Role of Occupational Therapy and Physiotherapy in ... of Occupational Therapy and Physiotherapy in...
Transcript of Role of Occupational Therapy and Physiotherapy in ... of Occupational Therapy and Physiotherapy in...
Role of
Occupational Therapy
and Physiotherapy in
Paediatric Burns
Beth Kershaw Naylor – Physiotherapist
Chriscelle Calladine – Occupational Therapist
Frenchay Hospital, Bristol
Aims of Presentation
Therapists’ Role
Techniques Used
Different types of scarring
Identifying those at risk of
problem scarring
Treatment for scars
Barbara Russell Children’s
Unit Therapy Team
Occupational Therapists
Alison Guy
Chriscelle Calladine
Physiotherapists
Amanda Dufley
Beth Kershaw-Naylor
Therapists Role Maintain correct joint/postural positioning
and protect wound as it heals
Promote early mobility and play
Prevent deformity from contracture
Increase exercise tolerance
Educate regarding skin care and desensitisation
Liaise and educate community therapists in preparation for discharge and post discharge
Assess for equipment needs
Scar Management
Active Exercise Through
Play Therapy
• Maintain/ improve function
• Encourage normal development
• Increase/maintain ROM
• Increase exercise tolerance
• Increase strength
ROM Exercises and
Stretches
Movement of joints through range either
actively or passively
Splints
Thermoplastic (mouldable at 60º) – keep away from heat
Washed with soap in luke warm water
Should not have any damage, or straps missing
Should be comfortable and not cause swelling or pain.
• to position correctly
• to prevent contracture,
deformity and loss of
function
Splints
Hands, (POSI)
Elbow, (extension)
Knee, (extension)
Ankles, (90 degrees dorsiflexion)
Axilla, aeroplane splint, (90 degrees)
Neck
Scar Management
To control and treat problematic scarring
To improve cosmetic outcome
To prevent contractures and improve function
To reduce pain and discomfort
Aims
How is a scar different to
normal skin?
Quality and texture different
Collagen type and formation
Tendency to contract
There are no hair follicles or
sweat glands
More susceptible to ultra violet
radiation
Scar: The fibrous tissue that replaces
normal tissue destroyed by injury or
disease
Types of scarring
Flat Pale Scar -
normally slightly paler than the
surrounding skin, flat and soft
Atrophic –
sunken or
pitted scar
e.g. acne or
chickenpox
Problem Scarring
Hypertrophic Scar A widened or red, raised scar
Often itchy or painful
Problem Scarring
Keloid Scar An abnormal scar that grows
beyond the boundaries of the
original site of injury
Excessive Collagen
Scar much larger than original
site of injury
Less responsive to treatment
Problem Scarring
Contracture Scar Problem scars can lead to
contracture - where the scar
causes tightening of the skin which
in turn may effect movement
Wound healing is different to
scar maturation
Problem scarring may not be seen until 2-4
months after wound healing has occurred.
A problem scar can take up to 2 years to
mature
Who is at risk of problem
scarring?
Grafted burns 70% more likely
Burn Injury taking longer than 3 weeks to heal
Infection
Depth of burn
Site on body
Skin Type
History of scarring
Cream and Massage
Increased scar pliability and
decreased scar banding have
been reported - Roques (2002)
Reported benefits –
• Improved skin quality
• Decreased sensitivity
• Increased cutaneous
hydration
• Improved scar quality
• Better acceptance of scar by
patient - Field et al (2000)
Various techniques- none
validated
Silicone
Silicone Sheeting
Can be washed in mild soap
and warm water
Should last up to 6 weeks
Silicone Gel
Normally applied 2x daily
Area should be
washed before
reapplication
Check for rash
• Cream, sheet, spray or elastomer
• Reasonable evidence exists of its efficacy
but mechanism not well understood
• Gradiates the oxygen and moisture flow of
the skin Niessen et al (1998), Gilman (2003)
Pressure Therapy
Used since 1860 in the form of elastic bandages
Little scientific (but lots of experiential) evidence to
support use
Pressure controls collagen synthesis and encourages
realignment of collagen bundles Aityeh (2007)
The use of pressure garments to treat burns scars
A pressure garment is a made to
measure specially designed article of
clothing that is worn over burn scars.
They are normally
made from a fabric
called PowerNet, a
Lycra fabric which
should fit like a
second skin.
Pressure Therapy
Average pressure applied = 25mmHg
In order for the garment to work they must be: Applied as soon as possible after healing has occurred
Worn 24 hours a day, removed only for creaming and
bathing
Washed regularly following the manufacturers guidelines to
maintain elasticity
Fitted accurately and reviewed regularly
Other scar management
techniques
Surgery
Corticosteroid Injections
Radiotherapy
Laser Therapy
Cryotherapy
Micro pore tape
Dermobrasion
Topical Vitamin E
Hydrotherapy
Ultrasound
Pulsed electrical stimulation
Thomas A. Mustoe et al 2002
Anecdotal therapies
Camouflage
Assessment
Commence assessment and appropriate treatment as soon as the wound has healed
Assessment is carried out using a number of techniques and standardised scar scales
Considerations when
selecting treatment
Severity of scar
Location and size of scar
Length of time to heal
Number of risk factors, e.g. previous problematic scarring
PMH
Allergies
Age
Lifestyle of patient
Functional and cognitive ability of patient and available support network
Patient preference
Ability to attend appointments
Cost
Management
Follow-up for pressure
therapy generally:
Children every 2 months,
Adults every 3 months
Follow-up for patients using silicone only is judged on an individual basis
Follow-up for 2 years or until scarring matures
Aim for scarring to be soft, flat, pale, pain free and itch free and the individual to have returned to as close to their normal level as function as possible
Other considerations
Pain Management
Itch and hypersensitivity
Psychological health
Functional Ability
Return to work/school/leisure
Cosmetic techniques
References
Akita et al (2006) The quality of paediatric burn scars is improved by early administration of
basic fibroblast growth factor. Journal of burn care and research Vol27 page 333
Atiyeh, B (2007)Nonsurgical management of hypertrophic scars: Evidence-based therapies,
standard practices, and emerging methods. Journal of Aesth Plastic surgery. Vol31 page
468-492
Brusselaers et al (2010) Burn scar assessment: A systematic review of different scar scales.
Journal of surgical research Vol164 pages e115-e123
Field et al (2000) Post burn itching, pain and psychological symptoms are reduced with
massage therapy. Journal of burn care and rehabilitation Vol21 page 189
Gilman (2003) Silicone sheet for treatment and prevention of hypertrophic scar: A new
proposal for the mechanism of efficacy. Journal of wound repair and regeneration Vol11,
page 2365-236
Loladze et al (2005) Use of bilidase for the treatment of experimental hypertrophic post burn
cicatrices. Bull Exp Bio Med 139:98
Niessan F (1998)The use of silicon occlusive sheeting and silicon occlusive gel in the
prevention of hypertrophic scar formation. Journal of plastic and reconstructive surgery
Vol102 page 1962
Regina Fearmonti, MD et al (2010) Journal of Plastic Surgery. Vol10 1937-5719 June 21
2010
Thomas A. Mustoe et al (2002) International Clinical Recommendations on Scar
Management. Plastic and Reconstructive surgery. Vol110, No2 Aug 2002
Kristine M. Bombaro et al.(2003) What is the prevalence of hypertrophic scarring following
burns. Burns 29 (2003)299-302