Current Concepts Burn Rehabilitation, Part I: Care During Hospitalization

Effect of a Nurse-Led Rehabilitation Program: A Quasi-Experimental Study Examining Functional Outcomes in Patients With Hand Burns

PURPOSE

The model of early rehabilitation for people with burns is still relatively novel in developing countries such as Egypt. The study examined the effect of a nurse-led rehabilitation program on functional outcomes in patients with severe hand burns.

DESIGN

A quasi-experimental design was used in this study.

METHODS

The study was completed in the burn unit of a teaching university hospital in Alexandria, Egypt, with a convenience sample of 80 patients with severe hand burns. Participants were consecutively assigned to one of two groups: control ( n = 40), which received only routine hospital care and clinical interventions, or intervention ( n = 40), which received routine hospital care and clinical interventions and a 4-week nurse-led rehabilitation program (health education including audiovisual aids and burn rehabilitation education booklet, social support, and hand rehabilitation exercises). To assess functional outcomes, both groups were given pre- and posttests of the Disabilities of the Arm, Shoulder and Hand outcome and the Hand Motor Function Observational Checklist questionnaires. Descriptive and inferential statistics were conducted.

RESULTS

Functional outcomes were significantly improved in the intervention participants compared to the control participants ( t = 5.710, p < .001). The differences in index scores between the two groups were statistically significant ( p < .001).

CLINICAL RELEVANCE

The study provides information for burn rehabilitation nurses in developing countries to develop and test early interventions that improve functional outcomes in this population.

CONCLUSIONS

A 4-week nurse-led program may be a beneficial intervention for improving functional outcomes in adult patients with severe hand burns who are undergoing rehabilitation.

Inpatient Rehabilitation Following Burn Injury

Inpatient rehabilitation confers excellent benefit to burn survivors and should be considered as a potential destination during discharge planning. Consulting physiatrists identify and manage complications within the inpatient rehabilitation setting. Interventions can be taken to address medical sequelae of injury, including pain, itch, neuropathy, psychological coping and mood, and nutritional needs. Physiatrists also oversee and direct a rehabilitation program focusing on scar management, contracture prevention, dysphagia treatment, and evaluation and treatment of cognitive impairments. Aerobic and resistive exercise are key components of an inpatient rehabilitation program to reduce the systemic impact of a burn injury and improve quality of life.

Rehabilitation Management of the Burned Hand

Burns to the hands constitute a small total surface area burn, but can result in significant functional challenges and disability. The complexity of multiple anatomical structures and intricate interplay of bones, muscles, and connective tissues requires specialized knowledge of how burns of the hand can affect function and independence. This article will provide an evidence-based overview of rehabilitation of the burned hand across the burn care continuum including a focus on evaluation, pain management, treatment interventions, and outcome assessment. Additionally, various deficits that can put the hand at significant risk for loss of function will be discussed. Finally, the authors will address the special considerations and treatment caveats of addressing the pediatric hand burn.

Key Exercise Concepts in the Rehabilitation from Severe Burns

This article presents information on the benefits of exercise in counteracting the detrimental effects of bed rest, and/or severe burns. Exercise is key for maintaining physical function, lean body mass, metabolic recovery, and psychosocial health after major burn injuries. The details of an exercise training program conducted in severely burned persons are presented, as well as information on the importance of proper regulation of body temperature during exercise or physical activity. The sections on exercise and thermoregulation are followed by a section on the role of exercise in scarring and contractures. Finally, gaps in the current knowledge of exercise, thermoregulation, and contractures are presented.

Early Mobilization, Early Ambulation, and Burn Therapy in the Acute Hospital Setting

Rehabilitation therapies in the burn acute care environment continue to evolve. Immediate access to therapy is considered standard, and therapy is a key component of the transprofessional care team. Early positioning, edema management, and therapy care in the intensive care unit (ICU) environment can limit later complications; mobility in the ICU can be engaged safely using a systems-based approach in the absence of nondirectable agitation. Later in the course of acute care, early ambulation is an appropriate intervention that can improve outcomes.

Efficacy of a Novel LAM Femoral Cutaneous Block Technique for Acute Donor Site Pain

Patients with severe burn injuries often require split-thickness skin grafting to expedite wound healing with the thigh being a common donor site. Uncontrolled pain is associated with increased opioid consumption, longer lengths of stay, and delay in functional recovery. Peripheral nerve blocks are increasing in popularity although supportive literature is limited, and techniques vary. The purpose of this case series is to assess the safety, feasibility, and clinical efficacy of a recently demonstrated novel continuous LAM (lateral, anterior, medial) femoral cutaneous block technique in a larger cohort. The study was a dual IRB approved, observational case series from a single verified burn center. The electronic health record was retrospectively reviewed for patients admitted between June 2018 and May 2021 who had the continuous LAM block performed for donor site pain by the acute pain service team. Demographics were reported with descriptive statistics and morphine milligram equivalents (MME) were analyzed via Friedman analysis of variance. Forty-seven patients had a total of 53 blocks placed, where 2 patients received the LAM block on two separate occasions and 4 patients had bilateral LAM blocks placed. Most were African-American males, but mechanism of injury varied. Over half had a neurologic (17%) or psychiatric history (34%) outside of substance use. Almost three-quarters had a history of substance use with 17% being opioids, and a quarter had a history of polysubstance use. Median day from admission to LAM was 7 (2.5, 11.5) with a median duration of 4 (3, 5) days. Temperature and pressure sensation were reduced at the donor site. Quadricep strength remained intact, and median day until first ambulation after LAM placement was 2 (1, 3) days. Pain was adequately controlled, and there were no significant adverse events associated with the block. There was a significant reduction in MME after block placement (p < .001). Continuous peripheral nerve blocks offer an advantageous means of analgesia, while reducing potential adverse events associated with opioids or multimodal regimens. The novel LAM technique reduced sensation and pain without inhibiting early ambulation, and patients were able to fully participate in their rehabilitation.

Secondary injuries caused by ill-suited rehabilitation treatments: Five case reports

BACKGROUND

Increasing attention is being given to burn rehabilitation, and an increasing number of burn patients are undergoing rehabilitation. However, little attention has been given to secondary injuries caused by ill-suited rehabilitation practices. Patients, especially those in undeveloped countries, sustain injuries due to inadequate burn rehabilitation practices and the nonstandard implementation of rehabilitation treatments.

CASE SUMMARY

This study reports 5 cases of secondary injuries caused by ill-suited burn rehabilitation practices in our institute, including first web space contracture caused by a single orthosis treatment, finger deformity caused by improper compression therapy with a self-adhering bandage, developmental impairment of the affected limb caused by continuous improper compression therapy, and fracture caused by overly intensive rehabilitation exercise.

CONCLUSION

More attention should be given to burn rehabilitation to reduce the incidence of secondary injuries caused by ill-suited rehabilitation practices. Burn rehabilitation system should include specialized hospitals (burn rehabilitation centers), community hospitals, and family rehabilitation clinics. Precise instruments and equipment, accurate measurement methods, objective monitoring indicators and standardized guidelines and recommendations will help improve the quality of burn rehabilitation. Additionally, more attention should be given to burn rehabilitation in children.

Recommendations for burns care in mass casualty incidents: WHO Emergency Medical Teams Technical Working Group on Burns (WHO TWGB) 2017-2020

Health and logistical needs in emergencies have been well recognised. The last 7 years has witnessed improved professionalisation and standardisation of care for disaster affected communities - led in part by the World Health Organisation Emergency Medical Team (EMT) initiative. Mass casualty incidents (MCIs) resulting in burn injuries present unique challenges. Burn management benefits from specialist skills, expert knowledge, and timely availability of specialist resources. With burn MCIs occurring globally, and wide variance in existing burn care capacity, the need to strengthen burn care capability is evident. Although some high-income countries have well-established disaster management plans, including burn specific plans, many do not - the majority of countries where burn mass casualty events occur are without such established plans. Developing globally relevant recommendations is a first step in addressing this deficit and increasing preparedness to deal with such disasters. Global burn experts were invited to a succession of Technical Working Group on burns (TWGB) meetings to: 1) review literature on burn care in MCIs; and 2) define and agree on recommendations for burn care in MCIs. The resulting 22 recommendations provide a framework to guide national and international specialist burn teams and health facilities to support delivery of safe care and improved outcomes to burn patients in MCIs.

Return to employment for working-aged adults after burn injury: a scoping review protocol

INTRODUCTION

Cutaneous burns can have a catastrophic effect on people's lives and may restrict opportunities for employment due to physical impairment and psychosocial deficits. Failure or delay in return to work can result in loss of income and support for the family unit. It can also negatively affect life role and identity and present difficulties with future opportunities. Current literature indicates multiple discrete influences on return to work as a result of burn injury but an understanding of how working-aged adults resume employment after burn injury is lacking. This scoping review will provide a comprehensive overview of the current literature by mapping and consolidating knowledge in this area of burn recovery and thus provide an informative basis for developing return-to-work programmes for survivors of burn injury.

METHODS AND ANALYSIS

This scoping review protocol will follow the Arksey and O'Malley's (2005) methodological framework. A comprehensive search strategy has been developed with subject expert librarians. These databases were used: OvidSP: Medline, Embase, PsycINFO, PubMed and Cochrane Central Register of Controlled Trials and EBSCOhost: CINAHL and Scopus. Reference lists of selected full text will be hand searched for additional literature. To enhance consistency and rigour, all reviewers will undertake a calibration exercise before paired reviewers independently screen all records using Rayyan. Full-text articles meeting the study inclusion criteria will be retrieved and examined. Extracted data will be analysed using the International Classification of Functioning, Disability and Health.

ETHICS AND DISSEMINATION

Ethics approval is generally not required for scoping reviews. Findings of this scoping review will be reported in a peer-reviewed journal and presented at conferences.

Rehabilitation of Burn Injuries: An Update

A major burn is a severe injury with a global impact. Our system of medical evacuation has led to the survival of many severely injured service members. Burn rehabilitation is a complex and dynamic process and will not be linear. Recovery requires a comprehensive, interdisciplinary team-based approach, individually designed to maximize function, minimize disability, promote self-acceptance, and facilitate survivor and family reintegration into the community.