Let’s set the scene. You’re a physical or occupational therapist working in an inpatient acute rehab facility or a subacute rehab facility. The next patient on your schedule is an evaluation for a burn patient who has just been admitted post-hospitalization.
What should your plan of care and treatment look like?
How does the rehabilitation change for a burn survivor?
This is strongly impacted by the percentage total body surface area (TBSA) affected and whether skin grafting was performed or not. Large burns that require skin grafting consequently require a significant amount of individualized therapy services. This article will explore some of the areas specific to burns that should be included in your plan of care.
Assessing a Burn Patient in Physical Therapy
There is a very high likelihood that the patient’s wounds will still be open to some extent when they arrive at your facility. A patient with a bigger burn (>25% TBSA) or a patient with a complicated healing process (comorbidities, infections, etc.) will probably require more extensive wound care. It’s important for you to be a part of the dressing changes with nursing staff at least a few times a week to see what’s underneath the dressings and how it could impact your plan of care. For example, if the wounds cross a joint then it will be especially important to focus on range of motion (ROM) at this area.
Also, dressing changes usually coincide well with pain medications. Therefore, it can be easier to perform ROM exercises when the dressings are off for pain control and to see how the wounds/grafts are affected by the ROM. If you find that a fresh graft is being pulled on by a particular ROM activity, it may be best for wound healing to temporarily limit that ROM activity until it no longer pulls and potentially opens. It’s a very fine line between facilitating wound healing and maintaining mobility.
Scar Prevention for Burn Victims
One of the biggest focuses on burn therapy is scar prevention, because scarring leads to contractures and loss of ROM and function. When it takes more than 21 days for a burn to heal or if a skin graft was required, the area is at risk for contracture. This is especially true when the area crosses a joint like the shoulder or knee. The patient needs to be positioned in the anti-contracture position at these joints.
The patient might have positioning devices or splints that come with them from the acute setting. Continue to monitor these for proper fit, as with gradual edema reduction and scar formation there could be new areas of pressure that lead to skin breakdown. In addition to splints and positioning, these patients will require aggressive ROM and stretching to all affected areas. Some patients may be able to perform active assisted ROM on themselves or have a caregiver that performs stretching as part of their home exercise program.
However, with big burns, the patient frequently requires a skilled therapist to perform stretching to ensure contracture prevention. It’s also important to include face and trunk stretching, though this is difficult to perform without the patient actively assisting. Compression garments are used for areas that have completely healed with no remaining open areas.
Meeting Functional Goals for Burn Rehabilitation
As with most patients in these settings, burn patients also require an emphasis on function and return to independence to facilitate discharge to the next level of care. All of the basic rehab focuses such as bed mobility, transfer training, gait training, and balance activities will still apply. Some burn patients will require amputations, so their plans of care may be specific to both amputation and burn. Patients with large burn injuries will likely experience a hypercatabolic state during their hospitalization, and therefore become significantly deconditioned and weak. They will require a generalized strengthening and endurance training program to build back their lean body mass.
Continued Care of a Burn Patient
All burn patients should be following up in the outpatient burn clinic that is affiliated with the acute burn hospital. Ideally, there is a therapy presence that sees the patients when they follow up in this clinic. These therapists will follow the patients’ compression, scar, and splinting needs. You should attempt to contact the therapist from the burn center in order to get on the same page and determine what aspects of care they will be following or assisting with. This is also helpful to ensure the splinting schedule is being followed appropriately as the patient transitions to the different levels of care. The burn therapist may also be able to give you more therapy-specific information about the patient that is not necessarily stated in the chart.
Burn patients have very distinct rehabilitation needs while in the acute and subacute rehab settings. In addition to the basic functional mobility and activities of daily living, they will also need attention on wound care/healing, scar management, ROM and stretching, positioning and splinting, strengthening, and endurance training. It’s important to get in contact with the burn therapist from the burn center where the patient was hospitalized, as they can relay valuable burn-specific information and should follow the patients for scarring and splinting needs. Although working with burn patients can be challenging due to the multi-faceted therapy approach, it is always worth it in the long run to see how far they come. After all, isn’t that why we all do what we do?
About the Author
This article was contributed by Lauren Higgins, DPT. Lauren is a Physical Therapist who provides specialized treatment for burn patients. After completing her DPT from Washington University in St. Louis, she pursued a career in acute care rehab with a specific interest in treating patients with burns and traumatic brain injuries.