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Rehabilitative Needs of the Burn Survivor – Part 1

David J. Lorello, DPT Derek O. Murray, MS PT

Combined Sections Meeting February 9, 2012

8:00 – 10:00

Objectives

• Understand the role of the Physical Therapist in the care of the patient with burn injuries

• Understand the assessment of the burn wound including depth, size, and mechanism of injury

• Understand the phases of burn wound healing

• Learn common dressings used to treat burn wounds and latest advancements in dressings

Functions of the Skin

• Protect from infection and injury

• Prevent loss of body fluid

• Regulate body temperature

• Receives external stimuli

• Indicator of internal events

• Determines identity

←Burn injuries cause a loss to some or all of these

Epidermis

• Basement Membrane:

– Area of connective tissue between the epidermis and dermis

– Acts as a scaffolding where ridges in the epidermis fit within projections in the dermis

– These projections are called rete pegs and the prevent shearing forces

Classifying the Burn

mechanism of burn

depth of burn

extent of burn

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• Scald

• Contact

• Flame

• Chemical

• Electrical

• Radiation

Classification of Burns Mechanism

Temperatures

• hot coffee 180

• sauces, soups/broths, noodles make things worse

• hot grease 350°

• grease fire 400°

Burn Depth

Superficial Partial Thickness

Full Thickness

Superficial

Deep Partial Thickness

Burn Depth

• Superficial Burn

– signs & symptoms

• reddened skin

• pain at burn site

• involves only epidermis

– healing time 3-7

days

• injured epithelial cells peel away

• seldom clinically significant

Superficial Partial Thickness

• involves the entire epidermis and the papillary layer of the dermis

• appearance is moist, red, and weepy

• extremely painful

• good capillary refill

• typically heals in 7-21 days

Deep Partial Thickness

• involves the epidermis, and both the papillary and reticular layers of the dermis

• can appear mottled white, pink, or deep red

• some hair follicles and sebaceous glands remain

• less sensation

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Full Thickness Burn

Entire thickness of epidermis and dermis including epidermal appendages

White, charred, yellow, brown

Dry, tough leathery

Insensate

Full Thickness Burn

• Compartment Syndrome: increased pressure within one or more fascial compartments so that vascular perfusion is compromised. Without prompt treatment, the resulting tissue hypoxia can lead first to nerve damage and eventually muscle death

• Escharotomy: Mid-lateral incision of burned eschar used to relieve pressure of an extremity or the trunk

• Fasciotomy: surgical procedure where the fascia is cut to relieve tension or pressure

Jackson’s Thermal Wound Theory

• Zone of Coagulation

– area nearest burn

– clotted blood and thrombosed vessels

• Zone of Stasis

– area surrounding zone of coagulation

– inflammation, decreased blood flow

• Zone of Hyperemia

– periphery of burn

– limited inflammation

Estimate Extent of Burn

• 2nd and 3rd degree burn only

• Rule of Nines – not accurate for infants and children

• Burn diagrams can illustrate the adult/child anatomical differences

• Lund and Browder used in most burn centers

calculating Total Body Surface Area (TBSA)

Estimate Extent of Burn

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Systemic Effects

Systemic Effects of the Burn Injury

• Skeletal

• Nervous

• Cardiovascular

• Respiratory

• Muscular

Systemic Effects of the Burn Injury

• Multiple Systems

– Cardiovascular

– Renal

– Gastrointestinal

– Respiratory

Systemic Effects of the Burn Injury

• Effects on the cardiovascular system

– Increased capillary permeability results in edema

– Destruction of red blood cells

– Plasma loss via evaporation at the burn site

– If left untreated, this state of hypovolemia can cause increased chance of renal failure

– Therapists must monitor patient blood pressure during activity, manage edema

Systemic Effects of the Burn Injury

• Effects on the respiratory system – Pulmonary failure is one of the leading causes of

death of a burn patient. Burn injury can lead to: • Hypoxemia

• Pulmonary hypertension

• Increased airway resistance

• Decreased pulmonary compliance

– Grafts to the torso can cause a decrease in chest expansion impairing ventilation

Systemic Effects of the Burn Injury

• Effects on the renal system:

– Decreased fluid volume and decreased cardiac output lead to decreased renal plasma flow

• Effects on the gastrointestinal system

– Gastric dilation and paralytic ileus in response to shock

– Decreased absorption

– Increased risk of ulcers

– Hypermetabolic state causes muscle catabolism

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Wound Healing

• Wound healing can be divided into three phases

Inflammatory → Proliferative → Maturation

Wound Healing

• Inflammatory phase

– Inflammation begins at the time of injury and can last 2-5 days

– Clotting takes place in order to obtain hemostasis, and various factors are released to attract cells that rid wound of debris, bacteria, and damaged tissue

– Wound is characterized by redness, edema, warmth, pain and decreased ROM

Wound Healing

• Proliferative phase

– Starts around the 3rd-5th day and can last up to 3 weeks. Characterized by:

• Angiogenesis

• Granulation tissue formation

• Collagen deposition

• Epithelialization

• Wound contraction

Wound Healing

• Maturation phase – Occurs for 18 months – 2 years post injury

– Collagen becomes more parallel in formation and creates stronger bonds

– Ratio of collagen breakdown to collagen production determines type of scar • Breakdown ≥ rate of production = flat, pliable scar

• Breakdown < rate of production = hypertrophic scar

Wound Healing

• Hypertrophic Scar

– Red, elevated, itchy

– Confined to original area of injury

Wound Healing

• Keloid Scar

– Type of hypertrophic scar

– Extends outside the area of injury

– Tumor-like appearance

– More common in African-American and Asian populations

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Wound Healing

• All phases of wound healing require oxygen

• Oxygen delivery to tissue can be impaired by reduced circulation, edema, or the presence of necrotic debris on the wound surface

• Burns develop necrotic tissue on the wound surface that support bacteria, encourages infection, and prolongs healing

Surgical Management

Surgical Management

• Primary Excision

– Removal of eschar surgically – Reduces need for repeated debridement

– Produces more rapid healing

– Reduces infection

– Reduces scarring

Surgical Management

• Skin grafting:

• Autograft: Skin taken from an unburned area of a patient and transplanted to cover a wound

• Allograft (homograft): Cadaver skin used as a temporary cover on a burn wound

• Xenograft: temporary covering, usually pig skin

• Cultured Epidermal Autograft (CEA): Skin grown in a laboratory from a patient’s own tissue

Surgical Management

• Skin grafting

• Split-thickness skin graft (STSG) contains the epidermis

and superficial layers of the dermis from the donor site

• Full-thickness skin graft consists of the full dermal layer

Integra®

• Bilayer membrane for skin replacement

• Top layer (epidermal) made of silicone and functions to control moisture loss

• Bottom layer (dermal) is made of a fibrous protein material (collagen) from bovine and shark cartilage.

• It allows blood vessels and other cells to grow while the collagen is absorbed into the body

Skin Substitutes

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• Comfort

– superficial partial-thickness burns are painful

– deeper burns become increasingly painful as eschar is debrided and skin buds appear

• Metabolic

– reduction in evaporative cooling

– maintaining a moist healing environment

• Protection

– barrier to microorganisms

• Wound hygiene

– debridement of eschar

Burn Wound Dressings Burn Wound Dressings

• Topical creams

• Gauze dressings

• Hydrocolloid

• Film

• Silicone mesh

• Hydrofiber

• Antimicrobial (silver)

• Skin substitutes

Topical Creams

• Silver sulfadiazine 1% cream – often thought of as the gold standard – synthesized from silver nitrate and sodium

sulfadiazine – reduces wound bacterial density – delays colonization of Gram-negative bacteria

Topical Creams

• AgSD – Causes a pseudoeschar – Dressings need to be changed BID which may

cause trauma to the wound bed – May delay wound healing

Silver Sulfadiazine

• Comparison of a hydrocolloid dressing and silver sulfadiazine cream in the outpatient management of second-degree burns. – Prospective, randomized study of 50 patients – Duoderm or Silvadene – Duoderm demonstrated significantly faster

wound healing, less pain, fewer dressing changes, less time to change dressing, less cost

Wyatt D, McGowan DN, Najarian MP. Comparison of a hydrocolloid dressing and silver sulfadiazine cream in the outpatient management of second-degree burns. J Trauma. 1990 Jul;30(7):857-65.

Enzymatic Debridement

• Santyl – Collagenase ointment – digests the collagen in necrotic tissue – not an antibiotic ointment

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Enzymatic Debridement

• Wound healing in partial-thickness burn wounds treated with collagenase ointment versus silver sulfadiazine cream. – multi-center trial – collagenase ointment applied with bacitracin

powder – sites treated with collagenase cleaned in less

time and healed faster

Hansbrough JF, Achauer B, Dawson J, Himel H, Luterman A, Slater H, Levenson S, Salzberg CA, Hansbrough WB, Dore C. Wound healing in partial-thickness burn wounds treated with collagenase ointment versus silver sulfadiazine cream. J Burn Care Rehabil. 1995 May-Jun; 16(3 Pt 1): 241-7.

Topical Creams

• Bacitracin – acts by interfering with bacterial cell wall

synthesis – effective against a wide range of gram-positive

and a few gram-negative bacteria

Gauze Dressings

• Xeroform – petrolatum protects wounds from contamination

– allows exudate to escape

– Inexpensive – dries out quickly

Gauze Dressings

• A prospective trial comparing Biobrane, Duoderm and Xeroform for skin graft donor sites. – randomized study of 30 donor sites

– xeroform found to heal donor sites most rapidly – most cost effective of the dressings

Feldman DL, Rogers A, Karpinski RH. A prospective trial comparing Biobrane, Duoderm and xeroform for skin graft donor sites. Surg Gynecol Obstet. 1991 Jul;173(1):1-5.

Film

• Film Dressings – thin, transparent, flexible – not suitable for highly exudating wounds

Silicone Mesh

• Silicone Mesh – porous, semi-transparent, low-adherent wound

contact layer

– coated with silicone – adheres to peri-wound area

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Hydrofiber/Silver • Aquacel Ag

– made from sodium carboxymethylcellulose

containing 1.2% silver in an ionic form

– ionic silver provides broad-spectrum antimicrobial properties

– The dressing absorbs wound exudate to form a

gel that traps bacteria and conforms to the contours of the wound

Hydrofiber/Silver

• Randomized clinical study of Hydrofiber dressing with silver or silver sulfadiazine in the management of partial-thickness burns

– randomized study comparing Aquacel Ag with AgSD

– Aquacel Ag was associated with less pain during dressing change, less nursing time, fewer procedural medications, lower total treatment cost

Caruso DM, Foster KN, Blome-Eberwein SA, Twomey JA, Herndon DN, Luterman A, Silverstein P, Antimarino JR, Bauer GJ. Randomized clinical study of Hydrofiber dressing with silver or silver sulfadiazine in the management of partial-thickness burns.J Burn Care Res. 2006 May-Jun;27(3):298-309.

Hydrofiber/Silver

• Clinical evaluation comparing the efficacy of aquacel ag hydrofiber dressing versus petrolatum gauze with antibiotic ointment in partial-thickness burns in a pediatric burn center.

– 20 pediatric patients (10 Aquacel Ag, 10 Xeroform with Bacitracin)

– Aquacel group associated with fewer dressing changes, fewer narcotics administered, less pain, less nursing time, less time to wound reepithelialization

Saba SC, Tsai R, Glat P. Clinical evaluation comparing the efficacy of aquacel ag hydrofiber dressing versus petrolatum gauze with antibiotic ointment in partial-thickness burns in a pediatric burn center. J Burn Care Res. 2009 May-Jun;30(3):380-5.

Silver

• Acticoat – absorbent core between layers of silver coated

polyethylene

– nanocrystalline silver exhibits antibacterial activity against a wide range of Gram +/- bacteria including resistant strains

– Effective against yeasts and fungi

Silver

• Acticoat – allows dressing to be left in place – must be kept moist to work

Silver

• A prospective, randomized trial of Acticoat versus silver sulfadiazine in the treatment of partial-thickness burns: which method is less painful? – 14 patients with a mean TBSA of 14.6% – one wound dressed with Acticoat, the other

dressed with AgSD – Acticoat left in place as long as it’s adherent – mean VAS for wounds dressed with Acticoat

was significantly less than wounds dressed with AgSD

Varas RP, O'Keeffe T, Namias N, Pizano LR, Quintana OD, Herrero Tellachea M, Rashid Q, Ward CG. A prospective, randomized trial of Acticoat versus silver sulfadiazine in the treatment of partial-thickness burns: which method is less painful? J Burn Care Rehabil. 2005; 26(4):344-7.

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Silver

• Mepilex Ag – absorbent foam dressing – outer layer acts as a barrier – bottom layer has silicone to allow adherence – foam contains a silver salt that inactivates

pathogens taken up by the dressing

Burn Wound Dressings

• Things to consider

– Patient

• anxiety

• ability to change dressing

• children

– may consider splinting

• cost

Rehabilitation

• PT occurs concurrently with wound healing

• Starts within 24-hours of admission

• Therapy consists of:

• Maintenance of normal ROM

• Maintenance or improvement in muscular strength

• Maintenance in cardiovascular endurance

• Prevention of scar contracture

Rehabilitation

• Initial Assessment • Depth and location of wounds

• Etiology of wounds

• Previous medical history

• Social history (family dynamics, school environment)

• Surgical procedures (grafts, donor sites)

Rehabilitation

• Initial Assessment

• Pain: can be a limiting factor, controlling it is very important in the therapist-patient relationship

• ROM of all joints including those unaffected by the burn

• Developmental screening (gross/fine motor, language, social)

• Strength

• Mobility

• ADL’s - self care activities, can often help to increase physical activity

• Gait – antalgic gait pattern is often seen with LE burns

Rehabilitation

• Goal Setting

– Based on the phase of wound healing, extent and depth of burn, patient’s current health status, age, physical and mental condition, time to heal

• Typical long-term goals

• Full ROM

• Meeting developmental milestones

• Pre-injury level of cardiovascular endurance

• Good – normal strength

• Independent ambulation

• Independent mobility

• Independent function in ADL’s

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Time to Heal

Goal is to achieve full wound closure in less than 21-days

Inflammatory Phase

Initial goals are controlling edema formation and preventing contractures

Inflammatory Phase

• Edema

– Creates stiffness and limits ROM

– Compromises circulation

– Causes pain

– Can become fibrotic if not alleviated

– Can cause deformity

Inflammatory Phase

• Edema control

– Elevating the extremities, involved and uninvolved

– Encourage active motion of the hands and ankles (fist pumps, ankle pumps, activity, exploring and self care)

– Use wedges, pillows, or blankets to prop the extremities above the level of the heart

– Use of compression (ace wrap, coban, JOBST stockings) may be needed

Inflammatory Phase

• Contracture prevention • Encourage early AROM

• Assist with AAROM/PROM if the patient cannot actively mobilize into full range

• Position patient in anti-contracture position

• Splinting (for periods of rest)

Position of comfort is the position of deformity

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Scar tissue continues to contract unless it is met with an opposing force. Its

contractile nature continues 24 hours a day, and it continues until the scar is

fully mature.

Richard RL, Staley MJ. Burn Care and Rehabilitation Principles and Practice. Philadelphia, PA: F.A. Davis Company, 1994.

Positioning

Not only important for contracture prevention, but important for pediatric development

Inflammatory Phase

• Range of Motion

• Active exercise is encouraged

• Patient should perform active exercises of all joints, including the unaffected ones

• AAROM and PROM should only be initiated if patient cannot achieve full AROM

• Do not force joints into optimal positioning if edema is not controlled

Proliferative phase

Proliferative Phase

• Edema control

– Positioning

– ROM

– Retrograde massage

Proliferative Phase

• Post Surgical Management

– Allograft / Xenograft: – ROM can begin POD #1

– ROM with dressings down

– If pt is moving well, splinting only at night

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Proliferative Phase

• Post-surgical Management

– Autograft (meshed) – Immobilized until POD 5

– Begin gentle ROM POD 5

Proliferative Phase

• Post-surgical Management

– Autograft (sheet)

– Dressings down POD 1

– Evaluate wound for presence of fluid or hematomas

– Evacuate fluid or hematomas

– Immobilized until POD 5

– Begin gentle ROM POD 5

Autografts

• Sheet Graft Management

– Evacuation of fluid and hematomas beginning POD #1

– Application of Xeroform with Bacitracin – Application of coban

Rehabilitation

• Mobility and transfers • Can be painful secondary to pressure on injured tissue

• Patients must be given time to find a more comfortable means to achieve the objective

Rehabilitation

• Play • Play is a great method to elicit active movement in

children

• Play is important in the development of cognition and social learning

• Play is a child’s occupation

Rehabilitation

• Ambulation

– Should be encouraged once the patient is medically stable

– Ace wrap should be used to wrap the lower extremities (LE’s) to prevent venous pooling and orthostatic hypotension

– Wrapping the LE’s that have burn injuries also slow increased blood flow into the legs which can cause a throbbing sensation

– Once the patient begins ambulation, it should be encouraged frequently, and progress daily until the patient is considered Independent

– If child is unable to ambulate secondary to pain, fear, behavior, try using a toy such as a big wheel or tricycle

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Case Study