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Physiotherapy Management for Burns Injury

Definition

Burns are injuries to the skin caused by material which are exposed to heat, chemicals, friction, ice, electric shock or radiation.

Injury classification:

a) Injury of burns are divided into: –

1. Heat (thermal injury) – fire, flammable liquids such as gasoline, gas, hot water, hot steam.

2. Chemical injury – acid etc

3. Electrical injury – electrocution, lightning.

4. Radiation injury – solar energy, radiotherapy and laser

5. Ice burn – frost bite 

b) Total Body Surface Area Burns (Percentage)    

  i) Rule of Nine     

 iii) LUND-Browder Chart    

  iii) Palm’s Rule

Figure: Rule of Nine

c) Degree of Burns

Degree of  Burns

 1st degree

 2nd degree

  3rd degree

 

    4th degree

Superficial

Deep

Layer of skin involved

 

Epidermis – the outer layer

 

Dermis-outer layer

Dermis-inside layer

Subcutaneous fat

 

Involve the muscles, tendons, and bones

Sign and Symptom

Redness, pain

 

Pink / red, blister, moist, sore

 

Dry, white and non blanching

Leathery, dry, white or red with thrombosed vessel

Black ,charred with eschar dry

Healing time

3-7 days

10-14 days

17- 21 days, require skin graft

 

Require skin graft

Require reconstruction

d) Inhalation Injury

Inhalation injuries refer to respiratory tract injury caused by inhalation such as smoke inhalation

Inhalation injuries are divided into 3 types:

i. upper respiratory tract (larynx and vocal cord)

ii. the main airways (tracheobronchial tree)

iii. terminal airways (bronchioles and alveoli)

Level

Duration

Physiology

1st Level

3 to 8 hours

Difficulty breathing (respiratory distress) is minimal as a result of bronchospasm or damage to the alveoli or both

2nd Level

8 to 48 hours

Obstruction of the respiratory tract caused by edema of the upper respiratory tract or lower or both.

3rd Level

After 72 hours

Pneumonia, often caused by gram-negative organisms

Inhalation Injury Complications 

1. Tracheal Stenosis

2. Trachea Inflammation

3. Tracheal Ulcers

4. Granuloma Formation

Physiotherapy Management

Treatment of burns cases can be divided into 3 phases: –

  • Acute Phase (Acute)
  • Sub-acute phase (Subacute)
  • Healing and scar maturation Phase (Post Epithelial healing)

Acute phase:

1. Respiratory Care, help to maintain or regain optimal respiratory function. Respiratory care is very important especially for cases of inhalation injury and burns to the chest. Chest physiotherapy is very important and the techniques are: ·  

  • Breathing exercises
  • ACBT (active cycle of breathing technique)
  • Manual techniques of chest physiotherapy – Percussion, Vibration
  • Postural drainage or Modified Postural Drainage
  • Suction (if necessary)
  • Thoracic mobility exercises
  • Positioning
  • Adjunct: Incentive spirometer, flutter if necessary

2. Positioning to the joint Involved

The correct position is at odds with the comfortable position and contractures. Performed on the first day of the patients admitted to hospital until the scars mature. Joint involved are positioned correctly to achieve goals such as: – 

  • Reduce swelling
  • Prevent deep vein thrombosis
  • Prevent further damage to the joints or exposed tendons
  • Avoid damage to new skin graft.
  • Avoiding pressure sores occur in certain area – such as the styloid process, the medial malleolus, the lateral malleolus and the Achilles tendon.
  • Maintain range of motion to prevent contractures Positioning Techniques:

Burns Area

Deformity

Position to prevent contracture

Technique

Head/Neck

Flexion

Extension  or slight hyperextension

Roll the towel and placed below the neck.

Elbow

Flexion

 

Extension and

Supination

Use Arm troughs, pillows or splints

 

Wrist and fingers

 

Flexion

 

Extension

Of wrist and fingers

Put Arm troughs, pillows or splints

 

 

 

Hip

Flexion,  External rotation

Hip Extension and lower limb in neutral position.

Lying supine or prone positions. No pillow under the knees.

 

Knee

Flexion

Extension

 

No pillow under the knees.

Ankle

Plantar Flexion

90 degree dorsi flexion.

Pillow or splint to support the ankle.

Notes :The correct position should always be continued until maturity to avoid scar contractures.

3. Therapeutic Exercise

Exercise should be done on the first day of admission until the scars mature. The purpose is to:

  •  Maintain Joint integrity
  • Maintain muscle flexibility and elasticity of the skin
  • Maintain range of motion to prevent contractures 
  • Increase muscle strength and endurance.
  • Restore the musculoskeletal function to optimal level.

Soaked During Exercise

  • The ideal time to exercise is when soaked in warm water to soften the tissue and provide comfort to patient. 

Sub-acute phase

 1.Continue with respiratory care

2.Continue with therapeutic exercise

3.Continue with the joint involved in the correct position

4.Do mobility movement / ambulation

Ambulation

Ambulation will start once:

  • Haemodynamic status is stable
  • There are no signs of  active bleeding in the joint involved
  • Bandaging of affected area is done

Action should be taken if there are signs like the following: 

Signs

Action

Increase of oedema

Elevate the limb involved

Damage to the healed skin

Refer to the doctor in-charge 

Increase of pain 

Pain management / Refer to the doctor in-charge 

 Precautions:

  • The movement of the hip joint cannot be moved if there are Femoral Intra Venous inserted unstable vital signs  

Healing and scar maturation phase (Post Epithelial Healing)

  1. Therapeutic exercise for circuit training so that patients are more independent.
  2. Stretching exercises
  3. Muscles strengthening exercise such as using Theraband, weights, dumbbells, etc
  4. Exercise to increase endurance. Examples of aerobic exercise such as climbing stairs.
  5. Exercise to improve coordination such as Proprioceptive Neuromuscular facilitation (PNF)
  6. Home exercise
  • Do exercise continuously until scars are matured
  • Elevation of the joints involved if there is swelling,
  • Encourage to do activities of daily living. 

Scar Care

Scarring of burn wound is a continuous process. Scar will stop when the skin is ripe. Understanding patient’s care related to scarring should be intensified to prevent the growth of hypertrophic scar Clinical presentations of a matured scar:

  • Soft
  • Align       
  • No tension in the scar
  • Scars return to original skin tone 

Hypertrophic scar have clinical features as below: – 

  • Redness of surface
  • Surface scars arising
  • Less flexibility
  • Pain and itch

Scar management: 

a. Scar massage

The manipulation of soft tissue combined with stretching can reduce scar formation. The manipulation of scars:-

  • Encourage the restoration of collagen
  • Helps to reduce irritation
  • Maintains moisture and elasticity

 Scars Massage Technique: –

  • Apply the lotion on the affected area. Use unscented lotion.
  • Apply pressure to the skin sufficiently
  • 3-way massage which is rounded up and down, and side to side
  • Sort through friction techniques more effective if combined with stretching and exercise.
  • Perform 3-4 times per day. 

Skin care 

i. Hygiene

  • Test the water temperature before entering the tub or shower because the new skin more sensitive to the water temperature.
  • Clean out by using a plain water to shower.
  • Use a soft, clean towel to wipe

 ii. Dry skin

The skin looks dry and scaly as a result of the destruction of oil refineries.

  • Use lotion or moisturizer to keep the skin moist.
  • Stay away from oils containing lanolin and alcohol resulting blister burns / blisters on the skin that is new.

 iii. Sun light

New heal skin is more easily injured when exposed to sunlight – ultraviolet rays. 

  • Wear long-sleeved dress, trousers, big hats to protect the wound. Do activities in the early morning or late afternoon.
  • Avoid exposure to direct sunlight. Apply cream / lotion to prevent ultraviolet ray 

 iv. Cold weather

Patients will experience a spectrum of sensory numbness in the tips of the toes and hands.

  • Wear thick clothing and stay away from exposure to cold weather too long. 

v. Itchy skin

Dry skin will cause the patient to experience irritation.

  • Wear loose clothing to avoid sweating• Avoid scratching the heal skin because it is very thin, sensitive and easily hurt
  • Use lotion intensively. 

vi. Burns / blisters

The new skin is easy to burn / blister caused by pressure and friction.

  • Avoid wearing clothes or shoes that are too tight.

General Prevention:

Hand Washing:

1. Dry hands according to proper procedure

2. Hands should be washed: –

  • Before and after treating / touching patients
  • After handling objects that are exposed to the fluid and the patient

References

  1. Burns and scalds , Clinical Knowledge summaries ( 2007 )
  2. Edger .D (2004 ) Rehabilitation after Burn Injury, BMJ 2004, 343-345
  3. Enoch S, Roshan A, ShahM: Emegency and early management of burns and scalds.
  4. Garis Panduan Perawatan Kes Kelecuran, Jawatankuasa Teknikal Profesion Fisioterapi, Bahagian Sains Kesihatan Bersekutu, Kementerian Kesihatan Malaysia.
  5. M.M, Cox.K Crawford .C. Werth.D (1987) .Burn Care and Rehabilitation Gene and Barbara Burnett Burn Centre kansas University Medical Centre Kansan City, kansas U.S.A
  6. Co.Uk- trusted medical information and support. http://www.Patient.co .uk/doctor/burns -Assessment-and-management.htm (accesed) 17 /5/2012.
  7. Physical Therapy Journal of the American Physical Therapy Association
  8. Ronald P. Mlcak a, Oscar E. Suman, David N. Herndon (2007), Respiratory management of inhalation injury.
  9. Standard of care: Inpatient Physical management of patients with Burns. Brigham and Women’s Hospital (2008)
  10. myhealth.gov.my/.cara-membasuh-tangan-yang-betul

 

Last Reviewed : 14 May 2018
Writer : Pauzilah binti Hj Dollah
Translator : Sahira Nadiah Shirlen binti Oyon
Accreditor : Halimah binti Hashim