REHABILITATION IN RECOVERING BURN PATIENT
As critical illness abates and wounds progressively close, the roles of the physical and occupational therapists (as well as the demands on the patient) expand and become more difficult.
Patients become more aware of what has happened to them, and they can become fearful of the therapist and the associated potentially uncomfortable procedures.
The principal components of burn therapy that characterize this period include the following:
Continued passive ROM
Increasing active ROM and strengthen
Minimizing edema
ADL training
Initial scar management
Preparing for work or play or school
Long-term favorable outcome requires hard work during this period, but it is important for the therapist not to push too hard. An early program of passive ROM greatly facilitates successful retention of normal ROM during this period. Intraoperative ROM also can be useful; in coordination with the operating room team, passive ROM can be performed between induction of anesthesia and preparation of the surgical site. Other maneuvers that can be used to increase the patient's tolerance for passive ROM include the following:
Timing of the ROM session with medication for dressing changes
Administration of opiates or benzodiazepines
Gentle conversation and encouragement
An unhurried approach to therapy sessions
Burned and grafted extremities commonly have lingering edema that can contribute to joint stiffness. Reducing this edema facilitates rehabilitation efforts.
The use of custom-fitted elastic garments this early after injury is expensive, as they frequently need to be downsized as the edema resolves; however, simply wrapping the fingers with self-adherent elastic helps reduce digital edema. Tubular elastic dressings, elastic wrap dressings, elevation, and retrograde massage also help reduce extremity edema.
Topical silicone may have a favorable influence on selected evolving hypertrophic scars.
As definitive wound closure nears and hospital discharge approaches, the focus of rehabilitation efforts becomes practical. Performance of ADL tasks and the impending return to play/school/work are important considerations.
Resisted ROM, isometric exercises, active strengthening, and gait training are important objectives.
When treating children, it is important to use developmentally appropriate play to facilitate rehabilitation goals. For example, children with serious hand burns are ideally engaged in play that requires the use of their hands at a motor level that is consistent with their development.
For many burn patients, the first 18 months after discharge are more difficult than the acute stay. The principal rehabilitation goals at this time include the following:
Progressive ROM and strengthening
Evaluation of evolving problem areas
Specific postoperative therapy after reconstructive operations
Scar management
Ideally, the same therapist who worked with the patient during the acute inpatient hospitalization continues through the outpatient setting. Not only does this continuity enhance the patient's experience, but also it helps the therapist monitor burn recovery. If, for reasons of distance or managed care, it is not possible to maintain this relationship, regular contact at each clinic visit back at the burn unit can achieve this goal indirectly.
Unfortunately, it is not uncommon for ROM and strength to be lost during the first months after discharge. This is particularly true if there is inadequate outpatient rehabilitation (eg, inexperienced therapist). The burn unit team should monitor the quality of outpatient rehabilitation services during routine clinic visits at the burn unit. If the patient is losing substantial ROM and strength due to inadequate therapy, readmission for focused rehabilitation efforts is appropriate.
The realities of distance, transportation, and managed care often cause patients to work with inexperienced therapists. Therapists should visit the burn unit prior to the patient's discharge, videotape therapy sessions (with the patient's written permission), and maintain frequent telephone contact. Family education and involvement with rehabilitation plans may facilitate early identification of evolving problems and rectify rehabilitation efforts.
Burn therapists play a central role in planning and performing reconstructive procedures in the months and years after acute discharge. They help to identify needed operations, plan sequencing of operations, and educate patients and families about perioperative care. Planning appropriate postoperative rehabilitation activities helps patients optimize surgical outcome.