Burns and Burn Rehabilitation

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There are three types of burn injuries:
1. Thermal – caused by heat sources such as flame, steam, hot liquid, hot surfaces, or radiation.
2. Electrical – caused by contact with active electrical sources.
3. Chemical – caused by contact with an acidic or alkaline substance.

The severity of a burn depends on the part of the body burned, as well as the duration and intensity of exposure to the burn source. When a burn occurs, the injury is classified by severity and total body surface exposed.

Burn Severity (Degrees)

Degree of Severity	Description	Photo
First degree	A superficial burn that only affects the top layer of skin (epidermis). -no blistering -painful, red skin -heals in 3-4 days
Second degree	The burn extends below the top layer of skin (epidermis) into the layers below (dermis). -blistering -top of blisters consist of dead skin. . There are two types of second degree burns: . 1. Superficial Partial Thickness – extend through the first half of the dermis. -pink, painful, moist skin under the blisters -heal in 7-21 days -no to minimal scarring or impairment . 2. Deep Partial Thickness – extend into the second half of the dermis. -cause skin color to change, scarring -heal in 3-5 weeks -may acquire scar management
Third Degree     * Fourth Degree	The burn extends all the way through all layers of skin. -white, brown, black or cherry red in appearance -may or may not have blisters -require specialized treatment and possibly surgery  . . . Some literature defines fourth degree burns as burns that extend into the fat tissue, muscle and bone. -Charred in appearance. -Often requires amputation of the affected limb. -Survival rate is low.

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Exposed Body Surface

Classification Method	Description	Examples
Wallace Rule of Nines	Body surface area is divided into sections that comprise 9% of the surface. -accurate for people of normal weight -other percentages have been proposed for people who are obese -can only be used with adults, as children have different body proportions	Head and neck = 9% Each upper extremity = 9% Each lower extremity = 18% Front of trunk = 18% Back of trunk = 18% Perineum = 1%
Lund and Browder Chart	Body surface is divided into body segments. -percent of body surface affected is calculated with adjustments for age -differentiation between partial thickness burns and full thickness burns is included

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Phases of Wound Healing

Phase	Duration	Description	Photo
Inflammatory Phase	From onset of burn to 3-10 days after onset.	Injury is painful, red, and warm. Edema develops.
Proliferation Phase	From about the 3rd day after injury until burn is healed.	Injury remains red, rigid scars may develop. -revascularization, re-epithelialization, and contraction of the injury take place.
Maturation Phase	From about the 3rd week after onset to 2+ years after onset or reconstructive surgery.	Redness fades, scars soften and flatten. -collagen remodeling occurs -tensile strength of scar increases to up to 80% of original tensile strength of skin

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Medical Management of Burn Injuries

Phase of Recovery	Duration	Goals of Medical Treatment	Photo
Emergent Phase	Onset of burn to restoration of capillary function. Often occurs at the site of the injury.	-stop burn, contain and cover wound to prevent infection -prevent shock -preserve vital organ function
Resuscitative Phase	From initiation of fluid replacement to return of capillary integrity to normal or near normal levels.	-replace fluids and end fluid shifting -prevent shock -maintain adequate circulation -maintain vital organ function
Acute Phase	From the first 72 hours after injury until the burn wound is completely closed.	-facilitate closing of wound. May include surgery and post-operative care. -prevent infection -reduce edema -prevent loss of joint and skin mobility -prevent loss of strength and activity tolerance -provide cognitive reorientation and psychological support -promote independence during self care skills -provide patient and caregiver education
Rehabilitative Phase	Overlaps the acute phase, begins with wound closure and ends when patient has achieved maximum function.	-scar management -prevention of contracture and deformity -improve joint mobility -restore muscle strength, coordination and activity tolerance -promote independence in self care tasks and IADLS -continued psychological support -continued patient and caregiver education with post -discharge planning

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Occupational Therapy Intervention for Burns

The following charts will review occupational therapy evaluation and treatment for second degree superficial partial thickness burns, second degree deep partial thickness burns, and third degree burns. Professional treatment is not usually needed for first degree burns.

Second Degree: Superficial Partial-Thickness Burns

Area of Function	Evaluation	Treatment	Photo/Video
Occupational history and roles	1. Obtain information from patient, family/caregivers, medical chart. 2. Document medical history, living situation, any social or environmental points of importance. 3. Obtain patient’s occupational history in work, self care and leisure. Document patient’s prior status and patient’s goals when therapy complete. 4. May use formal assessment tools: -Canadian Occupational Performance Measure.	1. Develop long term goals to achieve the patient’s desired outcomes related to occupational performance. 2. Modify goals based on any potential limitations or unrealistic expectations, based on observations and family/caregiver input.
Range of motion	1. Informal screening or formal goniometer measurements depending on the severity of the burn. 2. Assessment of wound and developing scar tissue, especially across joints. 3. Assessment and measurement of edema. 4. If surgery was completed, evaluate range of motion 72 hours post-op.	1. Edema control -elevation and positioning -coban wrap or compression garment when wound closed. 2. Wound care-sterile whirlpool -wound debridement if necessary to promote development of healthy tissue -dressing changes 3. Active and passive range of motion. Exercises as patient will tolerate. 4. Splinting to stretch and remodel scar tissue if necessary.
Sensation	1. Evaluate sensation when wound is healed. 2. Test sensation in and around affected area -occlude vision -cotton swab to test light touch -pencil eraser to test deep pressure -safety pin to test pain -hot/cold tubes to test temperature -small objects to test stereognosis -tuning fork to test vibration 3. Semmes-Weinstein monofilament test.	1. Complete stimulation activities to affected area when wound is healed. 2. Fluidotherapy at lower temperatures if wound is on hand or lower arm. 3. Immersion in textures as patient will tolerate. -sand -rice -beans -soft textures 4. Brushing, vibration as patient will tolerate if wound is not on the hand or lower arm. 5. Massage to affected area when wound is healed. 6. Stereognosis activities if wound is on the hand.
Strength	1. Evaluate strength when wound is healed. 2. Manual Muscle Test 3. Dynamometer and pinch meter measurements	1. Introduce strengthening to treatment when wound is healed if necessary – superficial burns may not impair strength. 2. Graded strengthening exercises as patient will tolerate.
ADLs and IADLs	1. Observation of self care tasks if possible. 2. ADL/IADL assessment -Klein-Bell ADL Scale -Functional Independence Measure (FIM) -Assessment of Motor and Process Skills (AMPS)	1. Begin ADL treatment as soon after onset of injury or surgery as possible. 2. Introduce IADLs as patient will tolerate. 3. Work and driving assessments if necessary.

Second Degree: Deep, Partial-Thickness Burns

Area of Function	Evaluation	Treatment	Photo/Video
Occupational history and roles	1. Obtain information from patient, family/caregivers, medical chart. 2. Document medical history, living situation, any social or environmental points of importance. 3. Obtain patient’s occupational history in work, self care and leisure. Document patient’s prior status and patient’s goals when therapy complete. 4. May use formal assessment tools: -Canadian Occupational Performance Measure.	1. Develop long term goals to achieve the patient’s desired outcomes related to occupational performance. 2. Modify goals based on any potential limitations or unrealistic expectations, based on observations and family/caregiver input.
Range of motion	1. Informal screening or formal goniometer measurements depending on the severity of the burn. Measure limitations across affected joints. 2. Assessment of wound and developing scar tissue, especially across joints. 3. Assessment and measurement of edema. 4. If surgery was completed, evaluate range of motion 72 hours post-op.	1. Edema control -elevation and positioning -coban wrap or compression garment when wound closed. 2. Wound care -sterile whirlpool -wound debridement if necessary to promote development of healthy tissue -dressing changes 3. Active and passive range of motion. Exercises as patient will tolerate 4. Splinting to stretch and remodel scar tissue
Sensation	1. Evaluate sensation when wound is healed. 2. Test sensation in and around affected area -occlude vision -cotton swab to test light touch -pencil eraser to test deep pressure -safety pin to test pain -hot/cold tubes to test temperature -small objects to test stereognosis -tuning fork to test vibration 3. Semmes-Weinstein monofilament test. 4. Pain scale, especially if nerve damage is present.   5. May want to assess patient’s psychological status.	1. Complete stimulation activities to affected area when wound is healed. 2. Fluidotherapy at lower temperatures if wound is on hand or lower arm. -patients with nerve damage resulting from the burn may not tolerate fluidotherapy 3. Immersion in textures as patient will tolerate.-sand -rice -beans -soft textures -start with easy to tolerate textures and grade upward 4. Brushing, vibration as patient will tolerate if wound is not on the hand or lower arm. 5. Massage to affected area when wound is healed. 6. Stereognosis activities if wound is on the hand.	A demonstration of upper extremity sensation testing.
Strength	1. Evaluate strength when wound is healed. Follow physician’s protocol if surgery was completed. 2. Manual Muscle Test 3. Dynamometer and pinch meter measurements	1. Introduce strengthening to treatment when wound is healed. 2. Graded strengthening exercises as patient will tolerate. 3. Strength will improve slowly in relation to nerve regeneration if nerve damage is present
ADLs and IADLs	1. Observation of self care tasks if possible. 2. ADL/IADL assessment -Klein-Bell ADL Scale -Functional Independence Measure (FIM) -Assessment of Motor and Process Skills (AMPS)	1. Begin ADL treatment as soon after onset of injury or surgery as possible. 2. Introduce IADLs as patient will tolerate. 3. Work and driving assessments if necessary.

Third Degree Burns

Third degree burns often require surgery, hospitalization, or both. The following chart reviews general principles for occupational therapy evaluation and treatment for third degree burns.

Fourth Degree Burns

Fourth degree burns are burns that have burned through to the fat, muscle, and bone. They do not heal and repairing them is difficult. Treatment for fourth degree burns is often not required because people do not often survive fourth degree burns. The survival rate improves if the burn is on a limb that can be amputated. In this case, occupational therapy treatment would proceed in the same manner as that for amputations.

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Considerations for Burns to Specific Parts of the Upper Body

This link refers to a document with pictures and examples of positioning for various parts of the body.

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Types of Scars

Scarring is common with burn injuries. The following chart reviews the types of scars.

Type of Scar	Description	Treatment	Photo
Hypertrophic	Thick, rigid scars that are red in color and appear 6 to 8 weeks after the wound closes. Hypertrophic scars are confined to the burned area. Most second degree deep partial-thickness burns and third degree burns develop this type of scarring.	-Positioning with the scarred area in extension to stretch tissue -Topical medications and dressings -Splinting -Pressure wraps or garments -Massage when tissue has healed
Keloid	Very thick, raised scars that extend beyond the burned area and are red or pink in color. These scars are caused by an overgrowth of scar tissue and usually start forming about 3 months after the burn onset.	-Pressure wraps and garments -Topical and injectable medications -Steroid injections -Cryotherapy -Laser treatments -Surgery
Contracture	Scar tissue that forms near or across a joint, causing the skin to tighten and pull. This scarring can limit the range of motion in the affected joint. Heterotopic ossification – a condition that can occur after severe burns, in which bone forms on the outside of the affected area. This can cause any joints affected to become immobile. The use of passive range of motion for heterotopic ossification has conflicting results in the research literature. Active range of motion is consistently used and supported by the research.	-Positioning with the joint in extension -Splinting -Pressure wraps or garments -Passive and active range of motion. Treatment for heterotopic ossification – active range of motion within pain tolerance, passive range of motion according to physician’s instructions. Home active range of motion program.

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Positioning and Splinting for Burns

This chart will review the types of contractures that may result from burns and the positioning/splinting used to prevent or minimize those contractures. Splinting prior to wound healing must be completed following physicians’ precautions to ensure the wound is not compromised. Splinting after wound healing follows guidelines to reduce scarring and contracture. It is important that splints have a close, contoured fit to help remodel scar tissue and prevent pressure areas. Splints for closed wounds often include silicone materials or silicone inserts to help reduce the effects of scarring.

Part of Body Burned	Type of Contracture	Positioning or Splinting	Photo
Wrist – Volar Surface	Flexion	Splint wrist in 30 degrees of extension
Wrist – Dorsal Surface	Extension	Splint wrist in 30 degrees of extension
Hand – Dorsal Surface or Circumference	Hyperextension of the PIP or DIP joints.	Splint with MCP joints in 50 to 70 degrees of flexion, IP joints in extension, thumb in abduction and extension
Hand – Palmar Surface	Cupped hand	Splint with MCP joints in full extension, IP joints in full extension, thumb in horizontal abduction
Hand – Thenar Space (first web space)	Limitations in thumb opposition and abduction	C-bar splint that positions the thumb in abduction and extension
Pectoral region	Shoulder protraction	1. Position shoulders in abduction and external rotation. Remove pillow from bed. 2. Place a rolled towel vertically down the spine with patient in supine. 3. Clavicle strap
Chest or abdomen	Kyphosis – upper spine flexed	Position shoulders in abduction and external rotation with shoulders retracted and trunk in extension. Bed should be flat with no pillow.
Lateral Trunk	Scoliosis – spine flexed laterally	Position in supine with the arm on the affected side abducted.
Hip	Internal rotation, flexion and adduction of the joint with subluxation if contracture is severe	1. Position with hip in neutral rotation, abduction, and mild extension. Patient should be in prone or in supine with a pillow under the buttocks. 2. Hip abduction pillow as needed.
Knee – Popliteal surface or circumferential	Flexion	1. Conforming knee immobilizer 2. Elastomer splint 3. Foot of bed flat with no pillows under the leg.
Ankle	Plantar flexion resulting from weakness or divided tendons in dorsiflexor muscles.	1. Splint in 90 degrees of dorsiflexion 2. Position with footboard and cushioning pillows at the foot of the bed.