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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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