OT Skills for working with the Burn/Wound Population

OT Skills for working with the

Burn/Wound Population

2021 KOTA Conference

Olathe, Kansas

Burns in the United States

• Every year there are approximately 450,000 burns that require medical treatment

• 60% of those burns are seen in the 128 Burn Center in the U.S.

• Most common types of burns happen at home or at work/businesses

• Most common burns are scalds (hot liquid or steam), building fires and flammable liquids/gases. Inhalation injuries accompany many of those that are indoors

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Depth of Injury

• The depth of the injury is not determined solely at the

time of the accident.

• Changes in the depth may occur as a result of infection or

vascular compromise.

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Depth of Burn Classification

• Superficial 1st degree

• Partial thickness

➢Superficial Partial Thickness 2nd degree

➢Deep Partial Thickness 2nd degree

• Full Thickness 3rd degree

• Deeper Structures 4th degree

Layers of skin

First Degree

• Erythema

• No blisters

• Sensation is present

• Wound can heal

spontaneously

Second Degree

• Erythema - deep red

• Blisters present, wet &

weeping

• Sensation present - very

painful

• Edema present

• Wound can re-epithelialize

in 14-20 days

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Second degree: superficial partial thickness burns

• Erythema - deep red

• Blisters present, wet &

weeping

• Sensation present - very

painful

• Edema present

• Wound can re-epithelialize in

14-20 days

Second degree: Deep Partial Thickness Burn

• Less wet and red +/-

blisters

• Minimal pain

• Wound can re-

epithelialize in 3-8

weeks with risk of

scar formation

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Third Degree• Color is white/brown , charred, leather

like appearance

• No blisters

• Area is insensate to touch, but is painful

• Wounds require skin grafting

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Fourth Degree

• Involvement of muscle, tendon, bone and fascia or exposure of deep structures

• Will often require local of distant tissue flaps for reconstruction-skin grafts must have a good bed for survival

• Often requires amputation of involved extremity or digit

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Wounds: open areas

• Size/Area: measured in square cm for wounds (tunneling/shelving/lip, concave/convex +1, analog of clock, 12 o’clock at head); TBSA% (total body surface area) for burns

• Edema: min/mod/max, pitting vs non pitting

• Drainage: serous(clear), serosanganous(blood tinted), purulent (infection)

• Color: pink,red,black, with eschar, granulation/budding

• Moisture: dry/moist

• Infection: redness beyond boundaries, warm to touch,runningfevers, increased pain, swelling, purulent drainage, foul smell

• Other: amputations, tendons exposed, broken bones, vascularity9/22/2021 12

Wound Healing Process

The cellular process begins from injury to full healing

This may take years!

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Three Phases of Healing

• Inflammatory phase

• Proliferative phase

• Remodeling phase

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Inflammatory phase

• When an injury occurs, different cells go into action

➢Platelets- assist with blood circulation and clotting injured vessels

➢Neutrophils- cleans the wounds

➢Macrophages: initiated angiogenesis, debrides wound to allow scar formation (Angiogenesis is the new blood vessel formation)

➢Fibroblasts- Protein fibres (collage-scar tissue)

➢Myofibroblasts- contains actin and myosin contractile system

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Inflammatory Stage

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Proliferative Phase

• Begins 3–5 days post injury and can continue up to 21

days

• Injury becomes shiny new tissue

• New capillaries form, supplies oxygen and nutrients to

allow healing

• If too aggressive and create bleeding – can go back to

inflammatory phase -

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Proliferative Phase (continued)

• Fibroblasts continue to produce the skin network, which is

the scaffolding which supports blood vessel and tissue

growth

• The network includes elastin and collagen

– Elastin is fibers that stretch and recoil

– Collagen is the most dominant connective tissue

• Re-epithelialization

– Reforming intact epidermis (skin), very fragile

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Proliferative Stage

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Remolding Phase

• This phase can last from 6 months to 3 years post injury

• Collagen becomes stronger

• The collagen is a necessary evil, need it to heal but can

be a hindrance

• Starts out very vascular (immature scar) to avascular

(mature scar).

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Remolding Phase (continued)

• Scar tissue doesn’t know to form the nice flat matrix we

were born with. It forms in bundles which can create

raised scars (hypertrophic).

• Collagen tissue 80% as strong as normal tissue

• During this phase you have collagen breakdown and

production

– If breakdown rate is greater than production – flat scar

– If breakdown is less than production – hypertrophic scar

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Remodeling Stage

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Scar Formation (happens as wound closed)

• Normal process to heal is through scarring

• Scarring is the fibrous tissue replacing normal tissues

• Goal is to minimize hypertrophic scars - improve

cosmesis, maintain full rom/function, and prevent

painful/itchy scars

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Burn scars

• Hypertrophic scarring occurs within 4-8 weeks from

wound closure

• It has a rapid growth phase for upto 6-9 months

• Hypertrophic scars often develop in automatic location

with high tension

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Ideal Scar

– Flat

– Supple

– Light in color

(vascularity)

– Regimentation to

natural color

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Hypertrophic Scar

• Red, elevated, itchy, painful

• Stays within boundaries of wound

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Factors Affecting Scar Formation

▪ 1. race= darker pigmented races scar more , 15 times

more likely to occur in darker-skinned individuals

▪ 2. age= tend to develop more readily during and after

puberty, pregnancy can exacerbate scarring.

▪ 3. location (sternum, deltoid region, buttocks scar more)

▪ 4. depth (deeper burns that involve the reticular dermis

scar more d/t the formation of granulation tissue and

prolonged healing time.

▪ 5. Individuals with ginger hair and freckles are also at an

increased risk of hypertrophic/keloid scars

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Emphasis for Early ManagementHome, Rehab, or Skilled Facility

• Scar Management is Key!!!!

➢Compression

➢Scar Massage

➢ROM

➢Splinting

➢Desensitization

➢Sun Precautions

➢Pain

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ADL’sOccupational Therapy Goals

ADL Goals

• Increase functional independence

• Increase ROM and strength / endurance

• Combines with mobility goals when OOB

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ADL’s/functional activities (FIM SCORES)

• Adaptive Equipment

– Built up handles

– Coban to drink cups

– Scoop plates

– Long straws

Be careful with Reacher, long handles, sock aides; Work more on stretching.

Same thing goes with walkers, canes.

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ADL’s/functional activities (FIM SCORES)

• If we maintain the range of motion; the function will follow.

• If we compensate; we can cause or emphasize the

contracture and make surgery a definite for our patients

later

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ADL’s/functional activities (FIM SCORES)

• Provide light built up

handles but be careful

with extending the

handles, Not needed in

left hand. Can also put

tubing in thumb web of

splint and still move

elbow/shoulder on her

right.

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PLAY

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Incorporate IADL

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Treatment

• Night splints- PRAFO/night time progressive splints

• Towel stretches

• Standing stretches

• Refer to PT with continued problems/not progressing

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Early mobility/ambulation/ADL

• Early mobility recommended

• Dependent position: inadequate venous returns, edema,

tissue engorgement, pain, bleeding

• Figure of 8 ace wraps/elastic bandages, or compresso

grips can help prevent the above. Always have

compression on for standing/walking

• Also, ROM exercises pre ambulation helps decrease the

throbbing pain in distal LE with dependent position

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Transfers/self care mobility• Must have compressions on donor sites

• May need to consider platform if UE involve

• Initiate out of bed mobility as early as possible

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Transfers/self care mobility

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Contractures

• Eyelids

• Mouth

• Neck

• Axilla

• Elbow

• Palmar hand burns

• Knees

• Ankle

• Toes

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Contractures and Considerations for Treatment

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Eye Lids

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Axilla

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Hand contractures

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Burn Claw Hand – 5th digit most common

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• Check range of motion in all planes. It might appear good

in sitting position, but it may be limited in supine

• Don’t forget the mouth, eyes ROM

• Make them touch themselves to massage and have the

family demonstrate massage. Will the helper really be

around?

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Neck contracture

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Neck contracture

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Neck contracture

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Arm and trunk Contractures

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Arm and trunk Contractures

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Elbow contracture

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Elbow and knee contracture

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Knee contracture

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Treatment Techniques

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ROM & Exercise

• ROM should be performed EVERY DAY! Contractures can

form in 1 - 3 days.

• It’s best during bathing

• ROM is usually extremely PAINFUL.

• Pain control is a team effort !

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ROM & Exercise (continued)

• Prevent skin contractures

• Maintain joint integrity

• Maintain tendon gliding

• Prevent adhesions

• Reduce edema

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Paraffin

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Fine motor activities

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Scar Massage • Place a small amount of lotion on the area to be massaged.

• Use 2 fingers placed close together to do the massaging.

• Use firm circular motions deep enough to turn the scar from pink to

white. This is known as ‘blanching‘.

• You may also massage in a side -to-side motion. The area you massage

should be placed on stretch as instructed in clinic.

• Focus on areas that are already developing small, hard, raised and firm

scars.

• Massage scars for at least 10 minutes, 2-3 times a day.

• Scar massage should be continued until the scars have matured, which

can be anywhere from 9-18 months.

• Wearing compression along with scar massage is key to preventing

and/or minimizing scar bands and raised scars66

Compression Options

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• Isotoner gloves

• Compressogrip/Tubigrip

• Ace wraps

• Coban

• Compression masks for

face/head

• Interim garments

(lycra/spandex

readymade

shirts/shorts/pants

• Custom compression

garments at outpatient

level

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Desensitization

• As the nerves regenerate, patients will complain of

increased pain, neuropathy which can be addressed both

pharmacologically as well as non pharmacologically

• Massage, massage, massage

• Neurontin, Lyrica

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Splinting, braces, collars

• Position to prevent contractures

• Protect a new graft (4-5 days)

• Range of motion is decreasing

• Common Splints/braces: next few slides

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Night time extension splinting

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Wrap in fist position to tolerance 15-20 minutes

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Soft neck collar to prevent neck contractures

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Mouth splints/device

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Risk for hand contractures contracture

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Intrinsic plus splint: to maintain optimal position

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Risk for webspace contracture: Web spacer splint to

prevent contracture

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Risk for knee flexion contracture: Knee immobilizer

to prevent contracture

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Risk for Ankle plantar flexion contracture:

PRAFO to prevent ankle contracture

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Who Do You Call? ☺

• Problems or concerns when the patients are on the Rehabilitation

Unit, you may call the burn therapists or the Burn Unit/physicians.

•

• Anushree Sharma, OTR/L

• Anne Schwartz, DPT

• Traci Edwards, OTR/L

• BURN REHAB 588-6542

• BURN UNIT: 588-6540

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QUESTIONS??

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