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Comprehensive Rehabilitation After Burn Injury
Burns
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Comprehensive Rehabilitation After Burn Injury John A. Boswick, Jr., M.D. *
There are many principles that must be applied early after injury to ensure the earliest and optimal rehabilitation of the burned patient. One of the most important considerations in burn rehabilitation is to start as early as possible after injury; with raro/exceptions, rehabilitative care should start the day of injury. We can define rehabilitative goals in many ways, but basically they are to limit or prevent loss of motion, prevent or minimize anatomic deformities, prevent loss of body weight (especially muscle mass), and return the patient to work and activity as early and completely as possible. Many important considerations must be given to a program of rehabilitation for the burned patient, and it is essential that every patient have an individualized plan of care. Common to all plans and applicable in all situations are four important principles for rehabilitation of the patient with burn injuries: 1. The program should start early, preferably the day of injury, unless there are circumstances that prevent early rehabilitative care. 2. Programs of care should avoid prolonged immobilization of the patient, and any part that is able to move actively or can be moved passively should be moved frequently. 3. Active motion should be started the day of injury, if possible. This recommendation applies to the entire patient in most circumstances and to all or at least part of all the extremities in all patients. 4. There should be a program of planned activity and rehabilitative care each day. This plan should be reviewed at least once daily, for rehabilitative needs change frequently and valuable time can be lost in a few hours.
EARLY REHABILITATIVE CARE To suggest that rehabilitative care for the burned patient should start early, even the day of injury, might imply that these measures are more *Secretary General, International Society for Burn Injuries, and Past President, American Burn Association
Surgical Clinics of North America-Vol. 67, No.1, February 1987
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important than some aspects of care that can be life- or limb-saving. The replacement of lost fluids and decompression of constricting eschars are items of priority in the initial care of a burned patient. However, while these more essential measures are being performed, methods of preventing the loss of motion and the development of anatomic deformities can be explained to the patient. These measures include standing and walking frequently unless there is a specific contraindication. All extremities should be actively moved frequently throughout the day with a specific plan reviewed early each day and changed as indicated. Proper positioning of the extremities is an important consideration in assuring early rehabilitation of the burned patient. This includes unburned as well as burned areas of the extremities. It is not uncommon to develop adduction contractures of the shoulders, flexion contractures of the elbows and wrists, hyperextension of the metacarpophalangeal joints, flexion of the interphalangeal joints, and adduction of the thumb in unburned extremities. In most patients these deformities or contractures can avoided through the use offrequent active or appropriate passive motion and proper resting positions. Most patients with burns up to 50 or 60 per cent of the total body surface area (TBSA) and some patients with even larger injuries can and should be taught the value of early active motion of burned and unburned parts, as well as proper positioning during periods of rest and sleep. One of the most effective ways to encourage early active and/or passive motion and proper positioning is to avoid procedures that contribute to prolonged immobilization. This includes avoiding the start of intravenous fluid replacement unless necessary and, when necessary, using an anatomic location that will allow the patient to stand and walk. Nasogastric tubes and catheters should be avoided unless there is an absolute or strong relative indication. The more personal approach of observing for bowel sounds and encouraging a patient to urinate can reduce or eliminate unnecessary and prolonged immobilization of the patient because of nasogastric tubes and catheters. Without intravenous lines, nasogastric tubes, and urinary catheters, patients will be much more inclined to stand and walk even with burn wounds that are uncomfortable and may require the use of dressings and splints. When intravenous lines, nasogastric tubes, urinary catheters, and even endotracheal intubation are necessary, burned patients can be encouraged to stand and walk periodically. Except in the most extensively burned patients, and usually those with pulmonary injuries, endotracheal tubes usually can be disconnected every hour or two for a few minutes for the patient to stand and walk. Intravenous lines should be placed centrally or in the proximal upper extremity. This position will allow the patient to stand without significantly interfering with fluid replacement. Nasogastric tubes and urinary catheters usually can be clamped for a few minutes every hour to allow the patient the ability to be out of bed frequently and therefore avoid prolonged immobilization. This option helps patients feel that they can move, stimulates the appetite, and prevents loss of muscle mass. It also can reduce or prevent the problems of skin breakdown.
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Blisters and epidermal ulcerations can occur in 24 hours or less when the skin is in contact with sheets and the patient is immobile. It is not only important to prevent prolonged immobilization of the entire patient but also of the individual parts. The joints of all extremities should be moved on a regular basis unless there is a strong contraindication. Patients with open wounds from fasciotomies, escharotomies, or decompressing incisions can almost always actively move these parts. This is especially true when such activity is started early. When early active motion is not possible, or when it is insufficient to accomplish an adequate range of motion, passive motion is usually indicated. Passive motion to an edematous or stiff hand is an extremely delicate procedure. It should be performed only by an experienced person or under the supervision of someone experienced in these techniques. The same is true of larger joints, especially those that have not been moved for several days. A basic principle in active exercising of the patient with burn injuries is starting early each morning, haVing an organized program for the day, and having the activities performed frequently. This schedule can be implemented by having the patient exercise and bathe (preferably by showering) at the beginning of each morning. Unless it is necessary for proper rest, patients should start their day at 6:00 or 6:30 A.M. When possible, they should be encouraged to walk to the shower or tub and exercise before or during bathing. This activity tends to stimulate the appetite, helps the patient have a greater desire to eat when he or she is clean, and often makes it possible to feed the patient enough protein and calories by mouth to avoid nasogastric or intravenous feeding. Breakfast should be a high-protein and high-calorie meal, because patients are usually hungry at this time. If they have exercised and bathed, they usually will have an appetite to consume a large percentage of the calories required for the day. Almost immediately after breakfast, the first exercise program should begin. Programs of active motion that are not rigorous and that will not interfere with the digestive process are recommended for this time. They should include walking if possible, or standing at the bedside and extending and flexing all joints of both the upper and lower extremities. If there are burns on the dorsal aspects of the fingers with actual or potential damage to the extensor mechanism, forceful flexion and extension should be avoided, and splinting of the proximal interphalangeal joints in almost full extension during periods of rest may be indicated. However, active exercising should be performed frequently throughout the day. As long as the extensor mechanism can extend the joint 20° or more from the fully flexed position, there is usually no problem of tendon erosion. A specified period of time for exercising should be recommended and performed. It is preferable to start with shorter periods such as 3 to 5 minutes each hour. Early after injury, the shorter, more frequent periods are preferable to longer, less frequent ones; the objective is to maintain motion and prevent deformities. If the hourly 3- to 5-minute exercising periods are tolerated without undue fatigue for 2 to 3 days, the periods of exercise should be lengthened to 25 to 30 minutes and can be performed twice a day.l It is the longer periods of activity that will increase muscle
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strength and prevent loss of muscle mass. As the periods of exercising are increased to 25 to 30 minutes twice daily, a variety of activities can be used to increase muscle strength and cardiopulmonary .work. The lifting of weights and isometric exercising often can be used within 2 to 3 weeks after injury. Riding a stationary bicycle is an excellent technique for increasing cardiopulmonary work. Most patients with burn injuries can start stationary bicycle riding within 3 to 4 weeks after injury, depending on the extent and location of the injuries. If the lower extremities are extensively involved with deep burns, it may be a problem to have patients stand for prolonged periods or to exercise with the feet. This ability can be determined early after injury by observing for swelling of the feet and ankles when the patient stands. Swelling or edema of the feet and ankles may occur in patients with burn injuries when the lower extremities are not involved or are minimally involved by the injury. This problem develops in some patients with extensive thermal injury from the vascular response that occurs in unburned areas. Especially in elderly patients, edema of the feet and ankles occurs when the patient stands, owing to venous disease that is often insidious in the middle-aged and elderly population. Swelling or edema of the feet or ankles may result when the lower extremities are not involved or are minimally involved in the injury. If the patient with a thermal burn has swelling of the ankles and feet early in his or her rehabilitation exercise program, further activity with the feet should be deferred. The problem of exercising the lower extremities to regain strength, retard the loss of muscle mass, and develop a cardiopulmonary response can be overcome by having the patient perform these exercises on his or her back, with the lower extremities elevated. Alternating flexion and extension of the hips and knees for 5 to 10 minutes can be as strenuous as swimming or riding a stationary bicycle. Exercising the upper extremities to maintain motion, regain strength, and prevent the loss of muscle mass is as important as in the lower extremities. Maintaining motion in the hand is the most important part of all rehabilitative efforts. Failure to move the elbow adequately has been suggested as the cause of heterotopic bone formation in this joint. Of all the rehabilitative efforts used in treating the patient with a thermal injury, early active motion of all joints is probably the most important. This goal should be accomplished first by short, frequent periods of exercising, that is, for 2 to 3 minutes each hour and gradually increased to 25 to 30 minutes once or twice a day. A program of this type will ensure the maintenance of motion of all joints where motion is possible, reduce or prevent the development of anatomic deformities, and prevent the loss of muscle mass that occurs from inactivity. Even in the most cooperative patients, programs of active motion alone may not prevent the development of deformities and contractures. There is the rare situation when a patient with burn injuries is too sick to move all or certain joints actively. In these situations, passive motion is necessary and appropriate positioning is extremely important.
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POSITIONING
Although active motion is the most important factor in preventing loss of motion and muscle mass, and preventing anatomic deformities in patients with burn injuries, adjunctive measures are necessary in some patients. For example, appropriate resting positions are critical for maintaining joint motion in a patient with burn injuries. The beneficial effect of frequent exercise while patients are awake from approximately 6:00 A.M. to 10:00 P.M. in large part can be lost if they sleep in inappropriate positions for 8 hours. We have found that most patients will tend to assume some undesirable positions while at rest. They often request or find a pillow to place under their head. This position is especially undesirable if they are burned on the lower face and anterior neck. Flexion contractures of the neck often are accompanied by deformities of the lower face. These problems or complications can be significantly reduced by keeping the head extended during the periods of rest by placing a foam-covered sand bag or pillow under the neck. A plastic or orthoplast collar or a snug dressing may be used after skin graft or healing of partial-thickness wounds. In the upper extremities, a sleeping patient often will assume an undesirable position of all the joints, including unburned areas. We tend to sleep and rest in positions of comfort, which can lead to deformities if they are not changed frequently.2 Encouraging the patient to rest with the shoulder abducted between 80° and 90°, the elbow fully extended, and the wrist extended to 30° to 40° usually will prevent undesirable positions of small joints in the hand and thumb. When the wrist is extended to 30° to 40° (readily accomplished by having the patient rest his or her hand over the edge of a bedside or other table that is covered with foam or a pillow with the wrist extended to this degree), the metacarpophalangeal joints will asssume a flexed position owing to pull of intrinsic muscles. In this position, the interphalangeal joints will be in a position of rest (i. e., mid-flexion) and the pull of the thenar muscles will bring the thumb into a position of midabduction. 3 It is occasionally difficult to have a patient maintain these positions during rest or sleep. If this cannot be accomplished, the use of splints may be necessary (see following section on splinting). Appropriate positioning of the lower extremities in patients with burn injuries is much easier to achieve than the upper extremities. There is a natural tendency for patients to want a significant portion of their rest and sleeping time in the supine position. This position will usually maintain the hips and knees in an extended position. However, this is not always the situation, especially when there are burn injuries on the anterior trunk and thighs and on the posterior thighs and calves. Burn wounds on the lower portion of the anterior trunk and thighs tend to pull the hips into flexion. With the hips flexed, there is a natural tendency for the knees to flex. If there are burn wounds on the posterior thighs and legs, the problem of knee flexion is compounded by pull or contraction of the burned tissue. Active motion and appropriate positioning (and occasionally passive
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motion) are important factors in preventing loss of joint motion and anatomic deformities. However, there are patients who cannot or will not cooperate in a program of active exercising and proper positioning. In these situations, the use of restraints and splints is necessary.
SPLINTING AND RESTRAINTS The basic principles and considerations in using splints and restraints in the treatment of patients with burn injuries are the same as appropriate positioning. Some anatomic areas are more difficult to treat by positioning than others, and there is great variation from patient to patient. It is not uncommon for a patient to lose motion and develop anatomic deformities in several locations. Depending on the location and depth of injury, the patient who develops anatomic deformities in one location is more likely to lose motion and develop deformities in another. This problem probably results from the inability or unwillingness of a patient to cooperate in a program of active motion and appropriate positioning. Splints and restraints are required occasionally in patients with burns of the lower face, anterior neck, and upper chest. Although active extension of the neck is important in these patients to prevent flexion deformities and loss of motion, it is appropriate positioning during sleep and rest that is most effective in preventing flexion deformities of the neck. When appropriate positioning of the neck during sleep and rest cannot be achieved, and there is a tendency for a flexion deformity and loss of motion to occur, the use of well-padded splints that push upward on the chin and hold the neck extended are effective in preventing and correcting deformities. It is easier to flex a neck that has been extended for several hours than to extend the neck that has become stiff in a flexed position. A shoulder that becomes stiff in adduction is usually easy to correct a few days after injury. However, it is easier to prevent an adduction deformity of the shoulder than to correct one, especially if the lateral chest, axillae, and inner arm are burned. With burns in these areas, and if the patient is unable to keep the arm abducted to at least 80° during rest, a restraint to aid appropriate positioning is indicated. This result can be achieved by placing a dressing over the arm and maintaining shoulder abduction with a restraint that holds the arm in approximately 80° to 90° abduction. This restraint also will serve to keep the elbow extended. If a soft dressing is not adequate to maintain elbow extension, an orthoplast or plaster of Paris splint will maintain this position. One of the more common problems that requires splinting in the burned patient is the wrist. In patients with burn injuries, there is a strong tendency for the wrist to assume a flexed position. This problem occurs in patients with and without burns of the hands and wrists. Wrist flexion is considered to be the position of comfort; however, there is usually considerable discomfort in moving the wrist that has been held in a flexed position for several hours and there is usually little or no discomfort in moving a wrist that has been extended 20° to 40°. In addition to the problem of moving the wrist that has been held in flexion, there are also associated
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problems in the metacarpophalangeal and interphalangeal joints of the fingers and in the intrinsic muscles of the thumb. 5 When the patient with burn injuries does not actively move the wrist and keep it properly positioned during periods of rest, splinting is indicated. This problem occurs in about 20 per cent of patients hospitalized with burn injuries and is more common in patients where the wounds exceed 50 per cent TBSA. If the problem of wrist flexion in the burned patient is detected early, it is usually easy to correct and the secondary problems will be corrected simultaneously. All that is required is a simple splint made of plaster of Paris, orthoplast, or other similar material. This splint, like all splints, can be placed over the dressing required for the burn wound. The splint should start in the proximal part of the forearm, extend into the palm on the ulnar side of the hand, and stop at the palmar crease. It should extend the wrist 20° to 40° and allow the thumb to rotate and the fingers to flex at the metacarpophalangeal joints. 4 The associated problems that occur when the wrist is held in flexion are a tendency for the metacarpophalangeal joints to hyperextend with flexion of the interphalangeal joints of the fingers, and loss of thumb abduction or rotation. Fortunately, most of these secondary or associated problems are corrected when the flexion deformity of the wrist is treated. When the wrist is extended, the intrinsic muscles tend to pull the metacarpophalangeal joints in a flexed position. The interphalangeal joints of the fingers usually will assume a slightly flexed position, and the thumb will be held in mid-abduction. In some patients with burn injuries, correction of a wrist flexion dt;formity will not correct the hyperextension of the metacarpophalangeal joints, the flexion of the interphalangeal joints, or adduction of the thumb. This problem usually occurs in patients with burns on the dorsum of the hand or with 10ngstanBing flexion deformities of the wrist. To correct the problem with the fingers and tHumb, the splint should extend to the fingertips and be molded to hold the metacarpophalangeal joints in 70° or more of flexion, with thC(. interphalangeal joints almost fully extended and the thumb widely abducted. This splint, like all splints, should be worn as little as required, and active motion of the involved joints is encouraged. 5 A few patients with burn injuries of the hand will have problems with only the interphalangeal joints of the fingers and/or loss of thumb abduction. The patients who have only flexion deformities of the interphalangeal joints are usually those with burn injuries of the dorsum of the fingers. These deformities should be corrected with splints that either push (from the volar surface) or pull (from the dorsal surface) the interphalangeal joints into aimost full extension. These splints also should be worn as little as possible. Active motion should be encouraged, and the ability to extend the proximal interphalangeal joints of the fingers actively must be monitored carefully. If the proximal interphalangeal joints cannot be actively extended 20° front a fully flexed position, internal fixation should be considered. If internal fixation is used to correct a flexion deformity of the interphalangeal joints (almost always the proximal interphalangeal joints of the fingers and occasionally the distal joints or interphalangeal joint of the thumb), it should be left in place until the skin wounds are grafted or healed spontaneously.
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Upon removal of the internal fixation, motion of the involved joint should be observed closely. Occasionally some degree of flexion will be restored and full extension maintained. More commonly there is limited flexion and extension. In a few patients the flexion deformity will recur almost immediately. These patients should have the internal fixation reinserted and left for 6 to 8 weeks, which will allow healing of the capsular structures; however, very little motion is attained where repinning is required. It is preferable in most patients to have a stiff proximal interphalangeal joint in 10° to 15° of flexion rather than in 90° or more, which will occur if the deformities are untreated. Adduction contractures of the thumb are occasionally the only deformity that occurs in the burned hand. This problem almost always occurs in patients with burn injuries on the dorsum of the hand and usually in the first web space. Like most deformities in the burned hand, they are easy to treat if detected early. A simple splint of plaster of Paris, orthoplast, or other materials that pushes the thumb into abduction is all that is required. The splint should be worn at night and during periods of rest. Active exercising should be encouraged and splinting continued only if the deformity recurs.
SUMMARY Comprehensive rehabilitation of patients after burn injury requires the organized application of sound, recognized principles. The basic concerns are the prevention of loss of joint motion, loss of muscle mass, and the prevention of anatomic deformities. Important considerations are starting the rehabilitative program as early as possible after injury and avoiding techniques that unduly immobilize the patient or parts of the body. The use of early active motion to the patient and all movable joints, along with appropriate positioning while at rest, is crucial to a successful program. Passive exercising along with the use of restraints and splints is necessary in certain patients. REFERENCES 1. Adams RH, et al: Physical therapy in the treatment of burns. Phys Ther Rev 38:481-482, 1958 2. Boswick JA Jr: Management of the burned hand. Orthop Clin North Am 1:311-319, 1970 3. Dobbs ER, et al: Burns: Analysis of results of physical therapy in 681 patients. J Trauma 12:242-248, 1972 4. Gronley JK: Early intensive physical therapy for the burned hand. J Am Phys Ther 44:875880, 1964 5. Gronley JK: The positioning of severely burned hands when treated by the exposure method. Phys Ther Rev 40:521-522, 1960 Midtown II, Suite 600 2005 Franklin Street Denver, Colorado 80205
0039--6109/87 $0.00
+
.20
Comprehensive Rehabilitation After Burn Injury John A. Boswick, Jr., M.D. *
There are many principles that must be applied early after injury to ensure the earliest and optimal rehabilitation of the burned patient. One of the most important considerations in burn rehabilitation is to start as early as possible after injury; with raro/exceptions, rehabilitative care should start the day of injury. We can define rehabilitative goals in many ways, but basically they are to limit or prevent loss of motion, prevent or minimize anatomic deformities, prevent loss of body weight (especially muscle mass), and return the patient to work and activity as early and completely as possible. Many important considerations must be given to a program of rehabilitation for the burned patient, and it is essential that every patient have an individualized plan of care. Common to all plans and applicable in all situations are four important principles for rehabilitation of the patient with burn injuries: 1. The program should start early, preferably the day of injury, unless there are circumstances that prevent early rehabilitative care. 2. Programs of care should avoid prolonged immobilization of the patient, and any part that is able to move actively or can be moved passively should be moved frequently. 3. Active motion should be started the day of injury, if possible. This recommendation applies to the entire patient in most circumstances and to all or at least part of all the extremities in all patients. 4. There should be a program of planned activity and rehabilitative care each day. This plan should be reviewed at least once daily, for rehabilitative needs change frequently and valuable time can be lost in a few hours.
EARLY REHABILITATIVE CARE To suggest that rehabilitative care for the burned patient should start early, even the day of injury, might imply that these measures are more *Secretary General, International Society for Burn Injuries, and Past President, American Burn Association
Surgical Clinics of North America-Vol. 67, No.1, February 1987
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important than some aspects of care that can be life- or limb-saving. The replacement of lost fluids and decompression of constricting eschars are items of priority in the initial care of a burned patient. However, while these more essential measures are being performed, methods of preventing the loss of motion and the development of anatomic deformities can be explained to the patient. These measures include standing and walking frequently unless there is a specific contraindication. All extremities should be actively moved frequently throughout the day with a specific plan reviewed early each day and changed as indicated. Proper positioning of the extremities is an important consideration in assuring early rehabilitation of the burned patient. This includes unburned as well as burned areas of the extremities. It is not uncommon to develop adduction contractures of the shoulders, flexion contractures of the elbows and wrists, hyperextension of the metacarpophalangeal joints, flexion of the interphalangeal joints, and adduction of the thumb in unburned extremities. In most patients these deformities or contractures can avoided through the use offrequent active or appropriate passive motion and proper resting positions. Most patients with burns up to 50 or 60 per cent of the total body surface area (TBSA) and some patients with even larger injuries can and should be taught the value of early active motion of burned and unburned parts, as well as proper positioning during periods of rest and sleep. One of the most effective ways to encourage early active and/or passive motion and proper positioning is to avoid procedures that contribute to prolonged immobilization. This includes avoiding the start of intravenous fluid replacement unless necessary and, when necessary, using an anatomic location that will allow the patient to stand and walk. Nasogastric tubes and catheters should be avoided unless there is an absolute or strong relative indication. The more personal approach of observing for bowel sounds and encouraging a patient to urinate can reduce or eliminate unnecessary and prolonged immobilization of the patient because of nasogastric tubes and catheters. Without intravenous lines, nasogastric tubes, and urinary catheters, patients will be much more inclined to stand and walk even with burn wounds that are uncomfortable and may require the use of dressings and splints. When intravenous lines, nasogastric tubes, urinary catheters, and even endotracheal intubation are necessary, burned patients can be encouraged to stand and walk periodically. Except in the most extensively burned patients, and usually those with pulmonary injuries, endotracheal tubes usually can be disconnected every hour or two for a few minutes for the patient to stand and walk. Intravenous lines should be placed centrally or in the proximal upper extremity. This position will allow the patient to stand without significantly interfering with fluid replacement. Nasogastric tubes and urinary catheters usually can be clamped for a few minutes every hour to allow the patient the ability to be out of bed frequently and therefore avoid prolonged immobilization. This option helps patients feel that they can move, stimulates the appetite, and prevents loss of muscle mass. It also can reduce or prevent the problems of skin breakdown.
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Blisters and epidermal ulcerations can occur in 24 hours or less when the skin is in contact with sheets and the patient is immobile. It is not only important to prevent prolonged immobilization of the entire patient but also of the individual parts. The joints of all extremities should be moved on a regular basis unless there is a strong contraindication. Patients with open wounds from fasciotomies, escharotomies, or decompressing incisions can almost always actively move these parts. This is especially true when such activity is started early. When early active motion is not possible, or when it is insufficient to accomplish an adequate range of motion, passive motion is usually indicated. Passive motion to an edematous or stiff hand is an extremely delicate procedure. It should be performed only by an experienced person or under the supervision of someone experienced in these techniques. The same is true of larger joints, especially those that have not been moved for several days. A basic principle in active exercising of the patient with burn injuries is starting early each morning, haVing an organized program for the day, and having the activities performed frequently. This schedule can be implemented by having the patient exercise and bathe (preferably by showering) at the beginning of each morning. Unless it is necessary for proper rest, patients should start their day at 6:00 or 6:30 A.M. When possible, they should be encouraged to walk to the shower or tub and exercise before or during bathing. This activity tends to stimulate the appetite, helps the patient have a greater desire to eat when he or she is clean, and often makes it possible to feed the patient enough protein and calories by mouth to avoid nasogastric or intravenous feeding. Breakfast should be a high-protein and high-calorie meal, because patients are usually hungry at this time. If they have exercised and bathed, they usually will have an appetite to consume a large percentage of the calories required for the day. Almost immediately after breakfast, the first exercise program should begin. Programs of active motion that are not rigorous and that will not interfere with the digestive process are recommended for this time. They should include walking if possible, or standing at the bedside and extending and flexing all joints of both the upper and lower extremities. If there are burns on the dorsal aspects of the fingers with actual or potential damage to the extensor mechanism, forceful flexion and extension should be avoided, and splinting of the proximal interphalangeal joints in almost full extension during periods of rest may be indicated. However, active exercising should be performed frequently throughout the day. As long as the extensor mechanism can extend the joint 20° or more from the fully flexed position, there is usually no problem of tendon erosion. A specified period of time for exercising should be recommended and performed. It is preferable to start with shorter periods such as 3 to 5 minutes each hour. Early after injury, the shorter, more frequent periods are preferable to longer, less frequent ones; the objective is to maintain motion and prevent deformities. If the hourly 3- to 5-minute exercising periods are tolerated without undue fatigue for 2 to 3 days, the periods of exercise should be lengthened to 25 to 30 minutes and can be performed twice a day.l It is the longer periods of activity that will increase muscle
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strength and prevent loss of muscle mass. As the periods of exercising are increased to 25 to 30 minutes twice daily, a variety of activities can be used to increase muscle strength and cardiopulmonary .work. The lifting of weights and isometric exercising often can be used within 2 to 3 weeks after injury. Riding a stationary bicycle is an excellent technique for increasing cardiopulmonary work. Most patients with burn injuries can start stationary bicycle riding within 3 to 4 weeks after injury, depending on the extent and location of the injuries. If the lower extremities are extensively involved with deep burns, it may be a problem to have patients stand for prolonged periods or to exercise with the feet. This ability can be determined early after injury by observing for swelling of the feet and ankles when the patient stands. Swelling or edema of the feet and ankles may occur in patients with burn injuries when the lower extremities are not involved or are minimally involved by the injury. This problem develops in some patients with extensive thermal injury from the vascular response that occurs in unburned areas. Especially in elderly patients, edema of the feet and ankles occurs when the patient stands, owing to venous disease that is often insidious in the middle-aged and elderly population. Swelling or edema of the feet or ankles may result when the lower extremities are not involved or are minimally involved in the injury. If the patient with a thermal burn has swelling of the ankles and feet early in his or her rehabilitation exercise program, further activity with the feet should be deferred. The problem of exercising the lower extremities to regain strength, retard the loss of muscle mass, and develop a cardiopulmonary response can be overcome by having the patient perform these exercises on his or her back, with the lower extremities elevated. Alternating flexion and extension of the hips and knees for 5 to 10 minutes can be as strenuous as swimming or riding a stationary bicycle. Exercising the upper extremities to maintain motion, regain strength, and prevent the loss of muscle mass is as important as in the lower extremities. Maintaining motion in the hand is the most important part of all rehabilitative efforts. Failure to move the elbow adequately has been suggested as the cause of heterotopic bone formation in this joint. Of all the rehabilitative efforts used in treating the patient with a thermal injury, early active motion of all joints is probably the most important. This goal should be accomplished first by short, frequent periods of exercising, that is, for 2 to 3 minutes each hour and gradually increased to 25 to 30 minutes once or twice a day. A program of this type will ensure the maintenance of motion of all joints where motion is possible, reduce or prevent the development of anatomic deformities, and prevent the loss of muscle mass that occurs from inactivity. Even in the most cooperative patients, programs of active motion alone may not prevent the development of deformities and contractures. There is the rare situation when a patient with burn injuries is too sick to move all or certain joints actively. In these situations, passive motion is necessary and appropriate positioning is extremely important.
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POSITIONING
Although active motion is the most important factor in preventing loss of motion and muscle mass, and preventing anatomic deformities in patients with burn injuries, adjunctive measures are necessary in some patients. For example, appropriate resting positions are critical for maintaining joint motion in a patient with burn injuries. The beneficial effect of frequent exercise while patients are awake from approximately 6:00 A.M. to 10:00 P.M. in large part can be lost if they sleep in inappropriate positions for 8 hours. We have found that most patients will tend to assume some undesirable positions while at rest. They often request or find a pillow to place under their head. This position is especially undesirable if they are burned on the lower face and anterior neck. Flexion contractures of the neck often are accompanied by deformities of the lower face. These problems or complications can be significantly reduced by keeping the head extended during the periods of rest by placing a foam-covered sand bag or pillow under the neck. A plastic or orthoplast collar or a snug dressing may be used after skin graft or healing of partial-thickness wounds. In the upper extremities, a sleeping patient often will assume an undesirable position of all the joints, including unburned areas. We tend to sleep and rest in positions of comfort, which can lead to deformities if they are not changed frequently.2 Encouraging the patient to rest with the shoulder abducted between 80° and 90°, the elbow fully extended, and the wrist extended to 30° to 40° usually will prevent undesirable positions of small joints in the hand and thumb. When the wrist is extended to 30° to 40° (readily accomplished by having the patient rest his or her hand over the edge of a bedside or other table that is covered with foam or a pillow with the wrist extended to this degree), the metacarpophalangeal joints will asssume a flexed position owing to pull of intrinsic muscles. In this position, the interphalangeal joints will be in a position of rest (i. e., mid-flexion) and the pull of the thenar muscles will bring the thumb into a position of midabduction. 3 It is occasionally difficult to have a patient maintain these positions during rest or sleep. If this cannot be accomplished, the use of splints may be necessary (see following section on splinting). Appropriate positioning of the lower extremities in patients with burn injuries is much easier to achieve than the upper extremities. There is a natural tendency for patients to want a significant portion of their rest and sleeping time in the supine position. This position will usually maintain the hips and knees in an extended position. However, this is not always the situation, especially when there are burn injuries on the anterior trunk and thighs and on the posterior thighs and calves. Burn wounds on the lower portion of the anterior trunk and thighs tend to pull the hips into flexion. With the hips flexed, there is a natural tendency for the knees to flex. If there are burn wounds on the posterior thighs and legs, the problem of knee flexion is compounded by pull or contraction of the burned tissue. Active motion and appropriate positioning (and occasionally passive
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motion) are important factors in preventing loss of joint motion and anatomic deformities. However, there are patients who cannot or will not cooperate in a program of active exercising and proper positioning. In these situations, the use of restraints and splints is necessary.
SPLINTING AND RESTRAINTS The basic principles and considerations in using splints and restraints in the treatment of patients with burn injuries are the same as appropriate positioning. Some anatomic areas are more difficult to treat by positioning than others, and there is great variation from patient to patient. It is not uncommon for a patient to lose motion and develop anatomic deformities in several locations. Depending on the location and depth of injury, the patient who develops anatomic deformities in one location is more likely to lose motion and develop deformities in another. This problem probably results from the inability or unwillingness of a patient to cooperate in a program of active motion and appropriate positioning. Splints and restraints are required occasionally in patients with burns of the lower face, anterior neck, and upper chest. Although active extension of the neck is important in these patients to prevent flexion deformities and loss of motion, it is appropriate positioning during sleep and rest that is most effective in preventing flexion deformities of the neck. When appropriate positioning of the neck during sleep and rest cannot be achieved, and there is a tendency for a flexion deformity and loss of motion to occur, the use of well-padded splints that push upward on the chin and hold the neck extended are effective in preventing and correcting deformities. It is easier to flex a neck that has been extended for several hours than to extend the neck that has become stiff in a flexed position. A shoulder that becomes stiff in adduction is usually easy to correct a few days after injury. However, it is easier to prevent an adduction deformity of the shoulder than to correct one, especially if the lateral chest, axillae, and inner arm are burned. With burns in these areas, and if the patient is unable to keep the arm abducted to at least 80° during rest, a restraint to aid appropriate positioning is indicated. This result can be achieved by placing a dressing over the arm and maintaining shoulder abduction with a restraint that holds the arm in approximately 80° to 90° abduction. This restraint also will serve to keep the elbow extended. If a soft dressing is not adequate to maintain elbow extension, an orthoplast or plaster of Paris splint will maintain this position. One of the more common problems that requires splinting in the burned patient is the wrist. In patients with burn injuries, there is a strong tendency for the wrist to assume a flexed position. This problem occurs in patients with and without burns of the hands and wrists. Wrist flexion is considered to be the position of comfort; however, there is usually considerable discomfort in moving the wrist that has been held in a flexed position for several hours and there is usually little or no discomfort in moving a wrist that has been extended 20° to 40°. In addition to the problem of moving the wrist that has been held in flexion, there are also associated
COMPREHENSIVE REHABILITATION AFTER BURN INJURY
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problems in the metacarpophalangeal and interphalangeal joints of the fingers and in the intrinsic muscles of the thumb. 5 When the patient with burn injuries does not actively move the wrist and keep it properly positioned during periods of rest, splinting is indicated. This problem occurs in about 20 per cent of patients hospitalized with burn injuries and is more common in patients where the wounds exceed 50 per cent TBSA. If the problem of wrist flexion in the burned patient is detected early, it is usually easy to correct and the secondary problems will be corrected simultaneously. All that is required is a simple splint made of plaster of Paris, orthoplast, or other similar material. This splint, like all splints, can be placed over the dressing required for the burn wound. The splint should start in the proximal part of the forearm, extend into the palm on the ulnar side of the hand, and stop at the palmar crease. It should extend the wrist 20° to 40° and allow the thumb to rotate and the fingers to flex at the metacarpophalangeal joints. 4 The associated problems that occur when the wrist is held in flexion are a tendency for the metacarpophalangeal joints to hyperextend with flexion of the interphalangeal joints of the fingers, and loss of thumb abduction or rotation. Fortunately, most of these secondary or associated problems are corrected when the flexion deformity of the wrist is treated. When the wrist is extended, the intrinsic muscles tend to pull the metacarpophalangeal joints in a flexed position. The interphalangeal joints of the fingers usually will assume a slightly flexed position, and the thumb will be held in mid-abduction. In some patients with burn injuries, correction of a wrist flexion dt;formity will not correct the hyperextension of the metacarpophalangeal joints, the flexion of the interphalangeal joints, or adduction of the thumb. This problem usually occurs in patients with burns on the dorsum of the hand or with 10ngstanBing flexion deformities of the wrist. To correct the problem with the fingers and tHumb, the splint should extend to the fingertips and be molded to hold the metacarpophalangeal joints in 70° or more of flexion, with thC(. interphalangeal joints almost fully extended and the thumb widely abducted. This splint, like all splints, should be worn as little as required, and active motion of the involved joints is encouraged. 5 A few patients with burn injuries of the hand will have problems with only the interphalangeal joints of the fingers and/or loss of thumb abduction. The patients who have only flexion deformities of the interphalangeal joints are usually those with burn injuries of the dorsum of the fingers. These deformities should be corrected with splints that either push (from the volar surface) or pull (from the dorsal surface) the interphalangeal joints into aimost full extension. These splints also should be worn as little as possible. Active motion should be encouraged, and the ability to extend the proximal interphalangeal joints of the fingers actively must be monitored carefully. If the proximal interphalangeal joints cannot be actively extended 20° front a fully flexed position, internal fixation should be considered. If internal fixation is used to correct a flexion deformity of the interphalangeal joints (almost always the proximal interphalangeal joints of the fingers and occasionally the distal joints or interphalangeal joint of the thumb), it should be left in place until the skin wounds are grafted or healed spontaneously.
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BOSWICK, JR.
Upon removal of the internal fixation, motion of the involved joint should be observed closely. Occasionally some degree of flexion will be restored and full extension maintained. More commonly there is limited flexion and extension. In a few patients the flexion deformity will recur almost immediately. These patients should have the internal fixation reinserted and left for 6 to 8 weeks, which will allow healing of the capsular structures; however, very little motion is attained where repinning is required. It is preferable in most patients to have a stiff proximal interphalangeal joint in 10° to 15° of flexion rather than in 90° or more, which will occur if the deformities are untreated. Adduction contractures of the thumb are occasionally the only deformity that occurs in the burned hand. This problem almost always occurs in patients with burn injuries on the dorsum of the hand and usually in the first web space. Like most deformities in the burned hand, they are easy to treat if detected early. A simple splint of plaster of Paris, orthoplast, or other materials that pushes the thumb into abduction is all that is required. The splint should be worn at night and during periods of rest. Active exercising should be encouraged and splinting continued only if the deformity recurs.
SUMMARY Comprehensive rehabilitation of patients after burn injury requires the organized application of sound, recognized principles. The basic concerns are the prevention of loss of joint motion, loss of muscle mass, and the prevention of anatomic deformities. Important considerations are starting the rehabilitative program as early as possible after injury and avoiding techniques that unduly immobilize the patient or parts of the body. The use of early active motion to the patient and all movable joints, along with appropriate positioning while at rest, is crucial to a successful program. Passive exercising along with the use of restraints and splints is necessary in certain patients. REFERENCES 1. Adams RH, et al: Physical therapy in the treatment of burns. Phys Ther Rev 38:481-482, 1958 2. Boswick JA Jr: Management of the burned hand. Orthop Clin North Am 1:311-319, 1970 3. Dobbs ER, et al: Burns: Analysis of results of physical therapy in 681 patients. J Trauma 12:242-248, 1972 4. Gronley JK: Early intensive physical therapy for the burned hand. J Am Phys Ther 44:875880, 1964 5. Gronley JK: The positioning of severely burned hands when treated by the exposure method. Phys Ther Rev 40:521-522, 1960 Midtown II, Suite 600 2005 Franklin Street Denver, Colorado 80205