With the improvement of medical level and treatment methods, repairing trauma and saving life are no longer the only goals of burn treatment, but prevention and reduction of deformity, restoration of function, improvement of appearance, and helping patients to return to their families and society are getting more and more attention. The concept and technology of burn rehabilitation is gradually being accepted by many burn treatment units.
In order to standardize the form and content of rehabilitation treatment in burn surgery, the Burn Surgery Branch of the Chinese Medical Association and the Burn Physicians Branch of the Chinese Medical Association have initially formulated a burn rehabilitation treatment guideline suitable for the current medical environment in China, based on the experience of burn rehabilitation treatment in foreign countries and the survey knot of 39 burn treatment units nationwide in carrying out rehabilitation treatment, with the burn rehabilitation treatment guidelines in Europe and the United States as the blueprint. It is hoped that the guidelines will be revised and improved continuously through clinical practice, so as to gradually form a burn rehabilitation treatment guideline suitable for the domestic medical model and benefit burn patients.
1.Objectives of burn rehabilitation treatment
Immediate goal: to maintain and gradually increase the range of motion (ROM) of uninjured and injured joints, reduce edema and pain, improve muscle strength and endurance, prevent contracture, and reduce scar growth.
Long-term goal: to improve joint muscle strength and ROM, improve motor ability, flexibility and coordination, and gradually restore body transfer and walking ability.
Referable discharge standard: to be able to independently complete daily living activities such as standing, walking, dining and toileting, and to achieve basic self-care.
Ultimate goal: to achieve good family and social return of burn patients. Through the rehabilitation treatment, the patient can return to the pre-injury living condition as much as possible: (1) having the ability to complete daily life independently (actives of dailyliving, ADL) and corresponding learning and working ability; (2) better appearance; (3) good post-traumatic psychological adaptation.
2.Burn injury rehabilitation treatment concerns
(1) muscle atrophy and decrease of muscle strength, endurance, balance and coordination ability caused by braking; (2) soft tissue adhesion and decrease of joint ROM caused by precipitation and proliferation of periarticular fibrous tissue due to braking; (3) joint stiffness and deformity caused by scar hyperplasia or contracture of soft tissue such as scar, tendon and muscle after braking; (4) decrease of cardiopulmonary function caused by braking, pulmonary infection, (5) adjuvant treatment of burn wounds, infected wounds, and swollen limbs; (6) adjuvant treatment of abnormal skin pigmentation and changes in appearance due to scar growth caused by burns; (7) adjuvant treatment of post-burn concomitant somatic discomfort such as abnormal sensation, pain, itching, and sleep disturbance; (8) post-burn organ dysfunction; (9) follow-up and follow-up of post-burn treatment outcomes. (10) ADL, learning ability and work ability caused by declining joint ROM or physical disability; (11) social and psychological problems caused by burn injury, including work, learning, interaction and family, etc.
3.The main contents of burn injury rehabilitation treatment
(1) publicity and education of post-burn rehabilitation knowledge; (2) post-burn rehabilitation assessment; (3) correct post-burn position placement; (4) exercise therapy to improve patients’ muscle strength, endurance, balance, coordination, cardiopulmonary function and prevent deep vein thrombosis and pressure sores; (5) active and passive exercise therapy to maintain and expand joint ROM; (6) occupational therapy to improve patients’ ADL, vocational guidance and training; (7) prevention and correction of joint deformities and application of orthoses to maintain joint function; (8) physical factor therapy to promote wound healing and assist in infection control; (9) physical factor therapy for scar growth and contracture, limb swelling, acute and chronic inflammation, pain, and pruritus; (10) comprehensive treatment of post-burn scar and wound healing, including compression therapy, scar massage, scar retraction intra-scar drug injection, skin care (for uneven pigmentation, hyperpigmentation, congestion, etc.), laser treatment, and masking make-up techniques; (11) pharmacological treatment of post-burn somatic discomfort symptoms such as pain, itching, and sleep disorders; (12) post-burn psychological assessment, psychological counseling, and treatment; (13) monitoring and treatment of post-burn organism metabolic disorders; (14) monitoring and treatment.
4.Composition of burn rehabilitation treatment team and related responsibilities
(1) Composition of personnel
The good rehabilitation treatment of burn patients relies on team strength, and no one can achieve this goal alone. It is advocated that a multidisciplinary cooperation team treatment mode should be gradually established in each burn treatment unit to achieve the common goal of “making burn patients recover their pre-injury appearance and function to the greatest extent possible”, with a clear division of labor and mutual collaboration to complete the treatment of patients together. The treatment of the patient is done in collaboration with each other. In addition to the burn physicians and nurses required for conventional clinical treatment, the team should also include rehabilitation therapists or full-time rehabilitation-trained therapists and rehabilitation nurses, as well as additional burn rehabilitation physicians, psychologists or psychotherapists, nutritionists, trauma treatment professionals, volunteers, social workers, etc.
It is advocated that each burn treatment unit allocate full-time rehabilitation-trained therapists to carry out rehabilitation treatment, preferably with a background in rehabilitation therapy. In the case of sufficient staffing, rehabilitation therapists can also be subdivided into exercise therapists, occupational therapists (OT), vocational rehabilitation therapists, social rehabilitation therapists, physical therapists (PT), prosthetic orthotic fabricators, etc.; and in the case of insufficient staffing, the burn physicians and nurses can assume the duties of burn rehabilitation physicians and rehabilitation nurses after learning rehabilitation concepts and knowledge and skills.
(2) Responsibilities of members
The burn physician is responsible for critical resuscitation, medical treatment, daily treatment of trauma and surgical treatment of burn patients, and is the developer and implementation guide of the overall treatment plan for the trauma treatment stage of burns.
Burn rehabilitation physician: The burn rehabilitation physician is preferred to be a clinician with experience in burn surgery, familiar with the rules of trauma treatment and scar growth, and trained in rehabilitation treatment. During the patient’s trauma treatment stage, treatment plans should be proposed from the rehabilitation perspective and discussed and confirmed with the burn surgeon. After the basic completion of the trauma repair, he/she is responsible for the development and implementation of the overall rehabilitation plan, the monitoring and symptomatic treatment of the patient’s general condition, the treatment of residual trauma, and, for those who are capable of surgery, the later trauma repair and scar reconstruction surgery, in order to better promote the rehabilitation of the patient’s function and appearance.
Dedicated rehabilitation staff: Dedicated rehabilitation staff is responsible for the implementation of rehabilitation treatment in accordance with the medical orders of the burn physicians and rehabilitation physicians, and is responsible for conducting a comprehensive assessment of the functional status of patients, issuing assessment reports, formulating specific rehabilitation treatment goals and specific implementation plans based on the assessment contents, conducting regular reassessments, revising the rehabilitation treatment goals and plans, participating in clinical shift handovers, room inspections and case He/she also participates in clinical shifts, rounds and case discussions, and reports to the burn physicians and rehabilitation physicians on the progress of rehabilitation treatment and makes treatment recommendations. When there is no fixed staffing in the department, the rehabilitation physiotherapy department may send professional staff to participate in treatment. The duties of PT and OT in the classification of rehabilitation therapists are listed below.
Duties of PT: mainly implement and guide the position placement of burn patients, carry out joint ROM training as well as muscle strength, endurance, balance and coordination training, respiratory function training, limb movement, body transfer, walking and gait training, physical factor therapy, etc., in order to eliminate or reduce patients’ functional impairment, improve mobility, enhance the adaptability of social participation, and improve patients’ quality of life.
Responsibilities of OT: Maintain and improve joint ROM, enhance strength and endurance, improve flexibility and coordination of limb activities by designing activities for active participation of burn patients, assist in the use of orthotics, scar treatment means, etc., centered on restoring patients’ ADL and promoting patients’ family social participation and return.
Rehabilitation nurse: Rehabilitation nurses mainly cooperate with rehabilitation physicians and rehabilitation therapists, promote and educate patients on rehabilitation knowledge, instruct patients on position placement and ADL ability exercise, supervise patients to complete rehabilitation treatment on time, instruct and supervise the use of compression garments and orthotics, understand patients’ psychological changes, communicate with burn physicians, rehabilitation physicians, rehabilitation therapists and psychotherapists in a timely manner when problems are encountered, and It is an indispensable link between patients, their families and the rehabilitation treatment team.
Psychiatrist or psychotherapist: responsible for evaluating the psychological state of patients after injury, and according to the evaluation results, decide whether medication or psychological counseling and other therapeutic interventions are needed to help patients overcome post-injury anxiety, depression, pessimism and other psychological barriers, establish confidence in overcoming the disease, and help patients establish a good psychological adaptation to return to society.
5.Recovery assessment after burn injury
Rehabilitation assessment is the process of collecting, quantifying, analyzing and comparing the functional status of patients and related data, and forming the diagnostics of the disorder. For several aspects of organ system function, ADL, work and learning ability, and social adaptation ability, physical examination, instrument testing, clinical observation, questionnaire survey and other means are usually used to analyze and judge the functional status and potential ability of patients.
At present, there are no standard rehabilitation assessment indexes and methods for burn patients, but the more widely used assessment indexes and methods are as follows: (1) measuring joint ROM by angle ruler; (2) unarmed muscle strength examination and muscle strength assessment by grip strength meter. (3) Barthel index and functional independence scale were used to assess ADL. (4) Vancouver scar scale was used to assess scar. (5) Neuromyography was used for neuromuscular electrophysiological testing. (6) Cardiopulmonary function was assessed by exercise test and pulmonary function measurement. (7) Assessment of psychological and mental disorders.
6.Burn rehabilitation treatment in each stage
Although the treatment process of burn patients is clinically divided into shock period, infection period and trauma repair period, in fact, except for the shock period which is a clearer concept of “48h post-injury or 72h post-injury”, these three pathophysiological processes overlap each other in time and affect each other in the process, so it is difficult to separate them clearly.
A concept that needs to be popularized is that burn rehabilitation treatment is not a late supplementary treatment that starts after the patient’s wound has healed, which may miss the best time for treatment, and the treatment effect is not guaranteed, and the patient’s compliance with treatment is difficult to improve, and even resists to rehabilitation treatment. Burn rehabilitation should begin right after the patient is injured and continue throughout the treatment process, lasting several months to several years.
It is recommended to divide the burn treatment process into two major phases – the trauma treatment phase and the rehabilitation treatment phase, and to organize the rehabilitation treatment using the model of “full intervention and segmental treatment”. This model means that the rehabilitation treatment means should be involved in the whole burn treatment process, but in different stages, the treatment leader is different. In the stage of trauma treatment, the burn physician takes the lead in making decisions on various treatment methods; when the patient’s trauma is basically healed, the patient enters the stage of rehabilitation treatment, at which time the rehabilitation treatment of the patient should be arranged by the rehabilitation physician of the burn department.
The two phases can be subdivided according to the changes in the patient’s vital signs combined with the healing of the trauma. The trauma treatment phase can be divided into the critical phase (unstable vital signs) and the stable phase (relatively stable vital signs) because life-threatening conditions may occur repeatedly, so the two phases may alternate. The rehabilitation phase can be further divided into 2 periods: trauma coverage completion, pre-discharge rehabilitation and post-discharge rehabilitation.
Rehabilitation in the critical phase
At this time, patients have potentially life-threatening conditions and their vital signs are unstable, so rehabilitation treatment should be chosen as the least disruptive means for the patient. The rehabilitation treatment in this phase mainly includes: (1) improving the swelling of the limbs, head and face through posture; (2) maintaining joint ROM; (3) using orthoses and posture to keep the joints in the anti-contracture or functional position; (4) maintaining long-term contact with the patient and family to ensure compliance with treatment and increase the patient’s confidence in recovery.
If the limb is braked for a long time, it can lead to joint capsule contracture and shortening of the tendon muscles across the joint. The following treatments can prevent and delay their development: (1) Passive joint ROM training for the uninjured joint and the injured joint at least twice a day; the rehabilitation therapist should closely observe the changes in the patient’s vital signs (heart rate, blood pressure, respiration) during the treatment, and the duration of treatment, the range of activity, and the intensity of training should be individualized so as not to cause significant changes in vital signs. (2) Rehabilitation treatment can reduce the patient’s pain if it is carried out at the same time as medication change and wound cleaning. (3) Proper anti-contraction position can minimize contracture of tendons, collateral ligaments, and joint capsule, which needs to be achieved jointly through passive joint ROM training, postural placement, and use of orthoses (Table 1).
Stabilization phase rehabilitation treatment
At this time, the patient’s vital signs are relatively stable, and attempts can be made to gradually increase the duration, amplitude and intensity of treatment, and to encourage case patients to begin to try active exercises within their capabilities. The rehabilitation contents in this stage are as follows: (1) continue passive joint ROM training; (2) increase active joint ROM and muscle strength training; (3) take various measures to reduce limb edema; (4) start ADL training within the limits of their ability; (5) start anti-scar therapy as early as possible; (6) start preparing for work, schooling and recreation.
Table 1 Common contractures and counteracting strategies at various sites after burn injury
Burn site
Common contractures
Orthotic application and postural placement strategies
Neck
Flexion
Daily motion, posterior extension orthosis, neck in mild posterior extension position
Shoulder joint
Adduction
Daily motion, axillary abduction orthosis
Elbow
Flexion or extension
Daily motion, alternating between flexion and extension orthoses
Wrist
Flexion or dorsiflexion
Daily motion, functional position orthosis (20° dorsiflexion)
Metacarpophalangeal joint
Hyperextension
Daily motion, functional orthosis (metacarpophalangeal flexion 70-90°, interphalangeal joint extension)
Interphalangeal joint
Flexion
Anti-contraction treatment in the same position as metacarpophalangeal joint hyperextension
Hip joint
Flexion
Daily exercise, orthosis in extension position, prone position if tolerated
Knee
Flexion
Daily exercise, knee orthosis
Ankle
Plantar flexion
Daily motion, neutral orthosis
Toe-plantar joint
Dorsal extension
Daily motion, functional orthosis
Periorofacial
Small mouth deformity
Daily exercise, labial expander and orthosis
Nostril
Nasal stenosis
Nostril dilator tube and orthosis
Completion of trauma coverage, rehabilitation before leaving the hospital
At this time, the patient’s trauma is basically healed, his physical condition is significantly improved, his willingness to improve somatic function is strong, and he is capable of withstanding a certain intensity of rehabilitation treatment. During this period, the focus should be on ADL training, improving the overall physical quality and considering the return to work, schooling and recreation. At the same time, as the scar problem starts to become prominent, comprehensive treatment of the scar is also an important task during this period. The rehabilitation in this phase is as follows: (1) joint ROM training for resistance, isometric muscle strength training, active strength training, and gait training; (2) ADL training; (3) comprehensive treatment against scar proliferation and contracture; and (4) for children, toys and games appropriate to their developmental level should be used to assist in the development of rehabilitation therapy.
Post-discharge rehabilitation treatment
Generally speaking, 1~2 years after injury is the most difficult period for patients. Although they have been discharged from the hospital, they still need to receive long-term treatment and follow-up observation. The rehabilitation contents of this stage are as follows: (1) outpatient rehabilitation treatment for burn patients should be carried out in units with conditions; (2) further strengthen joint ROM and strength training to improve physical quality; (3) strengthen scar treatment; (4) establish follow-up files for patients, formulate follow-up plans and implement them; (5) regularly assess the somatic functional status and existing problems and adjust treatment plans in a timely manner; (6) consider in due course reconstructive surgery and postoperative treatment.
7.Means and implementation of burn injury rehabilitation treatment
There is no treatment method that can only be used for a certain period of time. The responsibility of burn rehabilitation physicians and rehabilitation therapists is to select and combine rehabilitation treatment methods that are suitable for the patient’s condition at that time under the premise of fully assessing the patient’s condition and functional status.
(1) Positioning
After a burn injury, due to the presence of trauma and pain, the patient often adopts a position that is comfortable for him or her and remains motionless. The concept that “a comfortable position is often a position of limb contracture” should be kept in mind and patients should be informed to help them adopt the correct position to combat possible limb contracture and dysfunction.
Consistent good posture is the first step toward recovery and the first line of defense against joint contracture in burn patients. It is recommended that “postural positioning should begin after injury and continue throughout treatment”, and that postural positioning should also be used in conjunction with limb movement, as otherwise prolonged fixation may also result in reduced ROM and contracture of the joint.
The implementation of the position should be adapted to the local situation, and all available aids such as cotton pads, pillows, bedheads, foam pads, orthoses, restraint belts, etc. can be used to help maintain the position. Application examples: (1) Patients with deep burns around the mouth and lips can start applying small mouth expanders or orthoses during the course of trauma treatment to prevent the occurrence of small mouth deformities. (2) Patients with upper extremity and chest wall burns should fully abduct the upper extremity (shoulder joint abduction 90°) to prevent adhesions and scar contractures between the upper arm and axillary and lateral chest wall trauma, while the upper extremity should be horizontally abducted by 15-20° to prevent nerve injury caused by excessive stretching of the brachial plexus nerve. (3) For anterior cervical burns, take a de-pillowed posterior supination position, which can be padded with 1 long pillow under the shoulder to make the neck fully posteriorly extended. For posterior cervical burns, adjust the pillow so that the neck is slightly flexed forward to prevent posterior cervical contracture, and keep the neck in a neutral position for burns on both sides of the neck. (4) For burns on the flexor side of the elbow, the elbow joint should be placed in the straight position; for burns on the extensor side of the elbow, generally keep the elbow joint flexed 70~90°; for circumferential burns on the elbow, the straight position should be the main position, and the placement strategy of alternating the straight and flexion positions should be adopted. The forearm is kept in a neutral or rotated posterior position, with the palm up in the supine position. (5) When the hand is burned, the wrist joint is kept in palmar flexion position; for palmar or full wrist burns, the wrist is predominantly in dorsal extension. For full hand burns, the hand should be kept in a functional or anti-contraction position: thumb abducted to the palm position, wrist joint slightly dorsally extended, metacarpophalangeal joint naturally flexed by 50-70°, interphalangeal joint straightened, gauze rolls placed between fingers to prevent webbing adhesions, and orthotic fixation can be taken if necessary. (6) Hip and perineal burns should be kept in hip extension position with both lower limbs fully abducted. (7) Knee extension burns should be kept in a straight position and fixed with orthoses if necessary. (8) For ankle burns, the neutral position should be maintained, with the ankle joint dorsiflexed at 90° and the patient’s foot on the sponge pad or orthosis placed at the end of the bed to prevent the Achilles tendon from contracting and forming a foot drop (ankle plantarflexion deformity).
(2) Development of exercise therapy
Exercise therapy is the core of physical therapy and an important treatment tool of modern rehabilitation medicine at the provincial level. Exercise therapy is not a completely passive treatment for the patient, but ultimately requires a transition to active exercise for the patient to achieve the purpose of treatment. Exercise therapy does not require special, complex and expensive equipment. What is needed is a rehabilitation therapist with extensive knowledge, skilled and caring patients. Treatment under the guidance of a rehabilitation therapist can minimize sports injuries and ensure sports effects.
Traditional exercise therapy includes: (1) exercise therapy to maintain joint ROM; (2) exercise therapy to enhance muscle strength; (3) exercise therapy to enhance muscle endurance; (4) exercise therapy to enhance muscle coordination; (5) exercise therapy to restore balance function; (6) exercise therapy to restore walking function; and (7) exercise therapy to enhance cardiopulmonary function. These require rehabilitation therapists to carry out treatment through passive exercise, active-assisted exercise, active exercise, resistance exercise, and traction exercise according to the patient’s joint ROM, muscle strength, and endurance.
When the patient has the following conditions: unstable vital signs and life-threatening conditions; acute infection manifestations such as obvious redness, swelling, heat and pain at the treatment site; severe tissue necrosis, vascular rupture, deep vein thrombosis, fracture, etc. at the treatment site, which may cause serious injury and complications due to exercise therapy; the treatment site needs to be braked, such as after implantation, fracture fixation, etc.; there are obvious mental symptoms, If the patient is unable to cooperate with the treatment because of obvious mental symptoms and disorders of consciousness, the advantages and disadvantages should be fully weighed in the process of formulating and implementing exercise therapy prescriptions, and the principle of avoiding blind and rough exercise therapy is to avoid obvious interference with the patient’s vital signs, disrupting the clinical pathophysiological process and avoiding exercise injury.
Exercise therapy in the presence of trauma
Conduct passive, active-assisted, and active joint ROM training of the major joints of the body (burned or unburned) as early as possible, and determine the intensity of treatment according to the patient’s tolerance level. Reduce the amount of time spent in absolute bed rest and maintain a sitting position with the assistance of another person whenever possible. Aim for early ambulation as tolerated. All members of the treatment team should be aware that limb elevation and compression bandaging can control the development of limb swelling and master the points of operation.
Exercise therapy after autologous skin grafting
Moderate active and passive joint ROM training can be started after the dressing is opened on the 5th to 7th postoperative day (or as requested by the surgeon). If the skin graft is not in the joint site, joint ROM training can be performed much earlier postoperatively. If the skin graft is not affected, exercise and ambulation training can be performed early in the postoperative period.
Exercise therapy after allograft or xenograft skin grafting
ROM training of the active and passive joints can be resumed on the first postoperative day after bandaging or fixation with orthoses for 5-7 days as required by the surgeon.
Exercise therapy after artificial dermis transplantation
Bandage or orthotic fixation as required by the surgeon. Non-related limb exercises can be started on the 1st postoperative day. Post-transplant limb exercises can be started 5-7 d postoperatively as long as no joint is involved. When the graft involves a joint site, the timing of exercise is discussed by the surgeon as well as the rehabilitation therapist.
Exercise therapy after whole autologous skin grafting
The skin graft should be wrapped or fixed with an orthotic device for 5-7 days according to the surgeon’s requirements. ROM training of the joint can be performed gradually after the wrapping is opened, as long as the patient can tolerate it.
Exercise therapy in the donor area
Active and passive joint ROM training can be started early in the postoperative period (on the first postoperative day, if possible). Even if there is a donor area in the lower extremity, the patient can try to sit and walk as soon as possible with the assistance of the nursing staff, provided that the donor area is not affected.
Exercise therapy in the operating room (under anesthesia)
Joint ROM training and orthotic fabrication and use can be performed in the operating room at the discretion of the burn physician and rehabilitation therapist. Joint ROM measurement and diagnosis can also be performed in the operating room.
Exercise therapy under conscious sedation
For patients who cannot tolerate treatment with pain medication or pain management techniques, conscious sedation may be used to assist with joint ROM training and position placement. Conscious sedation may be used for 2 to 5 d in 1 week, depending on the judgment of the burn physician and rehabilitation therapist.
Aquatic exercise therapy
It refers to joint training in water to relieve pruritic and painful symptoms, improve the patient’s joint ROM, and improve the patient’s cardiopulmonary function as the therapeutic purpose. Aquatic exercise therapy can be selected according to the patient’s condition and the specific situation of each unit. The following 2 points should be noted: (1) the treatment should be supervised by a rehabilitation therapist, nurse or burn physician; (2) it is prohibited for patients under ICU supervision, with unstable vital signs, or during the infection period, and the specific application time for such patients should be decided by the burn physician.
Use of orthoses
Orthoses are made by rehabilitation therapists, or if the department has sufficient staffing, they can be made by prosthetic orthoses makers, and are mainly used to maintain the functional position or anti-contracture position of the injured joint. The proper use and maintenance of the orthosis is done by the rehabilitation therapist, nurse, burn physician, patient and accompanying staff. The schedule for the use of the orthosis is developed by the rehabilitation therapist and posted at the patient’s bedside, and a skin or trauma evaluation form is filled out for tracking any abnormalities that occur during the use of the orthosis. Any skin injury due to orthotic use should be reported to the rehabilitation team immediately. Depending on the orthotic and skin conditions at the site of use, the observation interval may vary from once every hour to once every 4 to 6 hours.
Continuous use protocol
Removal of the orthosis only during rehabilitation treatment, wound dressing changes, and skin examination can be used in the following situations: (1) for maintaining or enhancing the effectiveness of the dressing after skin grafting, when skin site examination is compromised by the dressing; (2) for maintenance of body position at the circumferential, flexion side, and transarticular depth burn sites; and (3) for maintaining and consolidating improvements in joint ROM.
Alternating use protocol
Specifically, 10 h of use and 2 h of rest may be used for (1) maintenance of position at more superficial circumferential or transarticular burn sites; (2) to assist in the fixation of skin fragments and maintenance of position after allografting; and (3) orthoses should be used as often as possible, but if this may interfere with or limit active joint motion, a burn physician and rehabilitation therapist should be available to discuss the full trade-off.
Nighttime or rest only programs
For patients who can move on their own but still need to maintain the required position at rest.
Precautions for the use of orthoses
(1) The orthosis should be closely observed for skin pressure injuries and trauma changes during use, and the use strategy should be adjusted in a timely manner. (2) The orthosis needs to be adjusted in a timely manner to accommodate changes in the patient’s joint ROM.
Comprehensive treatment of scarring
The possibility of scar proliferation occurs when the trauma heals for more than 2 weeks, and it gradually becomes obvious around 1 month after the injury. 3-6 months after the injury is the peak period of scar proliferation, which is manifested as persistently aggravated congestion and redness, hardness, elevation, uneven surface, tightness with itching and pain at the healing site, and may appear as obvious capillary hyperplasia. Scarring of the joint may interfere with joint movement and may also result in joint deformity due to scar contracture.
So far, there is no method to stop the proliferation of keloid scars at all, and it is possible to achieve better results with a combination of various treatments and long-term persistence. In addition to the aforementioned positioning, orthotics, traction and exercise therapy, which are irreplaceable tools in the comprehensive treatment of keloid scars and play an important role in fighting scar contracture and promoting scar softening, the following treatments can also be used to limit the extent of scar growth, shorten the duration of scar growth and reduce the accompanying symptoms, and are applied in combination according to the patient’s specific situation.
Compression therapy
Compression therapy is the preferred option for the treatment of large scars. It can reduce and control limb swelling, limit the magnitude and degree of scar growth, promote scar softening, protect healing skin, and reduce pruritus and pain. At present, commonly used compression products mainly include compression garments, compression pads, elastic bandages, rigid contact masks, and orthopedic devices, among which compression garments and elastic bandages are most widely used.
Precautions for compression therapy are as follows: (1) It is recommended that sites with a healing time of 2 to 3 weeks should undergo prophylactic compression therapy; sites with a healing time of more than 3 weeks, sites receiving skin grafts, and donor areas with medium-thickness or thicker severed skin pieces should undergo compression therapy. (2) The start of compression therapy should be as early as possible. For sites that have not healed for more than 2 weeks, an attempt at compression therapy with an elastic bandage over the dressing may be considered. (3) Fully weigh the pros and cons between pressure therapy and trauma treatment. When pressure therapy affects trauma healing, reduce the pressure, shorten the time of using pressure products, increase the frequency of dressing changes or suspend pressure therapy to improve the trauma, and then gradually resume pressure therapy. There is no need to wait for the non-invasive state. For patients with deep burns, it is almost difficult to achieve complete trauma healing in a considerable period of time. (4) Pressure therapy should be carried out gradually to reduce the appearance of pressure and friction injury blisters on newly healed skin and to improve the patient’s tolerance of pressure therapy. The treatment pressure should be gradually increased from low pressure, and for particularly thin and fragile newly healed areas, it can start with the pressure of elastic bandage and gradually increase the pressure to transition to pressure garment to improve the patient’s acceptance and compliance to pressure therapy. (5) The requirements for the use of compression products are as follows: they should be worn continuously every day except for necessary operations such as bathing, medication change and scar treatment, and the removal time in between should not exceed 30 min each time; the compression therapy should be adhered to for a long time until the scar decongestion, softening, flattening and elasticity improvement, and this process needs to be continued for a long time until 1-2 years or even longer after the injury. (6) The rehabilitation therapist should monitor the elasticity and pressure of the compression products, and consider adjusting or replacing them when the elasticity decreases and the pressure decreases. (7) For compression therapy on irregularly shaped areas, the use of pressure pads on depressed areas should be considered to ensure the effect of compression. (8) Pressure products can be used together with anti-scar medications and scar patches. (9) For children in the growth period, the compression therapy process should be closely followed and the compression garment should be adjusted and replaced regularly. Unsuitable compression garments are not only uncomfortable, but also may affect body development and cause abnormal deformities.
7. Scar massage and medicated film treatment
Although there is no exact mechanism to explain the principle of scar massage, it has been observed in clinical work that massage with strong, slow pressure has the effect of promoting scar softening, improving joint ROM, and relieving itching and painful discomfort of scar.
Scar massage is widely recommended for scar treatment and may have the following effects: (1) The surface of burn scars is often dry algae, making the patient feel uncomfortable while itching and breakage may occur. By applying some emollient or oil during massage, the scar surface will become softer, more malleable and less itchy, thus making the patient feel comfortable. (2) As the scar thickens and bulges, excess body fluid is retained within it, thus reducing its plasticity. Deep, vigorous massage can help absorb the fluid back into the scar, and limb stretching exercises with scar massage can help expand joint ROM.(3) Deep, small rotational massage can help order the collagen fibers and other tissue structures inside the scar formation process. (4) Deep burns are often accompanied by fading or sensitive skin sensation, and scar massage has a desensitizing effect on pain-sensitive areas and can promote sensory recovery.
After the scar massage, it can be combined with the use of drug dressing with the functions of lightening pigment, softening scar, promoting congestion and decongestion, moisturizing, etc. for the recovery treatment of healed skin, 2~3 times a week, with precise efficacy.
Use of silicone preparations
Silicone preparation has the function of moisturizing and promoting softening to the scar. Some patients may experience rash and itching after topical application of silicone preparations, but it is easy to subside after removal. At this time, consider shortening the duration of application daily and gradually extending the duration of application after adaptation. There is evidence that the use of silicone preparations alone can have some anti-scarring effect, with better results with pressure products.
Intra-scar drug injection therapy
For small, limited, pruritic and painful hyperplastic scars, intra-scar drug injections can be chosen to relieve symptoms and promote scar softening and regression. Currently, corticosteroids are commonly used for intra-scar injections, among which tretinoin and betamethasone are widely used. Although intra-scar injections have definite efficacy in inhibiting scar proliferation and promoting scar softening and regression, there is no unified and clear standard treatment plan, and each unit can choose the appropriate drugs for treatment according to the actual situation. (2) The changes of the scar should be recorded during the treatment, and the common evaluation methods are image recording (photography) and Vancouver scar scale; (3) Preference should be given to limited, cosmetically relevant sites and sites with obvious itching and pain symptoms; (4) Limit the total amount of corticosteroids used at one time and adjust the appropriate injection interval; (5) The occurrence of adverse reactions should be tracked during the treatment, and the frequency and dose of drugs should be adjusted in time to minimize the impact on the patient’s whole body. (5) follow up the occurrence of adverse reactions in the course of treatment, adjust the frequency and dose of drugs in a timely manner, and minimize the impact on the patient’s systemic condition.
Psychotherapy
The patient’s attitude and motivation are important factors affecting the effectiveness of rehabilitation treatment, and sometimes these psychological factors are even more profound than the trauma caused by the burn injury to the patient. Each member of the burn treatment team should pay attention to the patient’s psychological state and focus on this issue in their daily interactions with the patient.
At different stages of burn treatment, patients have different psychological problems: (1) When the vital signs are not stable and in critical stage, patients have psychological problems including anxiety, fear, hallucinations, and sleep disturbance. These problems can be attended to by the ICU team and psychotherapists. (2) When basically over the critical stage, surgery and supervision gradually decrease, physical therapy and occupational therapy gradually increase, and patients gradually understand the degree of injury and the possible impact on the future, they often show depression at this time, and the percentage of having post-traumatic stress disorder (PTSD) is about 30%, which is manifested as fear, sensitivity, and sleep disorder, etc., which can be improved by medication and individual psychological counseling. (3) In the 1~2 years after basic healing and discharge, patients often have emotional problems and need to adapt to family and work environment with physical limitations, and also suffer from PTSD images. Many patients will experience varying degrees of depression, which can be further exacerbated and amplified when not treated promptly and effectively. These psychological rehabilitations require a long-term therapeutic relationship between the patient and the psychotherapist, and if available, participation in psychological group therapy is recommended.
Physiotherapy
Physiotherapy uses the unique physical properties of light, dots, sound waves, magnetic fields, water, wax, temperature, pressure, etc. to produce effects such as reducing inflammation, relieving pain, improving muscle paralysis, inhibiting spasm, preventing scar growth, and promoting local blood circulation. Burn patients can make full use of these physical factors to achieve the therapeutic effects of assisting inflammation control, promoting wound healing, controlling swelling, softening scarring, and improving muscle soft tissue status. Physical factor treatments commonly used for burn patients include wax therapy, hydrotherapy, low-frequency electricity, medium-frequency electricity, microwave, short-wave, limb pneumatic pressure, laser, ultraviolet light, ultrasound, cold therapy, etc., which can be appropriately selected according to the specific conditions of the patient.
8.Extension of burn rehabilitation treatment
Due to the large changes in appearance, limb function, psychological condition and social role, burn patients often cannot return to normal family and social life for a long time, so it is necessary for the rehabilitation treatment team to mobilize forces including medical units, patients and their families, patient units, social organizations, government agencies, etc. to organize various activities to help burn patients better return to their families and integrate into society to promote their maximum The team needs to mobilize the efforts of medical units, patients and their families, social organizations, and government agencies to organize various activities to help burn victims return to their families and integrate into society to maximize their recovery. If conditions permit, activities such as post-burn cultural and sports activities, post-burn vocational skills training, burn patients’ associations, mutual aid organizations, summer camps for burned children, etc. can be considered.