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CHAPTER25 Skin substitutes
Further reading
Jansen LA, De Caigny P, Guay NA, et al. The evidence base for the acellular dermal matrix
AlloDerm:a systematic review. Annals of Plastic Surgery 2013;70:587– 94.
Nicoli, F, Rampinelli, I, Godwin, Y. The application of Integra in a challenging context. Scars, Burns &
Healing 2016;2:2059513116672789.
Pham C, Greenwood J, Cleland H, Woodru P, Maddern G. Bioengineered skin substitutes for the
management of burns:a systematic revie w. Burns 2007;33:946– 57.
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Chapter26
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Occupational and
physiotherapy
Occupational therapy 214
The occupational therapy role 216
Physiotherapy 218
The physiotherapy role 220
Reference 223
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CHAPTER26 Occupational and physiotherapy
Occupational therapy
Burns as a specialty demands occupational therapy skills and experience
drawn from a variety of clinical areas, ranging from musculoskeletal through
to mental health, and covers both in- patient and out- patient care simultaneously. As part of the wider burns MDT, the occupational therapist is involved in the treatment of a patient from injury through to scar maturation,
or until adulthood in the case of paediatric patients.
The core values and beliefs of occupational therapy are epitomized
within the eld of burns. Patient treatment is based upon a wide range of
dierent methods and theories focused around a biopsychosocial model,
where promoting independence and enhancing function is the central aim
of therapeutic engagement. The diversity of injury and the subsequent consequences that can aect the patient are wide- ranging. Therefore, a unique
approach to each patient to address their needs, encourage function and
ultimately full realistic goals as individuals is key.
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OCCUPATIONAL THERAPY
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CHAPTER26 Occupational and physiotherapy
The occupational therapy role
Occupational therapy begins on admission to a burn ward or intensive care,
and continues long after discharge. Most of the treatment modalities employed are used within both in- patient and out- patient care.
Treatments and interventions:
• Splinting
• To prevent joint/ soft tissue and scar contractures
• Protect graft sites
• Increase range of movement (ROM)
• Improve function
• Compensatory movement splints to encourage or allow normal
movement including dynamic splinting
• Positioning
• To prevent graft/ scar contractures
• Functional rehabilitation
• Aim to increase independence in activities of daily living (ADLs)
• ROM and strengthening exercises centred around activity, eg.
facilitating ADLs, workshop, play
• Graded activity including some assisted activity
• Use of some compensatory techniques either temporary or
permanent, eg adapted cutlery, custom- made adaptations
• Specialized upper limb rehab using task simulation equipment
• Mental and cognitive stimulation activities to enhance mood and
thought processes
• Wheelchair assessment and provision
• Discharge planning
• Identication of appropriate discharge destination
• Equipment provision and minor adaptations to home
• Home visits
• Liaison with social worker and identication of care needs.
• Social re- integration, life readjustment, and psychological support, eg.
supporting and facilitating leaving safe ward environment, and coping
with reactions to injury
• Scar management— to begin as soon as clinically possible to gain
optimum results
• Encourage normal movement and use of body to minimize
contractures
• Application of pressure garments
• Use of silicone gels and conformers
• Massage
• Splinting:to prevent contracture, stretch existing scar, or serial
splinting
• Cosmetic camouage
• Referral onto other agencies, eg. orthotics, maxillofacial
• Outreach
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THE OCCUPATIONAL THERAPY ROLE
• Return to work/ life roles
• Includes heavy rehabilitation programmes as an out- patient
• Work place/ school visits
• Liaising with employers and schools to ensure correct levels of
support are in place to maximize patient independence and encourage
job retention
• Support with redeployment where necessary
• Referral onto relevant external agencies
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CHAPTER26 Occupational and physiotherapy
Physiotherapy
The survival rate of major burns has improved with recent advances in care
resulting in more complex rehabilitation needs. All burns, irrespective of
severity, have the potential to aect people physically and emotionally and
the physiotherapists’ role within the multidisciplinary team is to ensure as
good an outcome as possible in terms of movement, strength, function,
and aesthetics.
The physiotherapist will be involved with the burn- injured patient both as
an inpatient and an outpatient and will address the following aspects of care
as applicable to individual patient’s needs.
This chapter has been written in accordance with the British Burns
Association Therapy Standards1 and it is assumed that individuals will work
within the boundaries of their professional body and knowledge. It is imperative that burns patients are managed by experienced therapists who
are regularly involved in the care of these patients.
• The aims of physiotherapy intervention are to
• Maintain respiratory function
• Manage oedema
• Assist in management of pain, itch and sensation
• Maintain joint range of motion
• Maintain cardiovascular tness/ strength
• Aid functional independence
• Scarring
• Provide psychological support
The extent of physiotherapy intervention that is required is dependent
upon the extent/ depth of the injury, the surgery required and patients’
individual needs.
For a greater depth of understanding of the physiotherapists role within
the care of the burn- injured patient the British Burns Association Therapy
Standards1 can be reviewed.
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PHYSIOTHERAPY
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CHAPTER26 Occupational and physiotherapy
The physiotherapy role
Respiratory function
• The aims of physiotherapy interventions are to
• Maintain clear airways
• Remove excess secretions
• Improve gaseous exchange
• Prevent and treat atelectasis
• Physiotherapeutic interventions to aid respiratory function are
• Education
• Mobility
• Breathing exercises
• Chest manual techniques
• Humidication of oxygen
• Suction via a nasal or oral airway
• Positioning to aid drainage and/ or gaseous exchange
• Continuous positive airways pressure (CPAP)
• Intermittent positive pressure breathing (IPPB)
• Tracheostomy management
Manage oedema
Oedema control will prevent later complications of soft tissue adherence
and loss of joint range of motion. This is especially important with hand
burns but applies to all areas of the body. Techniques that aid oedema
control are
• Elevation
• Positioning
• Massage
• Compression
• Active exercise
Assist inmanagement ofpain, itch, and sensation
Pain can be a signicant issue during physiotherapy treatment sessions for
a burn- injured patient. Analgesia is crucial to promote patient involvement
and compliance. In addition to pharmacological management the physiotherapist can assist in pain control and later both itch and sensory disturbance can be addressed with therapy interventions.
Techniques that aid management of pain, itch and sensation are:
• Entonox
• Education, reassurance and distraction
• Splinting
• Exercise
• Massage
• Sensory re- education/ desensitization
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THE PHYSIOTHERAPY ROLE
Maintain joint range ofmotion
Skin contractures at specic anatomical sites are inevitable following burn
injury, eg. anterior/ posterior axillary folds. The physiotherapist will use
therapy interventions to limit these skin contractures and prevent them
developing into joint contractures where the joint structures (capsule, ligaments etc.) also become shortened and restrict joint range of motion.
Range of movement exercises are started as soon as possible following a
burn injury then adapted appropriately following surgical intervention.
Interventions
Positioning
The patient’s joints are positioned in anti- contracture postures between
exercise sessions to maintain soft tissue length. This can be achieved using
static splints or by advising on resting postures. It is important that the
whole team, relatives, and the patient are aware of optimal positioning to
maximize compliance.
Active exercises
This involves the patient actively moving their joints through full range of
motion. Active motion is the ideal therapeutic intervention as it maintains
soft tissue extensibility, maintains muscle strength, creates a muscle pump to
reduce oedema, maintains normal sensory motor feedback, and promotes
independence. An individual exercise programme should be developed for
the specic needs of each patient.
Passive exercises
This involves the physiotherapist moving the patient’s joints through normal
physiological range. This is necessary if the patient is ventilated or unable to
exercise independently due to lack of strength/ nerve palsy/ compliance. It
is useful for the physiotherapist to go into theatre when the patient is anaesthetized so range of movement can be assessed and stretches performed
without any distress to the patient.
Maintain cardiovascular tness/ strength
The longevity of burn care management plus the systemic eects of burn
injury will cause a reduction in cardiovascular tness and strength. The
physiotherapist will endeavour to maintain the patients’ tness and strength
during the acute stages of their injury and regain their previous level of
tness/ strength to as near normal as possible during the later stages of
rehabilitation.
Techniques that aid cardiovascular tness/ strength are
• Mobility
• Active exercise
• Strengthening
• Optimization of cardio tness
• Education to patients and their family
• Resistive exercise
• Functional exercise
• Proprioceptive neuromuscular facilitation
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