Use of kinesio tape to promote function while improving resting position following superficial dermal burn to palm and fingers
Burn scar contractures are defined as an impairment caused by replacement of skin with pathologic scar tissue of insufficient extensibility and length, resulting in a loss of motion or tissue alignment of an associated joint or anatomical structure (Fig. 19.2; Richard et al. 2009). Contractures are a common problem following burn injury, with an incidence of 5–40 % in patients with burns reported across studies (Schouten et al. 2012). Contractures can occur not only in the extremities but also in regions such as the face, neck, and trunk. Hypertrophic scars with contracture have been found to develop earlier than hypertrophic scars without contracture and have a longer period to scar maturity. Burns of the lower limb have been found to be more likely to develop hypertrophic scarring as opposed to hypertrophic scarring with contracture, whereas neck burns have been found to be more likely to develop hypertrophic scarring with contracture than hypertrophic scarring alone (Gangemi et al. 2008). As discussed by Parry et al. (2010), assessing for trunk contracture is important as trunk mobility is likely to influence mobility of the extremities and overall function, although a survey to the occupational therapy and physical therapy special interest group of the American Burn Association (ABA) indicated the majority of therapists surveyed (56 %) did not assess for trunk contracture (Parry et al. 2010).
Contractures to wrist and fingers because of hypertrophic scarring
Minimizing contractures generally involves positioning of the actual joint. Positioning promotes extension and abduction (Fig. 19.3). Specific injuries require an individualized approach (Serghiou et al. 2012). Prophylactic splinting is rarely required, except if tendons are exposed or to prevent equinus deformity from prolonged bed rest (Spires et al. 2007). In this case, the ankles are positioned in a neutral position and ranged twice daily.
Anti-deformity positioning from the onset of burn care
Splinting of the burned area may be undertaken using a range of media (foam, thermoplastics, neoprene, and custom-made metal devices; Richard and Staley 1994). The time needed for use of both pre- and postsurgical splinting depends on factors such as the client’s age, the length of time since burn injury, and the severity of the deformity (Esselman et al. 2006). Prolonged static splinting is often commenced following skin grafting procedures, but more intensive therapy should be started within 2–3 weeks with the splint removed for each session. Six weeks after the surgery, night splinting alone should be sufficient and may need to be continued for 1 or 2 years (Schwarz 2007). If full range of motion (ROM) is not maintained, a program of stretching is recommended. A positioning and splinting schedule is developed for each client by the OT in collaboration with the burn team. Once the acute phase is over, OTs and physical therapists monitor and modify exercises and splints to maintain functionality until the reconstructive phase begins. At that time, prosthetic and orthotic devices and splints focus on rehabilitating the patient, with an emphasis on activities of daily living (Holavanahalli et al. 2011).
Considerations for Treatment
Treatment intensity for splinting is determined by scar blanching (the clinical sign that the tissue’s yield point is approaching) and tolerable pain (Spires et al. 2007). Skin recruited for joint movement has been demonstrated to extend far beyond the immediate proximity of the joint skin creases (Richard et al. 2009). Gentle, prolonged stretch to healing tissue at its longest tolerable length for at least 6–8 h/day has been reported to be most effective (Chapman 2007). The joint needs to be moved slowly and repeatedly to its end range several times before applying a prolonged stretch, which is maintained until the tissue blanches (Spires et al. 2007).
Splints must be “user-friendly,” as poorly applied splints can cause nerve injury, loss of skin grafts, pressure sores, and worsening of a burn wound. Splints should avoid pressure over bony prominences and be compatible with wound dressings and topical medications. Splints fabricated of remoldable materials can be modified, as the client’s needs change. Factors to consider when prescribing a splint include the area of the body injured, extent and type of injury, the functional goal being addressed, and patient adherence to the splinting regime (Kolmus et al. 2012; Spires et al. 2007). The therapist must be vigilant in providing education to the patient and/or their caregivers about the wearing regimes and risks of the splint. Splinting charts above the patient’s bed and/or in nursing folders is an important communication tool between therapy and nursing staff during hospital admission (Spires et al. 2007).
A recent systematic review of static splinting for burn contracture indicated that there is no high-level evidence for this widespread practice (Schouten et al. 2012) and that cellular changes stimulated by mechanical tension may actually increase the incidence of contracture . In addition, one randomized controlled study of axilla burns found no difference in clinical outcomes between patients receiving exercise only and those receiving exercise and shoulder splints (Kolmus et al. 2012). Clearly, further high-quality studies are required to determine the effectiveness of splinting including the angle of splinting that results in the best functional movement. Most studies have examined extremity contractures, with evidence lacking regarding trunk contractures (Parry et al. 2010).
Edema is an interstitial protein-rich substance that forms a gel-like consistency and impedes vascular clearance. The superficial lymphatic plexus resides within the dermal–epidermal junction; therefore, deep partial-thickness and full-thickness burns can cause impairment to the superficial or deep lymphatic system. Edema arises from the lymph vascular safety system being exceeded, or lymph transport capacity being compromised (Hettrick et al. 2004).
On admission to the hospital, the severely burned client requires fluid resuscitation, which increases edema in the extravascular space that can limit joint motion (Latenser and Kowal-Vern 2002; Spires et al. 2007). Edema may also form in noninjured soft tissues postburn (Edgar et al. 2011; Kramer 2012). Edema develops within 8–12 h after burn injury and peaks at approximately 36 h (Kramer 2012). Failure to reduce edema in the first 48–72 h can result in a fixed deformity (Richard and Staley 1994). Edema management is especially important with hand burns due to the dependent position of the hand (Esselman et al. 2006).
Lymphedema, that is, chronic edema that is sustained for more than 3 months, is a rarely reported complication associated with burn injuries. Risk factors for lymphedema development include circumferential extremity involvement and fascial excision (Hettrick et al. 2004) .
Considerations for Treatment
In the acute phase, edema likely contributes to decreased tissue oxygen diffusion and further ischemic insult to already damaged cells, with compromised blood flow increasing the risk of infection (Edgar et al. 2011; Kramer 2012). Edema reduction is pursued by elevation of the extremities above heart level. Elevating the hand and arm is accomplished using splints, bedside troughs, or similar devices (Richard and Staley 1994). Web spacers (i.e., strips of foam/dressing product/molds) can be placed between digits to prevent fluid collection and edema formation (Latenser and Kowal-Vern 2002), and elasticized bandages are used to decrease edema (Esselman et al. 2006). Exercise of the burned body parts helps to maintain joint mobility and muscle function (Latenser and Kowal-Vern 2002). If the patient is alert and able to participate, a program of active and active-assisted exercise is appropriate. In obtunded or critically ill patients, passive range of motion exercises to end range are prescribed to reduce contractures and functional loss.
Immediately following autografting, active and passive exercises are not performed on the limb. Depending on the type of graft, the condition of the graft wound, and the judgment of the surgeon, no exercise is performed for approximately 3 days on mesh grafts and 5 days for sheet grafts. Heterografts, synthetic dressings, escharotomies, and surgical debridements are not contraindications to exercise (Spires et al. 2007).
Wrapping burned extremities with elastic bandages when the patient is sitting or ambulating contributes to a decrease in edema and is used to avoid venous pooling, which can lead to graft sloughing (Spires et al. 2007). Should lymphedema be present, it can be managed with specific manual techniques, special bandaging and compression wraps, and remedial exercises (Hettrick et al. 2004).
The OT, in conjunction with the physiotherapist, is generally responsible for providing a positioning program, as well as either a passive or active exercise program from the day of admission until patients are fully mobilized and exercising (Latenser and Kowal-Vern 2002). The OT enables clients to complete their daily functional tasks independently. The OT looks for the presence of edema or lymphedema using assessment tools with demonstrated reliability (such as the bioimpedence spectroscopy; Edgar et al. 2009) or the deepening of skin folds and absence of visible venous alterations and Stemmer’s sign (Hettrick et al. 2004).
Education and communication among all team members, clients, and caregivers are necessary if an effective positioning and exercise program is to be successful.
In one single-center study, the use of electrical stimulation in combination with standard physiotherapy significantly reduced local acute hand burn edema (p = 0.02) and increased active hand motion (p = 0.0003; Omar et al. 2004). Further research would benefit from a scrutiny of the methods in both adult and pediatric populations in multi-center trials, as well as focusing on the relationship between impairments to body structures and functions, and participation in a broad range of activities postburn injury.
Scar management interventions include compression (such as pressure garments and/or transparent face orthoses) and the use of silicone. The use of pressure as a major treatment modality for scar suppression commenced in the early 1970s, following observed improvements of scarring with the use of a pressure garment (Macintyre and Baird 2006). Transparent face orthoses (Rivers 1979) are commonly used in the treatment of facial burns, with up to 87 % of therapists in North America reporting their use (Parry et al. 2012). The use of silicone gel sheeting started in 1981, with treatment of burn scars (Perkins et al. 1983). The purpose of scar management is to prevent the development of impairments of body structures and functions from hypertrophic scarring, or musculoskeletal changes, and to remediate or compensate for musculoskeletal or neurologic deficits. Hypertrophic scarring is collagen arranged in random orientation with whorls and nodules. Mechanical pressure facilitates the alignment of collagen fibers in a more parallel, normal orientation (Spires et al. 2007). Additionally, it is widely believed that pressure controls collagen synthesis by limiting the supply of blood, oxygen, and nutrients to the scar tissue and reduces collagen production to the levels found in normal scar tissue more rapidly than the natural maturation process by replacing the pressure exerted by the destroyed skin on underlying tissues. A common belief is that the application of pressure alleviates the itchiness and pain associated with active hypertrophic scarring (Macintyre and Baird 2006).
Considerations for Treatment
Pressure garments or transparent face orthoses are typically introduced as soon as the patient is able to tolerate pressure (Fig. 19.4). The use of pressure in the pregrafting or healing stages has been advocated by some authors to prepare the wound bed and assist graft retention. However, pressure is usually applied to healed wounds early on (i.e., in the first few days or weeks post wound healing) to prevent raised scarring and to accelerate scar maturation (Chapman 2007; Van den Kerckhove et al. 2005). Patients are usually advised to wear pressure garments continuously for at least 23 h, removed only for hygiene purposes and laundering. However, garments worn for a lesser time (i.e., a mean of 20.4 h/day) have been found to reduce hardness and thickness for a group receiving a mean pressure of 25 mm Hg (Engrav et al. 2010). Pressure is continued until scar maturation has occurred, which generally takes up to 6–18 months, and in exceptional cases up to 5 years (Chapman 2007; Macintyre and Baird 2006). Garments should extend at least 5 cm (2 in.) beyond the margins of the scar(s) in order to apply an even pressure (Spires et al. 2007). Where it is difficult to provide pressure, such as at the web spaces between fingers, additional inserts of silicone or moldable materials are required to ensure an intimate fit (Spires et al. 2007).
a Custom-made pressure garments or (b and c) transparent face orthoses are measured and fitted when the skin is able to withstand pressure and edema has resolved
The amount of pressure required for maximum benefit is unclear but 15 mm Hg is regarded to be the level required for an effect based on Engrav’s et al. (2010) review of literature. Regular checking of the tension in the garment is important as garments lose their tension over time, with high-pressure garments of 20–25 mm Hg losing their tension more than low-pressure garments of 10–15 mm Hg (Candy et al. 2010). The fit of the garment is assessed regularly by the therapist by visual inspection as well as by feeling the tension in the garment. Adjustments are made or new garments are supplied to ensure that adequate pressure is maintained (Macintyre and Baird 2006). The pressure achieved is not usually objectively measured during appointments. Even garments that provide low pressures of 10–15 mm Hg have been found to have some effect on scarring (Candy et al. 2010) which is an important consideration for patients that cannot or do not attend follow-up appointments for a review of garment fit. A reduction in the pressure of the garment has been found to be higher over the first month of wear, for garments that provide pressure > 20 mmHg (Van den Kerckhove et al. 2005). It is generally recommended that the garment be replaced every 2–3 months to retain optimal tension (Esselman et al. 2006). Complications from garments have been reported as wound breakdown, skeletal deformation, growth retardation, and obstructive sleep apnea (Bourget et al. 2007; Rappoport et al. 2008).
Silicone products may be used on intact skin (van den Kerckhove et al. 2001) once the burn wound has healed either alone or in combination with pressure garments, creams and dressings in the form of silicone gel sheeting, silicone cream, or silicone oil. While no clear guidelines exist for the ideal application time for silicone products, as scar remodeling and collagen synthesis continues for over 12 months, products should be continued for at least this length of time after wound healing. Application for between 12 and 24 h a day was recommended to patients in the majority of studies reviewed (O’Brien and Jones 2013). However, children and patients exposed to hot weather conditions may be advised to graduate the wear of silicone products starting with 12 h or less initially. Strict guidelines are necessary for cleaning and disinfecting both the product and the skin. Gel sheeting may be stabilized with tape along the edge of the sheeting to prevent slippage and displacement during body movement (Van den Kerckhove et al. 2001). Complications from silicone gel sheeting (rash, ulcer, erythema, and pruritus) have been reported in over 50 % of cases (Rayatt et al. 2006). While these complications are more common in children and when the gel is kept in place with pressure garments or adhesive tape, they usually resolve when the therapy is stopped temporarily or with hygiene measures. Contraindications for use include dermatological conditions where the skin may not be intact (Van den Kerckhove et al. 2001).
Education regarding the management of symptoms such as itch is important. Education can involve discussion about the reducing exposure to heat, and preventing fatigue and humidity/sweating which have been identified as the top three circumstances associated with itch (Parent-Vachon et al. 2008). The importance of applying cream, taking medication or being prescribed medication, or having a shower when itchy are additional aspects that OT can educate patients about, with these aspects reported by patients as the top three ways to relieve itch (Parent-Vachon et al. 2008).