THE REHABILITATIVE MANAGEMENT OF BURN PATIENTS IN THE POST-ACUTE PHASE
Civaia A., Fedele C., Gallino A., Oliva R.
TDR Department, RRF, CTO Turin, Italy
SUMMARY. The greatest commitment in rehabilitation after a serious burn trauma is the achievement by the patient of maximum autonomy and functionality in order to guarantee the best possible quality of life in the social, family, and working environments. Three phases can be distinguished: the acute phase, the post-acute phase, and the chronic phase. This paper examines the post-acute phase, and in particular contraindications to kinesitherapy, bandaging and compression therapy, manual lymphatic drainage, and physical therapy.
Introduction
The most important rehabilitative commitment after a serious burn trauma is to guarantee to the patient maximum autonomy and functionality in order to ensure the best possible quality of life in the social, family, and working environments. To achieve this aim, physiotherapists use a wide range of techniques, such as kinesitherapy, and a number of devices. It is possible to distinguish three phases:
Acute phase. Prevention of:
articular limitations
muscle or tendon contractures
breathing complications
oedema
Post-acute phase. Aims:
recovery of muscular tone trophism
return of patient to normal overall condition
restoration of patient’s autonomy in shortest time possible (depending on pathology)
Chronic phase (sequelae). Aims:
scar prevention
treatment of orthopaedic sequelae
treatment of neurological sequelae
return of patient to social environment, family, and working life
In this paper we will consider the post-acute phase, i.e. the period when the burn patient is still in hospital but in the plastic surgery ward, and no longer in the intensive care unit. Once the acute phase is over, treatment will be oriented towards early neuromotor recovery in order to reduce the negative effects of overlong immobilization in bed.1,2
Contraindications to kinesitherapy
Poor general condition of the patient
Skin graft (at least 5-10 days of immobility are necessary; initiation of rehabilitation to be arranged with the plastic surgeon)
Presence of muscle or tendon injuries
Procedures
Various procedures are used:
Assisted active mobilization
Active mobilization
Mobilization against resistance
Dynamic proprioceptive re-education
Stretching
Postural sequences
Recommencement of standing (orthostatism)
Re-education for the recommencement of walking
Splinting
Exercises
Numerous exercises are available:
Exercises performed with the help of the physiotherapist in order to overcome loss of articular and muscular movement.
Exercises performed autonomously by the patient during the day in order to improve circulation and metabolic exchange.
Exercises performed against resistance by the therapist in order to counteract muscular hypotrophy and restore the memory of movements.
Exercises in cases of neurological injury in order to make movements that are as precise as possible, using the whole kinetic chain and not just single isolated movements (as recommended by Freeman, Perfetti, and Kabat.
Exercises for the passive connective and active muscular parts of the body.
Kinesitherapy allowing the patient analytic recovery of movement. Postural sequences are the next step (variation of decubitus: lateral, sitting with legs straight, sitting with legs out of bed); helpful aids are elastic bandages on the lower limbs in order to prevent circulatory disorders. The patient will need to learn to do all this by himself in the shortest amount of time possible to reach autonomy in moving between bed and wheelchair and consequently in personal cleanliness.
There are two possibilities, depending on the patient’s clinical conditions: a. transfer from bed to wheelchair; b. sitting up in bed. A long stay in bed requires exercises aimed at transferring weight distribution and controlling the trunk.
Various devices are used to assist walking in the early stages, an activity that gradually becomes once again autonomous. The physiotherapist plays an important role here: he or she teaches the patient how to walk, initially with devices and later weaning the patient from their use in order to achieve autonomous walking, if possible. Care must be taken when there are skin grafts and orthopaedic or neurological injuries. Walking helps to orient the positioning of grafted skin (Benninghoff).
Static-dynamic exercises counteract hypertrophy and scar contractures by using forces that release scar tension in a constant, continuous, and adjustable manner. Such exercises, in cases of neurological injuries, compensate for the loss of movement. Silicon may be interposed to increase compression at the level of the hand, palm, and back. This is very important from the acute phase on.3-6
Bandaging - compression therapy
In 1968 Fujimori demonstrated that a moderate and constant compression of burned skin prevents scar hypertrophy. When compression is applied early, it prevents the formation of nodules and collagen spirals within the scar and creates hypoxaemia in its vascular network: this causes precocious, artificial ageing that will determine an orientation parallel to the cutaneous surface of the collagen fibres.
Bandaging is applied:
in the acute phase, to prevent oedema
after skin grafting
in burns in the course of healing
during the chronic phase
Compression is applied as follows:
pre-packaged elastic girdle
elastic bandaging
elastic garments
silicon
Girdles are made of elastic tissue that counteracts scar hypertrophy. Girdles are made to measure in order to adjust tension and compression (care must be taken to ensure they are be correctly worn, in order to avoid any haemostatic effect).
Adhesive bandaging can be applied by the physiotherapist (this is useful also during postural sequences in the acute phase for the reduction of circulation disorders) before the use of girdles, since the adhesive bandaging can be applied directly on the dressing; the only disadvantage is a further reduction in range of motion.
Made-to-measure elastic-compressive garments are useful only in the post-acute phase when oedema has stabilized and the skin has healed. These garments require continuous checking of their continued effectiveness.
Compression needs to be continuous over time to be effective; the use of pads in the lower back and subscapular area can be considered - this requires careful hygiene and good patient compliance.
Silicon has flattening, hydrating, decongesting, and softening effects on the scar. It can be placed in between elastic girdles (costs, however, are high).
Massotherapy is another useful technique. Massotherapy:
Reorganizes the capillary network and local circulatory flow
Reduces oedema and itching
Makes the skin more elastic, frees adhesions, and makes the new skin stronger
Helps the patient to regain sensitivity
Relaxes neighbouring tissues
Massaging must be gentle and superficial. Connective tissue massage is important as it stimulates body areas by modifying their connective trophism through the reflected action of the skin’s sympathetic terminal reticulum. The daily use of rapidly absorbed hydrating lotions is recommended, as this prevents avoid maceration under the girdles.7
Manual lymphatic drainage
Manual lymphatic drainage has analgesic and immunological effects on the vegetative nervous system, as also on the musculature of blood and lymph vessels. This technique is required when there is impairment of venous and lymphatic circulation, with consequent oedema; it enables the lymph to flow - even by alternative routes - and thus prevents the creation of fibrous tissue and consequent sclerosis.
The association of various bandaging techniques cannot always be used since the scars may still be open.
Vegetative effect - the vegetative nervous system is composed of two antagonistic systems: the sympathetic and the parasympathetic nervous systems. The sympathetic nervous system prevails over the parasympathetic; manual lymphatic drainage acts on the latter, increasing its effect.
Analgesic effect. Manual lymphatic drainage can excite the cells that inhibit pain, thus reducing it (see the gate control theory).
Immunological effect. Manual lymphatic drainage permits an increase of the body’s defence mechanisms by activating lymph routes. This defence depends on resistance, i.e. the set of possibilities for reaction activated by the organism before an immune response.
Effect on smooth musculature of blood and lymph vessels. Manual lymphatic drainage acts by toning the smooth musculature of blood vessels at capillary level, through contraction of the pre-capillary sphincters. Blood pressure diminishes, thus determining emptying of tissues.8
Physical therapy
Ultrasounds: these improve the detachment of adherences and reduce oedema (they reduce fibrosis): 3 Hz, intensity 1.5 W/m2.
Transcutaneous electrical nerve stimulation (TENS): this is to decrease pain during the process of scar healing.
Vacuum therapy: this therapy uses different-size nozzles that go over all the scars lengthwise. The action is exerted on the circulation in the scar, by increasing and reducing pressure.
At the end of each treatment it is useful to make an overall evaluation. This includes:
cutaneous assessment (baths, surgery)
articular, neuromotor, and breathing assessment
assessment of functional recovery (functional independence rating), with particular reference to walking and management of personal care.8
Bibliography
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Combi F., Silvello L., Torelli L.: Trattamento riabilitativo del paziente ustionato. In: Donati L., Baruffaldi Preis F.W., B & G Editori, 1997.
Malik H.M., Carr A.J.: “Manual on Management of the Burn Patient”, Harmaville Rehabilitation Center, Educational Resource Division, Pittsburgh, USA, 1982.
Marichy J., Marduel Y.N.: “Rieducazione degli ustionati adulti”, E.M.C., Roma-Parigi Medicina, Riabilitativa, 1998.
Corso di perfezionamento in riabilitazione e ortesi della mano, Università degli Studi, Milan, June 1995.
Vallbona C.: Risposta del corpo umano alla immobilizzazione. In: Kottke, Stillwell, Lehmann: “Trattato di terapia fisica e riabilitazione”, Verducci (ed.), 1990.
Carr-Collins J.A.: “Pressure techniques for the prevention of hypertrophic scar”. Clin. Plast. Surg., 19: 733-43, 1992.
Leduc, Wodder: “Tecniche di Linfodrenaggio Manuale”. http://www.medbc.com/annals/review/vol_16/num_1/text/vol16n1p10.asp
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