Burns – Occupational Therapy Evidence-based Interventions

Commonly used occupational therapy interventions for burns include:

  • Physical activity and conditioning
  • Pain management
  • Scar management
  • Orthoses and Splints
  • Participation in Occupations

Physical Activity and Conditioning

Occupational therapists can promote therapeutic activities and exercise to help correct impairments and improve musculoskeletal function.[1]Kottke FJ, Stillwell GK, Lehman JK. Handbook of physical medicine and rehabilitation. W B Saunders; 1982. Specific bottom-up strategies include addressing strength, flexibility (ROM), endurance, stability, and balance to promote functioning in a pain-free state.[2]Disseldorp LM, Nieuwenhuis MK, Van Baar ME, Mouton LJ. Physical fitness in people after burn injury: a systematic review. Arch Phys Med Rehabil. 2011;92(92):1501–10. Aerobic exercise may be incorporated as well and include functional activities such as walking for occupations.

Muscle strength has been shown to be significantly lower in burn patients compared to healthy controls.[3]Muscle strength in individuals with healed burns.
St-Pierre DM, Choinière M, Forget R, Garrel DR
Arch Phys Med Rehabil. 1998 Feb; 79(2):155-61.
A structured exercise program can provide substantial improvements in both children and adults.[4]Effects of a 12-wk resistance exercise program on skeletal muscle strength in children with burn injuries. Suman OE, Spies RJ, Celis MM, Mlcak RP, Herndon DN J Appl Physiol (1985). 2001 Sep; … Reference List[5]Effect of 12-week isokinetic training on muscle strength in adult with healed thermal burn.
Ebid AA, Omar MT, Abd El Baky AM
Burns. 2012 Feb; 38(1):61-8.

Widely used assessment parameters in practice include:

  • Range of Motion (75%)
  • Manual Muscle Testing (61%)
  • Quality of Life (61%)
  • Oxygen Consumption (17%)
  • Lean Body Mass (6%)
  • Patient Tolerance (6%)
  • 6-Minute Walk Test (4%)
  • Borg’s Rating of Perceived Exertion (2%)
  • Grip Strength (2%)
  • Other Scales (1%) [6]Diego, A. M., Serghiou, M., Padmanabha, A., Porro, L. J., Herndon, D. N., & Suman, O. E. (2013). Exercise training after burn injury: a survey of practice. Journal of Burn Care & … Reference List

Home exercise programs are often prescribed upon discharge (88%) of participants. Exercises may include resistive activities and should also incorporate cardiopulmonary conditioning exercises based on the patient’s preferences. Cardiopulmonary activity has been shown to contribute to faster recovery of functional independence after burns.[7]Intensive exercise after thermal injury improves physical, functional, and psychological outcomes.
Paratz JD, Stockton K, Plaza A, Muller M, Boots RJ
J Trauma Acute Care Surg. 2012 Jul; 73(1):186-94.

Pain Management

Common complaints:

  1. Tingling
  2. Stiffness
  3. Cold
  4. Numbness
  5. Warmth
  6. Pins and Needles
  7. Electric Shock
  8. Other sensations: cramping, itching, etc.[8]Norman, A. T., & Judkins, K. C. (2004). Pain in the patient with burns. Continuing education in anaesthesia, critical care & pain, 4(2), 57-61.

Interventions and modalities that may be effective for pain management after burns include:

  • Ultrasound (0.125 to 3 watt/cm2, 1-3 MHz) – commonly used to promote wound healing during the inflammatory, proliferative, and remodeling phases.
  • Electric stimulation and laser treatment (LT) – which accelerates the reactions needed for quality fibroblast activity and healing.[9]Sarı, Z., Polat, M. G., Özgül, B., Aydoğdu, O., Camcıoğlu, B., Acar, A. H., & Yurdalan, S. U. (2013). A comparison of three different physiotherapy modalities used in the physiotherapy of … Reference List
  • Virtual Reality – evidence of VR used in conjunction with pharmacological analgesics to help reduce both pain and anxiety during painful dressing changes and therapy sessions.[10]Morris, L. D., Louw, Q. A., & Grimmer-Somers, K. (2009). The effectiveness of virtual reality on reducing pain and anxiety in burn injury patients: a systematic review. The Clinical journal of … Reference List

Other methods include: music therapy, guided imagery, biofeedback, progressive muscle relaxation[11]Achterberg, J., Kenner, C., & Lawlis, G. F. (1988). Severe burn injury: A comparison of relaxation, imagery and biofeedback for pain management. Journal of Mental Imagery., and other distractions (e.g., tablet games).[12]Gillum, M., Huang, S., Kuromaru, Y., Dang, J., Yenikomshian, H. A., & Gillenwater, T. J. (2021). Nonpharmacologic management of procedural pain in pediatric burn patients: a systematic review of … Reference List The OT should also provide needed psychological support throughout all stages of recovery as survivors may experience body image issues, anxiety, depression, nightmares and hallucinations depending on the total body surface area of the burns.[13]Byers JF, Bridges S, Kijek J, LaBorde P. Burn patients’ pain and anxiety experiences. J Burn Care Rehabil 2001; 22:144-149. An excellent study with methodological success. It depicts details of … Reference List

Strategies should address itching (pruritus) for patients with burns (87% of patients). Topical treatments may alleviate symptoms. These include aloe vera, vaseline-based creams, cocoa butter, mineral oil, hydrogel sheets, topical glucocorticoids, silicone gels, compression garments, and massage therapy.[14]Goutos I, Dziewulski P, Richardson PM. Pruritus in burns: review article. J Burn Care Res 2009; 30:221.

Scar Management

Scar Characteristics:

  • Location
  • Height: thickness, thinness
  • Texture: normal, smooth, dry, firm, lump, callous, soft, supple, scabby, shiny, wrinkled
  • Color and pigmentation[15]: L.L. Jones, et al., Outcomes important to burns patients during scar management and how they compare to the concepts captured in burn-specific patient reported outcome measures, Burns (2017), … Reference List

Addressing risk factors:

  • Infection
  • Anatomic location
  • Burn severity
  • Burn depth

Wound Healing stages:

  1. Inflammation
  2. Proliferation
  3. Remodeling

OT Management:

  • Edema management (including wraps)
  • Range of motion exercises[16]Rehabilitation of the burned hand.
    Moore ML, Dewey WS, Richard RL
    Hand Clin. 2009 Nov; 25(4):529-41.
  • Elevation
  • Splinting in antideformity position: Intrinsic plus for the hand[17]OUTCOME OF PHYSICAL THERAPY AND SPLINTING IN HAND BURNS INJURY. OUR LAST FOUR YEARS’ EXPERIENCE. Rrecaj S, Hysenaj H, Martinaj M, Murtezani A, Ibrahimi-Kacuri D, Haxhiu B, Buja Z Mater … Reference List
  • Scar massage for management and hypersensitivity
  • Pressure garments – shown to decrease hypertrophic scar height[18]The effectiveness of pressure garment therapy for the prevention of abnormal scarring after burn injury: a meta-analysis. Anzarut A, Olson J, Singh P, Rowe BH, Tredget EE J Plast Reconstr Aesthet … Reference List
  • Laser therapy[19]Laser resurfacing and remodeling of hypertrophic burn scars: the results of a large, prospective, before-after cohort study, with long-term follow-up. Hultman CS, Friedstat JS, Edkins RE, Cairns BA, … Reference List[20]Biology and principles of scar management and burn reconstruction. Tredget EE, Levi B, Donelan MB Surg Clin North Am. 2014 Aug; 94(4):793-815.

Splinting

Splinting may be used throughout all phases of recovery as appropriate. OTs commonly splint in the antideformity position to manage tissue lengthening.[21] 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. Early splinting is key to recovery and to prevent contractures. Patients who wear splints for longer durations, e.g., 6 months, have less of a chance of developing scar contractures. Splinting types for burns include: static, progressive, and dynamic. Overall, splints should be simple, consider the wound depth, and range of motion. OTs should educate patients and staff on the wearing schedule and how to check for proper fit as well as be re-evaluated regularly. A commonly used schedule is 2 hours on and 2 hours off.[22]Richard R, Ward R. Splinting strategies and controversies. J Burn Care Rehabil
2005;26:392–6.
Specific splints are beyond the scope of this article.

Occupations

Burns can significantly impact one’s ability to return to meaningful occupations. Occupational therapists can use the therapeutic use of self and a holistic approach to treatment to promote occupational engagement.[23]Mata, H., Humphry, R., Sehorn, S., Dodd, H. S., Thornton, S. J., Prochazka, M., & Cairns, B. A. (2017). Meaningful occupations impacted by burn injuries. The American Journal of Occupational … Reference List In acute care, OTs often address basic ADLs. However, other occupations such as return to work and social integration are important as well.[24]van Bentum BHS, J. (2021). Supporting People Experiencing a Burn Injury to Return to Work or Meaningful Activity: Qualitative Systematic Review and Thematic Synthesis. New Zealand Journal of … Reference List

One consideration when working with burn survivors is their physical appearance. Be sensitive and ask if they are mentally prepared to see themselves in the mirror instead of having them caught by surprise. Seeing themselves may contribute to stress, anxiety, and depression if too early.

A useful measure is the COPM for burns to address the aspect of meaningful occupations through rehabilitation.[25]Mc Kittrick, A., Jones, A., Lam, H., & Biggin, E. (2021). A feasibility study of the Canadian Occupational Performance Measure (COPM) in the burn cohort in an acute tertiary facility. Burns. The Occupational Adaptation model can be useful for the burn population as it is holistic and focuses on enhancing the individual’s ability to adapt to occupational challenges.[26]Schkade & Schultz, 1992 Other commonly used measures include the FIM and CARE Tool in rehabilitation.

Clients should be encouraged to play a role in decision-making and to be made to feel in control. For example, patients may decide on the length and type of therapy they choose to participate in that is meaningful to them in addition to the commonly addressed BADLs.

Novel methods such as Wiihab and VR may be beneficial as they provide distractions and help to promote healing and rehabilitation. Don’t be afraid to use your creativity in therapy for patients with burns – have a little fun with it!

In closing, although these four aspects of burns are typically addressed, they are not the only aspects. By using a patient-centered and holistic approach with a focus on prevention, healing, and participation in meaningful occupations, occupational therapists can provide a valuable service to this population as they overcome major physical and mental barriers to recovery.

References

References
1 Kottke FJ, Stillwell GK, Lehman JK. Handbook of physical medicine and rehabilitation. W B Saunders; 1982.
2 Disseldorp LM, Nieuwenhuis MK, Van Baar ME, Mouton LJ. Physical fitness in people after burn injury: a systematic review. Arch Phys Med Rehabil. 2011;92(92):1501–10.
3 Muscle strength in individuals with healed burns.
St-Pierre DM, Choinière M, Forget R, Garrel DR
Arch Phys Med Rehabil. 1998 Feb; 79(2):155-61.
4 Effects of a 12-wk resistance exercise program on skeletal muscle strength in children with burn injuries.
Suman OE, Spies RJ, Celis MM, Mlcak RP, Herndon DN
J Appl Physiol (1985). 2001 Sep; 91(3):1168-75.
5 Effect of 12-week isokinetic training on muscle strength in adult with healed thermal burn.
Ebid AA, Omar MT, Abd El Baky AM
Burns. 2012 Feb; 38(1):61-8.
6 Diego, A. M., Serghiou, M., Padmanabha, A., Porro, L. J., Herndon, D. N., & Suman, O. E. (2013). Exercise training after burn injury: a survey of practice. Journal of Burn Care & Research34(6), e311-e317.
7 Intensive exercise after thermal injury improves physical, functional, and psychological outcomes.
Paratz JD, Stockton K, Plaza A, Muller M, Boots RJ
J Trauma Acute Care Surg. 2012 Jul; 73(1):186-94.
8 Norman, A. T., & Judkins, K. C. (2004). Pain in the patient with burns. Continuing education in anaesthesia, critical care & pain, 4(2), 57-61.
9 Sarı, Z., Polat, M. G., Özgül, B., Aydoğdu, O., Camcıoğlu, B., Acar, A. H., & Yurdalan, S. U. (2013). A comparison of three different physiotherapy modalities used in the physiotherapy of burns. Journal of Burn Care & Research, 34(5), e290-e296.
10 Morris, L. D., Louw, Q. A., & Grimmer-Somers, K. (2009). The effectiveness of virtual reality on reducing pain and anxiety in burn injury patients: a systematic review. The Clinical journal of pain, 25(9), 815-826.
11 Achterberg, J., Kenner, C., & Lawlis, G. F. (1988). Severe burn injury: A comparison of relaxation, imagery and biofeedback for pain management. Journal of Mental Imagery.
12 Gillum, M., Huang, S., Kuromaru, Y., Dang, J., Yenikomshian, H. A., & Gillenwater, T. J. (2021). Nonpharmacologic management of procedural pain in pediatric burn patients: a systematic review of randomized controlled trials. Journal of Burn Care & Research.
13 Byers JF, Bridges S, Kijek J, LaBorde P. Burn patients’ pain and anxiety experiences. J Burn Care Rehabil 2001; 22:144-149. An excellent study with methodological success. It depicts details of different aspects of psychological changes after the acute burn.
14 Goutos I, Dziewulski P, Richardson PM. Pruritus in burns: review article. J Burn Care Res 2009; 30:221.
15 : L.L. Jones, et al., Outcomes important to burns patients during scar management and how they compare to the concepts captured in burn-specific patient reported outcome measures, Burns (2017), https://doi.org/10.1016/j.
burns.2017.09.004
16 Rehabilitation of the burned hand.
Moore ML, Dewey WS, Richard RL
Hand Clin. 2009 Nov; 25(4):529-41.
17 OUTCOME OF PHYSICAL THERAPY AND SPLINTING IN HAND BURNS INJURY. OUR LAST FOUR YEARS’ EXPERIENCE.
Rrecaj S, Hysenaj H, Martinaj M, Murtezani A, Ibrahimi-Kacuri D, Haxhiu B, Buja Z
Mater Sociomed. 2015 Dec; 27(6):380-2.
18 The effectiveness of pressure garment therapy for the prevention of abnormal scarring after burn injury: a meta-analysis. Anzarut A, Olson J, Singh P, Rowe BH, Tredget EE J Plast Reconstr Aesthet Surg. 2009 Jan; 62(1):77-84.
19 Laser resurfacing and remodeling of hypertrophic burn scars: the results of a large, prospective, before-after cohort study, with long-term follow-up. Hultman CS, Friedstat JS, Edkins RE, Cairns BA, Meyer AA Ann Surg. 2014 Sep; 260(3):519-29; discussion 529-32.
20 Biology and principles of scar management and burn reconstruction. Tredget EE, Levi B, Donelan MB Surg Clin North Am. 2014 Aug; 94(4):793-815.
21 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.
22 Richard R, Ward R. Splinting strategies and controversies. J Burn Care Rehabil
2005;26:392–6.
23 Mata, H., Humphry, R., Sehorn, S., Dodd, H. S., Thornton, S. J., Prochazka, M., & Cairns, B. A. (2017). Meaningful occupations impacted by burn injuries. The American Journal of Occupational Therapy, 71(4_Supplement_1), 7111520302p1-7111520302p1.
24 van Bentum BHS, J. (2021). Supporting People Experiencing a Burn Injury to Return to Work or Meaningful Activity: Qualitative Systematic Review and Thematic Synthesis. New Zealand Journal of Physiotherapy, 49(3), 134-146.
25 Mc Kittrick, A., Jones, A., Lam, H., & Biggin, E. (2021). A feasibility study of the Canadian Occupational Performance Measure (COPM) in the burn cohort in an acute tertiary facility. Burns.
26 Schkade & Schultz, 1992
Jeff is a licensed occupational therapist and lead content creator for OT Dude. He covers all things occupational therapy as well as other topics including healthcare, wellness, mental health, technology, science, sociology, and philosophy. Buy me a Coffee on Venmo.