BURN REHABILITATION

BURN REHABILITATION

Until recently, survival was the only gauge of success in managing serious burn cases. More recently, the overriding objective of burn care has become reintegration of the patient into the home and community.

This goal has extended the traditional role of the burn care team beyond acute wound closure.

Three broad aspects are involved in this effort:

1.      Rehabilitation,

2.      Reconstruction, and

3.      Reintegration.

The importance of early and active focus on long-term rehabilitation goals cannot be overemphasized.

Modern burn care may be divided into the following 4 general phases:

• The First Phase, initial evaluation and resuscitation, occurs on days 1-3 and requires an accurate fluid resuscitation and thorough evaluation for other injuries and comorbid conditions.

• The Second Phase, initial wound excision and biologic closure, includes the maneuver that changes the natural history of the disease. This is accomplished typically by a series of staged operations that are completed during the first few days after injury.

• The Third Phase, definitive wound closure, involves replacement of temporary wound covers with a definitive cover; there is also closure and acute reconstruction of areas with small surface area but high complexity, such as the face and hands.

• The Final Stage of care is rehabilitation, reconstruction, and reintegration. Although this begins during the resuscitation period, it becomes time-consuming and involved toward the end of the acute hospital stay.

TREATMENT GOALS AND TREATMENT PLANNING

Burn rehabilitation is undeniably difficult and time-consuming, but the time spent on outlining short-term and long-term treatment goals and modalities is worthwhile. These goals and daily schedules ideally are posted where the patient and family can review them easily, thereby reinforcing the expectation that the goals be met.

Treatment goals and strategies vary, depending on the patient's injury, stage of treatment, age, and comorbidities.

Goals range from minimizing loss of range of motion (ROM) in the patient whom is critically ill to establishing a work hardening program in recovered patients.

• In critically ill patients, goals are to limit loss of ROM, reduce edema, and prevent predictable contractures through positioning and splinting. This process generally involves twice-a-day therapy sessions, which take advantage of planned anesthetics to allow more aggressive joint ROM.

• In patients who have recovered from critical illness but still are hospitalized, treatment is much more time-consuming, as well as physically and emotionally demanding of the patient and therapist.

  • Appropriate therapist time must be budgeted.

  • Realistic therapeutic goals, as well as an appropriate plan of care, should be devised by the treatment team, including the patient and family.

  • Prior to hospital discharge, appropriate functional goals for the patient should include the ability to stand, ambulate, feed, and toilet.

  • Regular meetings to discuss progress and a posted daily schedule are appreciated by adults and children.

PSYCHIATRIC ASPECTS OF RECOVERY

The patient's attitude and motivation are powerful factors that affect burn rehabilitation. Because these elements are commonly more important than the physical injury itself, all members of the burn team can and should provide this type of support.

Various authors have described the following 3 basic stages of burn recovery, each with unique psychologic implications:

• Critical illness stage of recovery

  • Survival often is in doubt, and immediate psychiatric issues dominate, including anxiety, fear, pain, delirium, sleep deprivation, and confusion.

  • These problems ideally are addressed by the ICU team and psychiatric consultants.

• Acute recovery phase of care

  • Patients enter this phase after survival is assured and the intensities of surgery and intensive care diminish.

  • This phase typically encompasses the noncritical remainder of the acute hospitalization and is characterized by intensive physical and occupational therapy, fewer smaller surgical procedures, and a growing awareness of the injuries impact and long-term implications.

  • Patients often become depressed, and up to 30% experience symptoms of posttraumatic stress disorder (PTSD) (eg, hyperarousal, fearfulness, sleep disturbances). Focused pharmacotherapy and individual counseling can be helpful.

• The final stage of psychological recovery encompasses the 1-2 years after initial hospital discharge.

  • This time is often emotionally difficult, as patients adjust to new limitations at home and at work while experiencing waning PTSD symptoms.

  • Moderate depression can be expected in many patients, and these problems can be magnified if optimal recovery potential has not been reached because of inexpert therapy.

  • Recovery can be facilitated by a long-term therapeutic relationship. In many patients, participating in peer support groups is beneficial. One example is the Phoenix Society.

Attitude and psychological well-being play powerful roles (either helpful or destructive) in physical recovery. The importance of understanding this concept cannot be overemphasized. Every member of the burn team can have a strong and favorable impact by considering these 2 factors during day-to-day patient interactions.