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This is necessary for both in and out patients. In–patients may be in a special ward, intensive care unit or a regional burns unit. The last is best because the patient receives highly specialist attention. The physiotherapist together with other team member must recognize the devastating effect a bad case of burning can have on the family. It is important to recognize moods of guilt, depression, anger, bewilderment and bitterness which can arise in the patient and family. The cause of the accident clearly has a bearing on these moods. The physiotherapist has to gauge what is the appropriate reaction–sympathy, cajoling, encouragement or optimism whilst achieving the aims of treatment. Given the long–stay nature of the recovery period, staff and patients develop a special relationship which must remain professional for the emotional well–being of all concerned.

Respiratory Care
Clearing secretions is achieved by shaking, clapping, postural drainage, coughing and suction. If it is very uncomfortable for the patient to have hand pressure on a chest burn, then a piece of foam may be used under the hands. Tipping is contraindicated if there is facial edema but the patient may lie supine or on either side. A ventilated patient usually requires suction and humidification. A little treatment, often, is the general theme. Steam inhalations may be necessary for the non–ventilated patient especially when there has been inhalation of smoke or fumes. Breathing (expansion) exercises are also important to maintain ventilation of all lung areas. The physiotherapist must not be afraid to treat with the vigor required to achieve the aims even when the chest skin is burnt.
Intensive respiratory care is required in the following situations:
  1. Elderly patients.
  2. Burns affecting face, mouth and inhalation burns.
  3. Immobile patients.
  4. A history of a chronic respiratory condition.
  5. Pre–and post–operatively.
  6. Patients with full–thickness burns on the chest–breathing exercises to keep the eschar mobile.
Prevention of Contractures and Deformities
Positioning, splinting and exercise are used for maintaining and gaining joint range.

Positioning
Unfortunately for the patient, the position of comfort is the position of contractures (mostly flexion). Positions of necessity are, therefore, as follows.

Head and Neck
Joint Range prevention Joint Range prevention
Small roll (towel) under the neck and/or a pillow under the shoulders to maintain extension. The patient may be in lying (chest and leg burns) or in half–lying with facial burns (because of facial edema)... Upper limbs.

Elevation (over 900) of the limbs with the shoulder in abduction and slight flexion, elbows and wrists in extension, metacarpophalangeal joints in flexion, IP joints in extension and thumb in abduction.

Lower limbs
Hips in extension and slight abduction, knees in extension and ankles in 900 dorsiflexion. Elevation is obtained by raising the end of the bed, not by placing pillows under the legs which would put the hips into flexion.


Splinting
Splints may be static or dynamic.

Static Splints
Static splints are used where it is essential to hold the position until movement can start.These are designed and made to individual requirements and changed as the patient recovers, e.g. from grafting. Splinting may be required only at night to prevent soft–tissue tightening whilst the patients is asleep. Sometimes joints are stabilized to facilitate the function of others.

Dynamic Splints
Dynamic splints permit controlled movement of various joints. For example, a foam roll placed in the hand allows extension and some flexion of the fingers, so allowing damaged extensor tendons to move in a limited range but not to be overstretched. Collars may be necessary to keep the neck positioned because the skin on the anterior aspect of the neck contracts very readily, pulling the lower jaw down to the chest. A soft material may be adequate for dynamic and a firmer one used at night.

General points for splinting Exercises
Every joint should, where possible, be moved through full range each day. An active exercise programmes must, therefore, be devised to achieve this. Assisted active exercise is necessary for the damaged limbs and free active exercise for undamaged areas. Hourly should be performed to reduce edema so that this does not consolidate and cause joint stiffness. During bath time, the patient is immersed in plain water with baby shampoo and it is very useful to have physiotherapy incorporated. Joints can be moved through full range and the patient’s sense of well–being is greatly enhanced, movement being a comforting contrast to recumbence. This can be started 2–3 days after injury and may take place every 2–3 days thereafter.

Regaining range when the surgeon decides mobility should start involves controlled passive stretching, hold–relax, repeated contractions and assisted active exercises. As soon as possible the patient must be encouraged to be independent in self–care and activities of daily living.

Muscle Strength
Where joints can be moved, the patient must work the muscles for each joint through full range twice a day. Muscle working over joints which are fixed can be worked isometrically, either by having the patient feel the muscle tightening or by overflow from muscle working in the same pattern, e.g. manual resistance to the knee extensors can produce overflow into the ankle dorsiflexors–or strong work in the muscles of one leg causes work in the muscles of the other leg. Both arms can be resisted to obtain overflow into the trunk muscles. As soon as possible the patient should be up and about and following an exercise/activity programmes in the gym and hospital locality.

Regaining maximum function
As soon as the wound condition is stable, the patient should go to the physiotherapy gym. Dressings are bandaged on securely and lower limb burns are supported by elastic bandages to control edema. An individual circuit is worked out which involves free exercise and equipment work. Goals should be set, e.g. so many miles on a cycle, so many repetitions without rest on skipping, spring work or ball bouncing, jumping a height, reaching a grip strength by a given time (in weeks). This programmes continues to discharge with modifications following grafting. Trips to the hospital shop and then to neighboring shops and pubs should be included so that the patient starts to feel like a member of society again. Discharge home is arranged as soon as patient and relatives are ready.

Out–patient physiotherapy
This continues to involve gym work. Contractures must be prevented by regular passive stretching, and mobility of scar tissue is maintained by kneading with the fingers of palm of hand. Pressure garments are fitted by the physiotherapist. These are used to reduce hypertrophic scarring which is excessive formation of collagen resulting in thick, rope–like, uneven scars which both limit function and look unsightly. Pressure by an elasticated garment worn more or less continuously for up to 2 years reduces this scarring.

Smaller burns
These may be treated by physiotherapy on an out–patient basis. Pulsed electromagnetic energy twice daily for 25 minutes has been shown to promote healing and there is some evidence that laser treatment increases the rate of wound healing and reduces pain. Active exercise is just as important for small burns as for larger ones so that scar tissue is kept mobile and prevented from causing adhesions between fascia, tendons, muscles and periosteum.

Grafting
Skin grafts
Skin grafts may be used for any part of the body in areas where there has been extensive damage by burns, lacerated wounds, ulceration, pressure sores, or for healed contracted scars.
Types of skin graft are
  1. Free grafts.
  2. Flaps and pedicles.
Free grafts
These consist of slices of skin removed from one part of the body and applied to a raw surface in another part. They vary in thickness. Split–skin varies from very thin to consisting of the whole epidermis and part dermis. Whole–thickness (Wolfe) consists of the skin down to but excluding superficial fascia. These grafts are transferred without blood supply. For the first 48 hours nutrition is obtained from free tissue fluids of the recipient site. Capillaries grow into the graft and vascularization is generally established after 48 hours.

This is a critical time because movement of the graft destroys the capillary buds, and then the graft usually fails. dressings fixing the graft many be kept on for up to 5 days at which time active exercise of the area may start. After about 14 days, the graft begins to contract and there is danger that it will become adherent to underlying tissues. Donor sites heal in 12–14 days depending on the thickness. A donor area used for full–thickness skin has to be covered by a split–skin graft.
Flaps and Pedicles
With these, the skin to be transferred remains attached one end to the donor area and the other end is attached to the recipient site. A pedicle may have intermediate as well as a final recipient site. A blood supply to these grafts is preserved throughout the procedure. Three weeks elapse between each stage so the patient is fixed in an awkward position for this time.

Free flaps may be used. In these, the skin is raised, together with its blood vessels which are then anastomosed with vessels of the recipient area. These operations are performed with the use of a microscope–hence the term micro–surgery. The operation is long and exacting for the surgeons but the patient is saved the distress and pain of fixation for 3 weeks at a time as a time as required for fixed flaps and pedicles.

Physiotherapy for skin grafts
The graft
Graft Graft
Once the grafted skin is established–at least 14 days later, finger kneading round the edges with lanolin is used to mobilize the tissues. The donor area of a split skingraft may be treated with ultraviolet rays (UVR) to promote healing 3–4 days after operation. An E1 is given to the area (often the anterior aspect of the thigh) which is screened to within 2–3cm of the actual site. The air–cooled mercury vapor burner is used at a distance of 45 cm and a daily treatment for 3–4 days is usually sufficient for healing to occur. This is helpful when the donor area may be needed again.

Where a graft has ‘Taken’ in all but UVR using either the Kromayer or the air–cooled mercury vapor burner to encourage epithelialization of the raw area. This has particular value in preventing the need for further surgery. Irradiation of the graft may or may not be considered wise–this is a matter for discussion between the surgeon and the physiotherapist. UVR is sometimes also given to an infected area to clean the surface prior to grafting .

Joints and muscles
Joints and muscles near the graft should be exercised through as full a range as possible and all other joints and muscles should be put through a general full–range movement programmes. The muscles near the graft over the immobilized joints should be moved isometrically, e.g. five contractions per muscle every hour. This eases some of the discomfort and maintains fluid flow through the tissues. These exercises usually start 5–7 days after grafting.

When a flap or pedicle is released, heat, kneading, hold–relax or mobilization may be used to relieve pain and relax muscle spasm. Free active exercises should start within a day or two after release. If heat is used, it must not irradiate the flap, pedicle o grafted surface, as the heat increases metabolism of these delicate tissues beyond the scope of the developing blood vessels.


First Aid & Management after Burns
First Aid
Flame Burns
These occurs when the patients is caught by fire e.g., in a house or in a car. Flames must be smothered with blankets or carpets. Cold water applied continuously over the burnt area relieves pain & limits the depth, because heat is conducted to the deeper tissues for several minutes after the flames have been extinguished.

Chemical Burns
Caustic substances cause partial thickness burns. Copious quantities of running water must be applied to the area, except where the burn is due to sodium or potassium. There metals must be pushed off the skin with a matchstick or picked off with forceps.

Scalds
Hot water is the commonest case of scalds. Again, running cold water can limit the extent of damage & reduce the pain.

Electrical Burns
Due to contact with the live wire, electrical burns can occur which can further cause cardiac/respiratory problems. The patient may require mouth to mouth respiration & external cardiac massage. The patient should be transported to the hospital as quickly as possible.

Hospital Management
Minor Burns: Major Burns: A. Early Management: B. Management after 3–4 days: