise, gradient pressure, and the patient's individual commitment to recovery.
PSYCHOSOCIAL MANAGEMENT The immediate reaction to a severe burn is one of psychological shock. This reaction involves delirium, emotional lability, nightmares of being burned, sleeping problems, and disorientation. This set of symptoms has been described as an acute traumatic reaction by Andreason et al. 1 The burned patient also experiences elevated anxiety which contributes to this reaction, and the family experiences panic, anxiety or fear, and perhaps guilt. Anxiety may be managed in several ways. Medication is useful initially because other methods, such as relaxation, are not likely to succeed if the patient is disoriented. As anxiety is reduced, the burn team and family can provide orienting information such as greeting the patient by name, reporting where he or she is, and what day and time it is. As orientation improves, relaxation training using deep breathing, biofeedback, or muscle relaxation can be initiated, and if effective, medication can be reduced. These techniques are preferable to medication because they put the patient in control, increase autonomy and independence, and decrease the probability of dependence on medication. Accurate medical information can be provided to minimize patient and family uncertainty about physical status and procedures that are occurring. Weekly rehabilitation rounds occur from admission to discharge. By returning to the patient after rounds, the social worker can learn whether the patient understood what was said by the physician or if there were other concerns. Such information should be fed back to the physician or other team members at weekly team meetings so that patient and family confusion can be reduced as much as possible. Approximately two weeks post burn the shock reaction resolves, and the patient becomes concerned about survival and how he is being treated. These concerns reflect preoccupation with needs for safety, comfort, and nurturance as well as attitudes about independence and autonomy. These needs and attitudes
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directly cause emotional responses including temper outbursts, rebellion, manipulation of staff, crying, whining, and many others. Management of survival related psychosocial problems requires provision of accurate information by the physician first, and then consistent reinforcement by other team members. If a foundation of honesty and open communication is established, the chances of team-family cooperation throughout the rehabilitation effort will be enhanced. Occasionally, staff reaction to patient complaints or behavior becomes a deterrent to progress. When this occurs, the needs and attitudes of the staff are involved in their reaction. Regular meetings of the nursing or the physical and occupational therapy staff, providing an opportunity to vent frustration and explore solutions, should be available. The psychologist or social worker can enhance the productivity of such meetings by contributing their skill in facilitating communication when personal feelings are involved. There are a variety ofpatien tin terpretations of pain that are crucial to understanding differences in pain tolerance and difficulty in management. Also involved are physician and staff attitudes regarding the reality of pain complaints and medication dependence. In response to their emotional reaction to hurting, patients manifest pain behaviors such as complaining, facial grimaces, crying, shouting, whining, and requests for medication. The goal of management is to minimize pain behaviors, maximize comfort, and reduce patient-staff conflict. A consistent approach based upon behavior modification principles is necessary. Such an approach should include administration of medication at routine intervals, punishment of pain behaviors, and reinforcement of desired behaviors. Punishment might involve mild reprimand or withdrawal of privileges; positive reinforcement includes compliments, smiles, and physical contact. Punishment strategies should be carried out in a neutral and business-like manner. If such a program is to be utilized, it is important to have a person available who is trained in behavioral methodologies. As a result of becoming more aware of other patients' burns and one's own burned skin, problems may arise. These include emotional responses such as anger, fear, and depression. The behavioral reactions to these emotions include crying, poor cooperation, shouting or swearing, manipulation, helplessness, excessive sleep, or a variety of rebellious behaviors. These problems can be understood from two perspectives, one involving patient needs, the other involving patient attitudes. Needs for acceptance and self-esteem become prominent, especially as survival ceases to be an issue. Attitudes or beliefs about appearance and ability to function are also integral to these problems. Therefore, emotional turmoil relative to anticipated consequences in personal, social, and vocational spheres of life because of cosmetic or functional deficits becomes a primary focus. Management requires counseling to assist patients and family to understand how their needs and attitudes contribute to their feelings, and to provide information about how they can deal more effectively with their problem situation.
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Seeing other patients in various stages of healing can also be a stimulus for hope. It is beneficial for new burned patients to talk with patients in later stages of the burn rehabilitation process. This experience provides first hand evidence to the patient that successful coping is possible. As time for discharge approaches, a weekend pass allows the patient and family to test in reality many of their fears and expectations and to become accustomed to the necessary new routine of dressing changes and exercises. Upon return a discussion with patient and family assists in preventing problems that have arisen from becoming chronic and destructive to rehabilitation outcome, and helps to prepare the patient for discharge to the home. Patient reactions after discharge become related to experiences in reality rather than imagined possibilities. Problems that may occur include rejection by family or friends, overprotection ofthe patient, conflict within the family, and impatience with the time required for total rehabilitation. Consistent follow-up is necessary to identify such problems. Overprotectiveness by the family may result from guilt feelings or intense anxiety about outcomes, and patients can become quite comfortable with the pampering and extra attention afforded them. Management requires close communication with both patient and family. Other issues that arise include requirements for supplies such as walkers, shoes, or pressure garments. The social worker is aware ofthese needs, and can facilitate necessary ordering, funding, and record keeping. When a vocational change is necessary, the patient may be referred to the state rehabilitation agency for training and job placement. The social worker's role also includes that of coordinator of rehabilitation team services, which involves attention to team-patient communication, appointments for services, transportation needs, and patient financial difficulties. Availability of a person to deal with these concrete issues increases the efficiency of the burn rehabilitation process.
SUMMARY The team concept in the treatment of burned patients is an effective approach in caring for the physical, psychological, and social needs of the patient. Through the initiation of early rehabilitation services, long-term problems can be prevented and a quicker return to a meaningful life style is possible.
REFERENCES l. Andreason, N. J. C., Noyes, R., Jr., Hartlord, C. E., et al.: Management of emotional
reactions in severely burned patients. New Engl. J. Med., 286:65-69, 1972. 2. Head, M. D., and Helm, P. A.: Paraffin and sustained stretching in the treatment of burn contractures. Burns, 4: 136-139, 1977. 3. Helm, P. A., Johnson, E. R., and Carlton, A. M.: Peripheral neurological problems in the acute burn patient. Burns, 3: 123-125, 1977.
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4. Henderson, B., Koepke, G. H., and Feiler, I.: Peripheral polyneuropathy among patients with burns. Arch. Phys. Med. Rehab., 52:149-151, 1971. 5. Koepke, G. H.: The role of physical medicine in the treatment of burns. SURG. CLIN. NORTH AM., 50:1385-1399, 1970. 6. Larsen, D. L., and Abston, S.: Techniques for decreasing scar fomation and contractures in the burned patient. J. Trauma, 10:807-823, 1971. 7. Larsen, D. L.: The prevention and correction of burnscar contracture and hypertrophy. Shriners Burn Institute, University of Texas Medical Branch, Galveston, Texas, 1973. 8. Nothdurft, D., Pullium, G., and Bruster, J.: Management of feet and ankle burns-A. Orthotic management of pre-existing deformity. B. Protocol for pre\ elltion of deformity. Burns, in press. 9. Torres, J.: Little finger splint. Am. J. Occup. Ther., 29:230, 1975. Department of Physical Medicine and Rehabilitation University of Texas Health Science Center Southwestern Medical School 5323 Harry Hines Boulevard Dallas, Texas 75235
Burn Rehabilitation-A Team Approach Ph ala A. Helm, M.D., * Marjorie D. Head, LP.T., t Gerry Pullium, O.T.R., t Maureen O'Brien, B.A., § and G. Fred Cromes, Jr., Ph.D.!/
The burned patient has multisystem involvement that requires treatment from various disciplines throughout the course of management. The burn rehabilitation team is an integral part of the multidisciplinary team approach in the total care ofthe burned patient. Physicians, physical therapists, occupational therapists, social workers, and psychologists make up the nucleus of a rehabilitation team. Individual team members have specialized roles that overlap and complement each other, resulting in better overall patient care. Each burned patient is automatically referred to the rehabilitation physician upon admission to the hospital. Thus, within 24 hours the physician evaluates the patient's condition, establishes rehabilitation goals, and initiates the treatment plan by requesting the services of the other team members as needed. Follow-up care is provided on weekly team rounds where goals of treatment are redefined to adjust the program plan to the patient's constantly changing condition. Early goals during the period of resuscitation may include only positioning of body parts and hand splints for 24-hour wear; as the patient's condition improves, goals change to increased mobilization, ambulation, and self-care activities. Primary in the delivery of optimal care utilizing the team approach is close communication between all disciplines. This ensures continuity of care, a better understanding of individual services, and the total program operation becomes more efficient; care is divided among several disciplines with confidence that all needs of the patient are met-physical, psychological, and social. One line of communication is regular conferences for the entire team, including surgeons, nursing staff, and all rehabilitation personnel. Open discussions are held, reviewing patient management, discharge planning, and personnel problems related to paFrom The University of Texas Health Science Center at Dallas, Southwestern Medical School, Department of Physical Medicine and Rehabilitation, Dallas, Texas ·Chairman and Associate Professor tClinicai Instructor : Clinical Instructor §Instructor /I Assistant Professor
Surgical Clinics of North America-Vol. 58, No.6, December 1978
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tient care. Team care and close communication are continued following patient discharge in a weekly outpatient follow-up clinic. In utilizing the team approach to burn care, four basic principles of management have proved effective. These are setting of priorities, proper timing ofvarious program components,jlexibility of the program, and total patient involvement. The first basic principle is setting of priorities. Obviously certain basic procedures in rendering patient care take precedence over others. This is al§lo true in the rehabilitation process with respect to what is best for the patient physically, emotionally, and socially. For example, a patient has both a flexion and extension contracture ofthe elbow. What kind of splint should be applied? Functionally, the patient would be much better off with increased elbow flexion; therefore a splint to obtain functional elbow flexion would be the priority before splinting for extension. In another case, a patient has been hospitalized for two months; he is stable, but very depressed and less motivated because he has not seen his family. If he goes home for a week, he will probably lose joint mobility; however, Table 1. Helpful Hints in the Treatment of Burns DON'TS
Give patient with anterior neck burn a pillow Forget proper positioning in a seated or standing position
WHY
Neck flexion contracture Achieved motion can be lost with positions of comfort in all positions
Statically position shoulders in abduction in prone position
Brachial plexus stretch injury with resultant flail or weak upper extremity
Allow prolonged elbow flexion
Tardy ulnar nerve palsy with resultant clawing of hand Peroneal nerve palsy with drop foot Peroneal nerve palsy
Allow frog-leg position with feet inverted Apply thick bulky pressure dressings over fibular head Give repeated injections in deltoid muscles Use hydrotherapy to increase joint mobility Apply moist heat packs to burned skin Exercise exposed tendons Just exercise individual joints Leave bandages in place while exercising burn wound Neglect ambulation
Small nerve fiber damage with resultant weak deltoid and tight shoulder Dries skin and potentiates contractures Can bum hypoesthetic skin May rupture tendon Does not allow for function as a body unit Can tear tissue without being aware resulting in increased scarring Increased risk of thrombophlebitis
DO'S
Position neck in extension or hyperextension Position to provide maximal stretch to bands of scar tissue while lying, sitting, or standing Frequently change position of shoulder from abducted to adducted position in prone lying Position elbow extended Position knees extended and feet dorsiflexed Window the dressing to prevent pressure on peroneal nerve Rotate intramuscular injections Discontinue hydrotherapy after burns heal Useparaffin(118°F.) for heat Immobilize exposed tendons Exercise entire band of scar tissue Remove bandages on parts exercising Ambulate when medically cleared
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upon returning to the hospital his increased motivational level may be more than adequate compensation for the loss of motion. Thus, decisions regarding priorities must be made and are based on what is in the best long-term interest of the patient. Proper timing for the delivery of various program components, such as exercise, splinting, psychological counseling, applying pressure garments, etc., can be critical in reducing complications common to the burned patient. Appropriate timing may also decrease the length ofhospital stay and reduce the time rehabilitation services are needed, enabling the patient to return to work, school, or household duties sooner, and thus decreasing the total cost of burn care. Goals outlined for each patient must be flexible, allowing for the extreme differences in patient motivation, emotional stability, pain tolerance, and many other factors that affect cooperation with the total treatment plan. A flexible program permits patients to pace themselves regarding frequency and duration of treatment periods each day with respect to how they feel physically and emotionally. The fourth basic principle, but by far the most important, is total patient involvement, that is, active participation by the patient in the treatment process. It is often more expedient to take care of the patient's needs than to allow him to do things for himself; however, it is more beneficial to the patient and hastens the rehabilitation process if he is independent in his care to the extent that he is able. Patient education should stress independence and imbue the individual with the understanding that his commitment to the treatment process is directly proportionate to his rehabilitation success.
ACUTE AND SUBACUTE PHASES Rehabilitation management in the acute and subacute phases of burn care will be briefly discussed since these phases of treatment are fairly consistent in most areas. General goals are wound healing, maintenance of range of motion, ambulation, and self-care. However, there are certain aspects in the early program that need to be emphasized in terms of priorities and proper timing so these goals can be reached as quickly as possible. In the first 24 hours after admission, positioning of all burned parts is stressed, and all burn personnel are aware of proper positions: shoulders in 90 degree abduction with elbows extended and supinated; hips and knees fully extended; and feet dorsiflexed to 90 degrees. An exercise program is initiated within the first 48 to 72 hours post burn and carried out two to four times daily. All involved joints receive active or active assistive exercises. Nonburned lower extremities are always exercised to help prevent venous stasis. Independent activities of daily living and early ambulation are an integral part of the early program. Hydrotherapy and wound care are begun immediately upon admission and are continued until the patient is auto grafted or homografted; exercise and hydrotherapy are resumed five days post graft to both the grafted areas and the donor sites. Patients with porcine heterografts continue to receive daily hydrotherapy and exercises.
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Overall, splinting is minimal during the acute and subacute phases and is used primarily in the post-healing stage. However, there are several instances when splinting is necessary. Volar positioning hand splints are applied early to burned hands for 24-hour wear over a 72-hour period until edema is decreased, and then are worn only at night. In children, a frequently used splint in this early phase is the knee extensiondorsiflexion splint for lower extremity burns. It is difficult to maintain proper alignment without splinting in children, whereas adults are able to cooperate in positioning. Early splinting is also necessary when joints or tendons are exposed; the part is immobilized by a splint that places the exposed tendon on a slack to p'revent possible rupture. The splint is applied for 24-hour wear until the area is covered by autograft. Exercises to areas with exposed tendons are discontinued. Other instances in the acute and subacute phases where positioning with splints is necessary is with neuropathic problems. Henderson et al. reported a 15 per cent incidence of peripheral polyneuropathy in acute burn patients; Helm, Johnson, and Carlton reported an incidence of 29 per cent. 3 , 4 Since peripheral polyneuropathy can cause a distal muscle weakness and this, combined with a burned extremity, can increase the potential for contractures, the need for additional splinting ofthe wrist and hands, and feet and ankles is indicated. Other common neuropathic problems that require early splinting to prevent deformities are peroneal nerve palsy with resultant drop foot, and tardy ulnar nerve palsy with clawing of the hand.
CONVALESCENT PHASE By the time the burns have healed, and the patient enters into the convalescent stage, many problems will have become apparent. Sequelae such as muscle weakness from nerve injuries, and established contractures from skin or joint tightness are obvious areas for concentrated treatment. However, due to the prolonged contractile nature of the burn wound, a patient who heals initially with full range of motion has the potential to develop severe deformities as the healed skin matures and hypertrophic scarring develops. For this reason special attention must be given to the condition of the healed skin. Skin problems such as blister formation, breakdown, excessive dryness and cracking, or the gradual buildup of hypertrophic scar tissue can lead to a rapid decrease in motion and functional ability. Major emphasis early in convalescence must necessarily be on wound care and control of current or potential skin and scarring problems. The goals of increasing motion, strength, and functional ability are then appro ached naturally in the rehabilitation program, utilizing various modalities, splinting, and exercise techniques in a properly timed sequence to produce the best results.
Wound Care Whirlpool is used in the care of open wounds only until the areas can be managed with local wound care. Prolonged use of whirlpool has a drying effect upon the healed areas leading to decreased motion and
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Fine mesh patches applied to open wounds.
increased cracking and breakdown of the skin. Local wound care consists of using a basin and sterile sponge, mesh, or wash cloth to gently cleanse each open area. Strong antiseptic soaps are not needed at this time, and indeed the continued use of such agents often leads to allergy, rash, and skin breakdown. A mild nonirritating soap such as white Dial or Ivory may be used if sud sing is needed to remove film, exudate, or topical agents. Otherwise, plain water and the mechanical action of washing the open area are sufficient to cleanse the wound. Whatever agent is used should be thoroughly removed by copious rinsing. Usually, a dry mesh dressing is sufficient to cover the open wound. However, ifthe areais fairly large and a dry dressing causes discomfort, wounds may be dressed with a topical agent such as silver sulfadiazine or neomycin. Coarse mesh patches stimulate the growth of granulation tissue in small deep areas. Fine mesh patches help to flatten areas of hypergranulation tissue. Patches are applied wet and allowed to dry on the wound and are changed two to four times daily (Fig. 1). Areas of hypergranulation tissue that cannot be adequately controlled with fine mesh patches are treated with one or two applications of silver nitrate. Blistering of the skin can be particularly trying for the patient. Very small blisters are opened with a sterile needle, drained, and flattened with a small dressing. These areas will usually dry, crust, and heal without further problems. Larger blisters may need to be removed, leaving open areas that require conservative treatment. Painting these areas with Mercurochrome speeds the drying and crusting process. It should be emphasized at this poin t that opposite to the philosophy in acute bum care of removing all dead and devitalized tissue, the crusts that form over blisters and small unhealed areas are better left alone as long as the areas are dry and clean. Repeated removal of scabs at this point is traumatic to new epithelium and prolongs the healing process. Gentle daily washing and dressing changes are sufficient.
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Skin Care, Scar Control, and Exercise Techniques The goal at this point is to keep the skin or scar as soft, pliable, and flat as possible. This is best achieved by proper timing in the use oflubrication, massage, and pressure as healing occurs and maturation of the skin takes place. All healed areas are kept lubricated with a mild nonirritating agent. Mineral oil and cocoa butter are examples of lubricants that have been used successfully. Patients respond differently to various lubricants and several may need to be tried to find one that gives the most relief from the itching and dryness. Lubricants are applied lightly and rubbed in gently up to and around open areas and are kept off of the open wounds. Heavy lubrication is avoided, as the grease and oil are hard to remove and build up on the skin, causing pimples and white heads. Lubricants are applied as often as needed to keep the patient comfortable and the skin oiled. Once all open areas are healed, another good lubricant is paraffin. A standard paraffin machine available in most physical therapy departments may be utilized. Paraffin with a melting point of 120°F. is mixed with heavy duty mineral oil in a ratio of2. 5 to 3 ounces of oil to each pound of paraffin. The thermostat on the machine is then adjusted to lower the mixture to 115 to 118°F. The patient is positioned comfortably with the scar tissue on maximum stretch and the paraffin is applied over the scar tissue until a thick coating is achieved. This area is then wrapped with plastic sheets and several layers of toweling to hold in the heat, and the paraffin is left in place for 20 to 30 minutes. This technique is well tolerated by patients and has the added benefit of combining sustained stretch to tight areas while providing moist heat to painful joints. When the paraffin is removed, an oily residue is left on the skin, leaving the scar softer and more pliable and easily stretched another few degrees. This softness and pliability often lasts for several hours, thereby making it easier for the patient to participate in normal daily activities. Gentle sustained stretching is an effective exercise technique for lengthening bands of scar tissue and increasing range of motion. 6 The paraffin application combined with positions of sustained stretch is an effective way to begin a treatment session. 2 When the wound involves a joint or several joints, the contractile nature of scar must be considered, and body positions devised that provide stretch along the length and width of the area involved. For example, a person who has burns involving the anterior chest, neck, and axillae is positioned supine with a pillow under his thoracic spine and shoulders are placed in maximum abduction (Fig. 2). This position stretches the width of the scars across the pectoral area from axilla to axilla and the length of the wound from the neck down the trunk. The paraffin is applied to the patient in this position and left in place for 20 to 30 minutes of sustained stretch. Following the removal of the paraffin, active assistive range of motion with the therapist applying mild manual stretching at the extremes of motion is well tolerated. A contract relax technique is also helpful with the therapist applying a gentle stretch during the relax phase. Massage of scar tissue after the skin is softened by the paraffin aids in maintaining pliability. Deep massage ofthe subcutaneous tissue is done
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Figure 2. A, Scarring involving anterior chest, neck, and axillas. B, Positioning for sustained stretch prior to application of paraffin.
with care to avoid friction to superficial layers of the skin that could cause blisters (Fig. 3). If the skin is stretched until it blanches, palpation of the band of scar tissue helps determine how much" give" the scar has and ifit will tolerate further stretching. Active programs can be devised for the patient that will allow him to continue from this point in the treatment plan with minimal assistance. Overhead pulleys are useful for increasing shoulder motion, and once adequate range is achieved the patient may be able to hang from stall bars or chinning bars using his own body weight to stretch shoulders, elbows, and trunk. Rolling over a large barrel or bolster pillow is useful for increasing trunk mobility and the patient should position himself over the barrel face lying, back lying, and side lying with his upper arm abducted over head. Following skin care, lubrication, paraffin, stretching, and general "loosening up" routines, treatment is then concentrated on areas of specific problems. Neuropathies require special attention for muscle
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Figure 3. Deep massage of the subcutaneous tissue.
reeducation and strengthening. Generalized strengthening is important for reconditioning and increasing endurance, as burned patients are often debilitated and weak. Strengthening to the muscle group opposing a contracture assists in increasing range. Refinement of normal body movements needs to be incorporated into the treatment program. Postural training and proper body mechanics emphasize normal rotational movements to avoid the robot-like motion that the patient tends to carry over into his daily activities.
Hypertrophic Scar Control The effectiveness of custom-made pressure garments for the control of hypertrophic scarring has been well documented. Prior to prescribing commercial garments, the newly healed sensitive skin is preconditioned to accept the stress and pressure exerted by the garments. Graduated gradient pressure, properly timed, promotes desensitization and increases the skin's tolerance to the shear force that is inherent in the wearing of the commercial garments. Initially, gentle elastic pressure (less than 15 mm per square inch) is applied using an Ace wrap, an elastic tubular bandage, or a Lycra spandex material used to fashion homemade garments, i.e., gloves, chin straps, and vests. As the skin toughens and becomes less fragile, pressure is increased an intermediate step (less than 25 mm per inch). This is accomplished by increasing the wrap tension of the Ace bandage, doubling the tubular bandage, or using greater wrap stretch spandex fabric for garments. As skin continues to toughen, a commercial garment is prescribed. After the garment is fitted it is usually necessary to pad some areas with foam to redistribute or apply extra pressure (Fig. 4). Anatomical bridging such as that created by the scapulae or nose produces gaps in pressure and requires foam padding or molded isoprene plates that are held in place by the garment. Areas susceptible to contracture such as finger web spaces, antecubital fossa, popliteal fossa, and axilla should also have additional foam pressure.
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Figure 4. A, Before foam padding. B, Foam pad held in place by garment. C, Twenty-four hours after application of foam.
Blistering may occur at any time, but pressure garments or wraps are not to be discontinued unless major skin breakdown occurs. Proper use of gradient pressure greatly increases the patient's comfort, which then enables him to perform daily activities in a more normal fashion.
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Orthotic Management The necessity for splinting during the post-healing stage of burn treatment is considerably reduced by utilizing specialized exercise techniques, sustained stretch, and early gradient pressure. Generally speaking, splinting is initiated for skin bands that bridge the joint and threaten to web, correction for neurological deficit, and hypertrophic scarring in an area difficult to control with gradient pressure. Specialized splinting, employed when these problems first become apparent, prevents deformity, decreases hypertrophic scarring, and precludes or minimizes the need for extensive reconstructive surgery. Criteria for splint application includes the following considerations: (1) Will the newly healed skin tolerate stress? If so, for how long? How much? (2) Would the scar respond best to constant pressure or dynamic stretch? (3) Are there conflicting deformities requiring equal attention? (4) Can the patient accept the restriction and cosmetic appearance of the device? The length of time a splint is to be worn each day is determined by the location of the scar, its malleability or density, the type of joint function, and the patient's physical and psychological tolerance. For example, to maintain contour in the neck and chin, a hard conforming collar is worn most of a 24-hour period, whereas a splint applied to the palmar surface of the hand to prevent contractures is worn at night. During the day, normal functional use plus exercise is encouraged to prevent gross muscle imbalance. Conforming splints are the most widely utilized forms of splinting in burn care. These types of splints are constructed from isoprene plastic, which is heated and then molded directly on the patient for maximum contact with the scar or band formation. Hard, nonyielding pressure provided by conforming splints quickly produces a softening and flattening effect on the scar which allows increased skin excursion and restores contour. Conforming splints are indicated in the following instances: when contracture begins to develop over the volar aspects of hand, wrist, elbow, and posterior knee; when contour is threatened in the face, neck, and chin; and when hard pressure is needed for resistant scarring or encroachment of areas such as the axilla or finger web spaces. In the event of existing deformity, serial or progressive splinting is utilized for nonsurgical correction of contracture. A dramatic application of this method is demonstrated with patients who have sustained burns to the dorsum of the ankle and foot and present the following complications: difficulty in plantar flexion due to hypertrophic scarring, tightness of grafted skin, and metatarsal subluxation caused by hyperextension of the toes. To correct this deformity an anterior, ankle-toe conforming shell with a counter-resistive metatarsal support is applied at night and high top surgical shoes are worn during the day (Fig. 5). Splint alteration for increased plantar flexion and toe flexion is made in two weeks with subsequent alteration as needed. In an average of 8 to 10 weeks the patient achieves maximum improvement in alignment of metatarsals and toes and increased plantar flexion with softening of grafted skin or hypertrophic scar tissue (Fig. 6). At this time, splinting is discontinued or held in reserve in the event of recurrence.
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Figure Figure5. 5.A ,A,Anterior Anteriorconforming conforming splint with metatarsal plates. B ,B, Anterior splint with metatarsal plates. Anterior conforming splint applied. conforming splint applied.
Burns challenges rehabilitaBumstotothe thehand handproduce producea amyriad myriadofof challengesforforboth both rehabilitative early tiveand andorthotic orthoticmanagement. management.ToTodemonstrate demonstratethe theimportance importanceofof early diagnosis diagnosiswith withspecific specificpreventive preventivesplinting splintingmeasures, measures,the thefollowing following example exampleisiscited. cited.The Thepatient patientsustained sustaineda apartial partialthickness thicknessburn bumononthe the dorsolateral the ulnar side ofof the wrist and hand. AsAs dorsolateralside sideofof thefifth fifthfinger fingerand and ulnar side the wrist and hand. healing early band formation, healingoccurs, occurs,slight slightblanching, blanching,indicative indicativeofof early band formation,apappears pears along alongthe thelateral lateralaspect aspectofofwrist wristand andhand, hand,but butthere thereis isnot not
Figure (above ) and Figure6. 6. Before Before (above) and after ) application ofof splint. after(below (below) application splint.
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Figure 7.
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Fifth finger deformity before (A) a nd after (B) splinting. C, Fifth fmger appli ed.
significant loss in range of motion. Failure to splint at this time allows band formation to progress, producing mechanical deformity of the fifth finger, metacarpophalangeal hyperextension-subluxation with external rotation, and flexion contracture of the proximal interphalangeal and distal interphalangeal joints (Fig. 7, A and B). Loss of this strong grasp component in hand function has a serious vocational impact. Splinting to prevent or correct this problem should position the metacarpophalangeal joint in slight flexion, and the proximal interphalangeal and distal interphalangeal joints in extension with lateral force applied in a radial direction (Fig. 7C). To correct existing contracture, serial adjustment is made daily. 9
Figure 8 . A , Circumferential bums to ha nds. B, Conforming splint provides h ard pressure for palmar surface. C, Wrist splint is eq uippe d with rubber bands, providing sustained stretch for dorsal surface.
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As a general rule, splinting for sustained stretch is provided for burns involving the extensor surfaces and constant hard pressure is used for those involving flexor surfaces. Limitation in finger flexion or loss of grasp produced by burns involving the dorsum of the hand responds to continuous sustained stretch provided by a wrist cock up splint equipped with rubber bands attached to finger cuffs or dress hooks that have been glued to the fingernails. Conversely, palmar burns require constant hard pressure along the entire surface to soften the band formation and to prevent or correct flexion contractures. This is best accomplished by positioning the affected areas on maximum stretch and then molding a conforming splint. Circumferential hand burns constitute conflicting problems which may require utilization of both of the above methods on an alternate wearing schedule (Fig. 8). It should be stressed that splinting is an adjunct to the total burn treatment program and is only effective when combined with good skin care, exercise, gradient pressure, and the patient's individual commitment to recovery.
PSYCHOSOCIAL MANAGEMENT The immediate reaction to a severe burn is one of psychological shock. This reaction involves delirium, emotional lability, nightmares of being burned, sleeping problems, and disorientation. This set of symptoms has been described as an acute traumatic reaction by Andreason et al. 1 The burned patient also experiences elevated anxiety which contributes to this reaction, and the family experiences panic, anxiety or fear, and perhaps guilt. Anxiety may be managed in several ways. Medication is useful initially because other methods, such as relaxation, are not likely to succeed if the patient is disoriented. As anxiety is reduced, the burn team and family can provide orienting information such as greeting the patient by name, reporting where he or she is, and what day and time it is. As orientation improves, relaxation training using deep breathing, biofeedback, or muscle relaxation can be initiated, and if effective, medication can be reduced. These techniques are preferable to medication because they put the patient in control, increase autonomy and independence, and decrease the probability of dependence on medication. Accurate medical information can be provided to minimize patient and family uncertainty about physical status and procedures that are occurring. Weekly rehabilitation rounds occur from admission to discharge. By returning to the patient after rounds, the social worker can learn whether the patient understood what was said by the physician or if there were other concerns. Such information should be fed back to the physician or other team members at weekly team meetings so that patient and family confusion can be reduced as much as possible. Approximately two weeks post burn the shock reaction resolves, and the patient becomes concerned about survival and how he is being treated. These concerns reflect preoccupation with needs for safety, comfort, and nurturance as well as attitudes about independence and autonomy. These needs and attitudes
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directly cause emotional responses including temper outbursts, rebellion, manipulation of staff, crying, whining, and many others. Management of survival related psychosocial problems requires provision of accurate information by the physician first, and then consistent reinforcement by other team members. If a foundation of honesty and open communication is established, the chances of team-family cooperation throughout the rehabilitation effort will be enhanced. Occasionally, staff reaction to patient complaints or behavior becomes a deterrent to progress. When this occurs, the needs and attitudes of the staff are involved in their reaction. Regular meetings of the nursing or the physical and occupational therapy staff, providing an opportunity to vent frustration and explore solutions, should be available. The psychologist or social worker can enhance the productivity of such meetings by contributing their skill in facilitating communication when personal feelings are involved. There are a variety ofpatien tin terpretations of pain that are crucial to understanding differences in pain tolerance and difficulty in management. Also involved are physician and staff attitudes regarding the reality of pain complaints and medication dependence. In response to their emotional reaction to hurting, patients manifest pain behaviors such as complaining, facial grimaces, crying, shouting, whining, and requests for medication. The goal of management is to minimize pain behaviors, maximize comfort, and reduce patient-staff conflict. A consistent approach based upon behavior modification principles is necessary. Such an approach should include administration of medication at routine intervals, punishment of pain behaviors, and reinforcement of desired behaviors. Punishment might involve mild reprimand or withdrawal of privileges; positive reinforcement includes compliments, smiles, and physical contact. Punishment strategies should be carried out in a neutral and business-like manner. If such a program is to be utilized, it is important to have a person available who is trained in behavioral methodologies. As a result of becoming more aware of other patients' burns and one's own burned skin, problems may arise. These include emotional responses such as anger, fear, and depression. The behavioral reactions to these emotions include crying, poor cooperation, shouting or swearing, manipulation, helplessness, excessive sleep, or a variety of rebellious behaviors. These problems can be understood from two perspectives, one involving patient needs, the other involving patient attitudes. Needs for acceptance and self-esteem become prominent, especially as survival ceases to be an issue. Attitudes or beliefs about appearance and ability to function are also integral to these problems. Therefore, emotional turmoil relative to anticipated consequences in personal, social, and vocational spheres of life because of cosmetic or functional deficits becomes a primary focus. Management requires counseling to assist patients and family to understand how their needs and attitudes contribute to their feelings, and to provide information about how they can deal more effectively with their problem situation.
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Seeing other patients in various stages of healing can also be a stimulus for hope. It is beneficial for new burned patients to talk with patients in later stages of the burn rehabilitation process. This experience provides first hand evidence to the patient that successful coping is possible. As time for discharge approaches, a weekend pass allows the patient and family to test in reality many of their fears and expectations and to become accustomed to the necessary new routine of dressing changes and exercises. Upon return a discussion with patient and family assists in preventing problems that have arisen from becoming chronic and destructive to rehabilitation outcome, and helps to prepare the patient for discharge to the home. Patient reactions after discharge become related to experiences in reality rather than imagined possibilities. Problems that may occur include rejection by family or friends, overprotection ofthe patient, conflict within the family, and impatience with the time required for total rehabilitation. Consistent follow-up is necessary to identify such problems. Overprotectiveness by the family may result from guilt feelings or intense anxiety about outcomes, and patients can become quite comfortable with the pampering and extra attention afforded them. Management requires close communication with both patient and family. Other issues that arise include requirements for supplies such as walkers, shoes, or pressure garments. The social worker is aware ofthese needs, and can facilitate necessary ordering, funding, and record keeping. When a vocational change is necessary, the patient may be referred to the state rehabilitation agency for training and job placement. The social worker's role also includes that of coordinator of rehabilitation team services, which involves attention to team-patient communication, appointments for services, transportation needs, and patient financial difficulties. Availability of a person to deal with these concrete issues increases the efficiency of the burn rehabilitation process.
SUMMARY The team concept in the treatment of burned patients is an effective approach in caring for the physical, psychological, and social needs of the patient. Through the initiation of early rehabilitation services, long-term problems can be prevented and a quicker return to a meaningful life style is possible.
REFERENCES l. Andreason, N. J. C., Noyes, R., Jr., Hartlord, C. E., et al.: Management of emotional
reactions in severely burned patients. New Engl. J. Med., 286:65-69, 1972. 2. Head, M. D., and Helm, P. A.: Paraffin and sustained stretching in the treatment of burn contractures. Burns, 4: 136-139, 1977. 3. Helm, P. A., Johnson, E. R., and Carlton, A. M.: Peripheral neurological problems in the acute burn patient. Burns, 3: 123-125, 1977.
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4. Henderson, B., Koepke, G. H., and Feiler, I.: Peripheral polyneuropathy among patients with burns. Arch. Phys. Med. Rehab., 52:149-151, 1971. 5. Koepke, G. H.: The role of physical medicine in the treatment of burns. SURG. CLIN. NORTH AM., 50:1385-1399, 1970. 6. Larsen, D. L., and Abston, S.: Techniques for decreasing scar fomation and contractures in the burned patient. J. Trauma, 10:807-823, 1971. 7. Larsen, D. L.: The prevention and correction of burnscar contracture and hypertrophy. Shriners Burn Institute, University of Texas Medical Branch, Galveston, Texas, 1973. 8. Nothdurft, D., Pullium, G., and Bruster, J.: Management of feet and ankle burns-A. Orthotic management of pre-existing deformity. B. Protocol for pre\ elltion of deformity. Burns, in press. 9. Torres, J.: Little finger splint. Am. J. Occup. Ther., 29:230, 1975. Department of Physical Medicine and Rehabilitation University of Texas Health Science Center Southwestern Medical School 5323 Harry Hines Boulevard Dallas, Texas 75235