OT Management

OT Dude Academy’s Free NBCOT® Exam Prep Course Burns OT Management

The occupational therapy practitioner is an integral part of the interdisciplinary burn team. The OTP is involved with assessment, treatment, education, communication, and facilitating the patient’s participation in meaningful occupations throughout their recovery and behind. General OT treatment includes optimizing function and independence, minimizing the risk of impairment to body structures and functions, managing symptoms, preventing complications, and promoting the healing of wounds. The client’s physical, psychological, and social needs should be met in each setting. 1 

Splinting

The occupational therapy practitioner should be knowledgeable of a range of static and dynamic splinting/casting techniques to remediate deficits. Splints should not impede the tasks of the burn team. The conscious state of the patient and their ability to co-operate should be considered. A wide range of media for the fabrication of customization of splints should be considered. The OTP should refer to allied health professionals for assistance if necessary.2 

Tissues should be maintained in an elongated state with splinting and positioning to prevent contractures and decubitus ulcers. Mechanical stretch facilitates alignment and lengthening of college fibers in the skin. Contractures may result from improper limb positioning, prolonged immobilization, and lack of function. Splinting protocols should be followed.3 4  More serious burns are at a higher risk for developing contractures, e.g., deep partial-thickness or full-thickness burns. Contractures may occur in up to 42% of patients with burns.5 

Positions to promote generally include extension and abduction, intrinsic plus for hands, anti-frog leg, and anti-foot drop. Ankle contractures should be prevented due to prolonged bed rest. Specific joints should be promoted in an anti-contracture position, based on an individualized approach. 6 7 

Static splinting should follow skin grafting procedures. Night splinting may be sufficient six weeks after the surgery, but should be continued for 1-2 years. Stretching should be maintained if full ROM cannot be achieved. Gentle, prolonged stretch to joint endpoints at what is tolerable should be performed at least 6 hours per day.8  Each client should have their own positioning and splinting schedule developed in collaboration with the burn team. As the acute phase is over, exercises and splints can be modified to maintain the client’s functionality in activities of daily living.9 10  Overall, splints should be user-friendly for both the client and caregivers to promote wearing compliance. Splints should avoid pressure over any bony prominences and should be compatible with wound care protocols by the burn team. Splinting factors to consider include the area of the burn, extent of injury, type of injury, and functional goals.7  Other factors include the susceptibility of the stiffness of joints and preventing injury to nerve structures.2 

Positioning and Splinting Goals11 

  • Acute: Edema control and pressure relief
  • Intermediate: Tissue elongation and graft protection
  • Long-term: Tissue elongation

Suggested Splinting Positions12 13 14 

Joint Position
Neck Extension
Shoulder Abducted 90-100°, Horizontally adducted 15-20°
Elbow Extension
Forearm Supination
Wrist Extension 15-25° with neutral deviation
MCP 60-70° of flexion
IP Extension
Thumb Palmar abduction
Hip Extension and abducted 20° with no external rotation
Knee Extension
Ankle Neutral dorsiflexion

The hand is often splinted in intrinsic plus position (MCP flexion + IP extension) for deeply burned hands. This helps to reduce the stress placed on the superficial tendons of the extensor mechanism over IP joints, as well as placing the hand in an antideformity position.15 16 

Traditional treatment of axillary contractures involved the use of airplane splints in fixed abduction at the shoulder joint. These splints may pose physical, social, and environmental restrictions for narrow spaces.17 

Edema

Fluid resuscitation increases edema and can limit joint motion. Edema can develop within 8 hours after burn injury and peaks at 36 hours. Reducing edema can help to minimize fixed deformities. Edema management is especially important in the hands. Elevate, range (ROM), and wrap (compression as necessary to control edema. OTPs should assess and grade the type and stage of edema formation and monitor it throughout rehabilitation. Adjust the level of compression as necessary. Be aware of any contraindications such as infection, arterial insufficiency, neuropathy, or decreased sensation. Fabricate devices such as foram and thermoplastics for edema control. Closely monitor for changes. Refer for assistance as necessary, e.g., orthotist.10 7 

Stages of Edema18 

  • Stage I: may pit (pitting edema) with pressure
  • Stage II: firm, rubbery, and non-pitting
  • Stage III: hard and fibroused

Non-pharmacological pain and sleep management 2 19 20 

  • Breathing
  • TENS
  • Visual imagery
  • Relaxation
  • Virtual Reality/distraction
  • Aromatherapy
  • CBT
  • Hypnosis
  • Adjusting environmental stimuli, e.g., noise, lights, sounds

Precautions and Contraindications

  • The presence of recent split-skin grafts or myocutaneous flaps to the trunk or lower extremity may prevent mobilization and may require bed rest.21 
  • Caution should be taken when performing passive range of motion on extensor tendons (superficial tendons in the hands and fingers). Position the wrist in 45-90° of extension to provide extra slack to the extensor tendons when ranging each joint of the hand and fingers or perform tendon gliding. 22 
  • For patients with deep dorsal burns involving the extensors, flexion at the PIP should be avoided because of the possibility of causing a boutonniere deformity. Exposed tendons should be splinted in a slack position.23 24 25 
  • Caution should be taken when exercising the ankle or foot for exposed Achilles tendons. Consider splinting the ankle in neutral or casting the ankle in slight plantar flexion.26 27 
  • Kirschner wires or direct contact casts may be used if tendons are exposed.28 
  • Caution should be taken with patients who develop heterotopic ossification. Limit ROM to active ROM within a pain-free range.29 
  • Volumeters to measure edema, e.g., hand, is contraindicated in patients with open wounds, abrasions or other skin conditions.30 
  • Be mindful of lines and equipment, including tracheostomies, especially if the patient is sedated.31 
  • Caution should be taken when applying a splint over burns, which can cause increased pressure and decreased blood perfusion.32 

Function and Exercise2 

  • Structured physical exercise programs have been shown to be effective for burn injury patients.33 34 
  • Be aware of physiological factors which may affect participation.
  • Consider the extent, location, and healing of burns and how it affects participation.
  • Be aware of skin grafts and any contraindications for their integrity.
  • Patients with more distal graft locations tend to have delayed postoperative ambulation.22 
  • Respect the patient’s pain and manage their pain.
  • Monitor the cardiovascular system, especially in the presence of inhalation injury; O2.
  • Monitor the vascular response and edema.
  • Monitor for complications from specific burn injuries including heterotropic ossification, osteoporosis, septic arthritis, joint dislocation, nerve injury, and amputation.
  • Monitor exercise tolerance and progression.

General OT Management 2 

  1. Perform a chart review, initial evaluation, and interview.
  2. Establish short-term and long-term goals with a client-centered approach.
  3. Evaluate joint ROM.
  4. Perform visual inspections.
  5. Age-appropriate education for clients and caregivers about burns, complications, wound care, support services, follow-up, and long-term goals.
  6. Explain the importance of protocols, procedures, activities, and treatments.
  7. Follow universal precautions for infection prevention
  8. Positioning and splinting in anti-contracture positions
  9. Manage burn symptoms, e.g., pain, edema with the burns team
  10. Promote early mobility.
  11. Engagement in functional activities as able, e.g, ADLs, IADLs (depending on the setting)
  12. Modify the environment to promote independent participation in occupations of self-care, leisure, productivity, and play.
  13. Measure functional outcomes.
  14. Use adaptive strategies and equipment as necessary, but continue its use if unnecessary.
  15. Promote hydration, nutrition, rest and sleep
  16. ROM, exercise, and activity of uninvolved joints and after immobilization
  17. Wound care: education, skin inspections, scar massage, scar management, over-the-shelf and custom-fitting garments and items for wound care,e.g., isotonic gloves.
  18. Address strength, hypersensitivity, itching, and sensory loss
  19. Wearing schedules (splints, garments)
  20. Promote return to school, work, and meaningful occupations
  21. Socialization and support groups
    • Burn camps
    • Cultural support
    • Clergy
    • Rehabilitation units
    • School visits
    • Workplace rehabilitation
    • Specific burn support groups
  22. Address psychosocial barriers – including fears and loss of occupational performance and roles; behavioral changes, resistance to treatment, and withdrawal.
  23. Making early referrals
  1. Simmons, M. (2009). International Handbook of Occupational Therapy Interventions. Springer.[↩]
  2. Simons, M., King, S., & Edgar, D. (2003). Occupational therapy and physiotherapy for the patient with burns: principles and management guidelines. The Journal of burn care & rehabilitation, 24(5), 323-335.[↩][↩][↩][↩][↩]
  3. Richard, R., and Ward, R.S. (2005). Splinting strategies and controversies. J Burn Care Rehabil, 26(5), 392–396.[↩]
  4. Schneider, J.C., Holavanahalli, R., Helm, P., Goldstein, R., and Kowalske, K. (2006). Contractures in burn injury: defining the problem. J Burn Care Res, 27(4), 508–514.[↩]
  5. Esselman, P.C., Thombs, B.D., Magyar-Russell, G., and Fauerbach, J.A. (2006). Burn rehabilitation: state of the science. Am J Phys Med Rehabil, 85(4), 383–413.[↩]
  6. Richard, R., and Staley, M. (1994). Burn Care and Rehabilitation: Principles and Practice. Philadelphia: F.A. Davis.[↩]
  7. Spires, M.C., Kelly, B.M., and Pangilinan, P.H., Jr. (2007). Rehabilitation methods for the burn injured individual. Phys Med Rehabil Clin North Am, 18(4), 925–948, viii.[↩][↩][↩]
  8. Chapman, T.T. (2007). Burn scar and contracture management. J Trauma, 62(6 Suppl), S8.[↩]
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  12. Hedman TL, Quick CD, Richard RL, et al. Rehabilitation of burn casualties. In: Lenhart MK, editor. Textbooks of military medicine, care of the combat amputee. Falls Church (VA): Office of the Surgeon General, Department of the Army; 2009. p. 277–380.[↩]
  13. Apfel L, Irwin C, Staley M, et al. Approaches to positioning the burn patient. In: Richard R, Staley M, editors. Burn care and rehabilitation: principles and practice. Philadelphia: F.A. Davis Company; 1994. p. 221–41.[↩]
  14. Birch JR, Eakins B, Gosen J, et al. Musculoskeletal management of the severely burned child. Can Med Assoc J 1976;115:533–6.[↩]
  15. Richard R, Baryza M, Carr J, et al. Burn rehabilitation and research: proceedings
    of a consensus summit. J Burn Care Res 2009;30:543–73.[↩]
  16. Madden J, Enna C. The management of acute thermal injuries to the upper extremity. J Hand Surg Am 1983;8:785–8.[↩]
  17. Gorka, R., Gupta, A. K., Prakash, S., Bakthavachel, I., Lamba, S., & Gohil, A. J. (2017). Simple, self-adjustable airplane splint for axillary contractures. Burns Open, 1(2), 54-58.[↩]
  18. Casley-Smith, J.R., & Casley-Smith, J.R. (1994). Modern treatment for lymphedema. The Lymphoedema Association of Australia, Inc.[↩]
  19. Miller, K., Rodger, S., Kipping, B., & Kimble, R. M. (2011). A novel technology approach to pain management in children with burns: a prospective randomized controlled trial. Burns, 37(3), 395-405.[↩]
  20. Richardson, P., & Mustard, L. (2009). The management of pain in the burns unit. Burns, 35(7), 921-936[↩]
  21. Stiller K: Safety issues that should be considered when mobilizing critically ill patients. Crit Care Clin. 2007; 23:35-53.[↩]
  22. Holavanahalli, R. K., Helm, P. A., Parry, I. S., Dolezal, C. A., & Greenhalgh, D. G. (2011). Select practices in management and rehabilitation of burns: A survey report. Journal of Burn Care and Research, 32, 210–223. https://doi .org/10.1097/BCR.0b013e31820aadd5[↩][↩]
  23. Helm PA, Fischer SV, Cromes F. Burn injury rehabilitation. In: DeLisa JA, Gans Bruce M, editors. Rehabilitation medicine: principles and practice. Philadelphia: Lippincott-Raven; 1998. p. 1571–97.[↩]
  24. Puddicombe BE, Nardone MA. Rehabilitation of the burned hand. Hand Clin 1990;6:281–92.[↩]
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  30. Borthwick, Y., Paul, L., Sneddon, M., McAlpine, L., & Miller, C. (2013). Reliability and validity of the figure‐of‐eight method of measuring hand size in patients with breast cancer‐related lymphoedema. European journal of cancer care, 22(2), 196-201.[↩]
  31. Sharp, P. A., Dougherty, M. E., & Kagan, R. J. (2007). The effect of positioning devices and pressure therapy on outcome after full-thickness burns of the neck. Journal of Burn Care and Research, 28, 451–459. https://doi .org/10.1097/BCR.0B013E318053D35B[↩]
  32. Richard, R., & Ward, R. S. (2005). Splinting strategies and controversies. Journal of Burn Care and Rehabilitation, 26, 392–396.[↩]
  33. Suman OE, Herndon DN. Effects of cessation of a structured and supervised exercise conditioning program on lean mass and muscle strength in severely burned children. Arch Phys Med Rehabil 2007;88:S24–S29.[↩]
  34. Storch EK, Kruszynski DM. From rehabilitation to optimal function: role of clinical exercise therapy. Curr Opin Crit Care 2008;14:451–5.[↩]
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