the whole puzzle - aer a burn trauma -...

TheWholePuzzle-a-eraBurnTraumaGre$aWilkinson,RNandMandyYelvington,MS,OTR/LArkansasChildren’sHospitalBurnCenter

ACHBurnCenter

•  OnlyBurnCenterinArkansas•  10bedcriIcalcareandstep-downunit•  TreatspediatricandADULTpaIents

Suppor8ngBurnSurvivorsInpaIent

MajorBurnTrauma/InhalaIoninjury/ICU/SedaIon/Assessment/Pain/Treatment/WoundCare

Circumstancesoftheevent/Loss

RehabilitaIon/LTAC/HomeHealth/ClinicAppointments/Pressuregarments/Therapy/Dressingchanges/Pain/ChronicPuriIs

Admission

Debridement/Allo-graSing/Auto-graSing/Donorsites/AmputaIons/Tracheostomy

Event

Surgeries

Discharge

nn

Inhala8oninjury

Intubatedformanyweeks,mulIpleBronchoscopies

Severelyburnedairway

Inseveralhoursforseveralweeks!!

Suppor8ngBurnSurvivorsFamily

TotaldisrupIonoflife/Work/Childcare/School/

Decisionsofcare/Surgeryconsents/Physicianupdates/

Learnwoundcare/Adaptthehome/ManagemedicaIons/Clinicappointments/Work/Children

DisrupIon

Managehomelife/Paybills/Needingtowork/Commute/Stayatthehospital/Selfcare/

Decisions

Management

Discharge

PhysicalRecoverya-eraBurnInjuryTheRehabilitaIonPhase

BurnInjuryComplexity• Long(1840)“Notasimpleinjurybutaverycomplicateddisease”• Burnsdirectlyaffectthelargestorganinthebody(integumentary)• ButcanhavedevastaIngeffectsonALLothersystems.

SystemicChanges• AllbodysystemscanbepotenIallyimpactedbyalargeburninjuryandshouldbeconsideredwhenformulaIngarehabilitaIonplan.• Respiratory• Renal

MusculoskeletalChanges• Osteoporosis• PeriostealnewboneformaIon•  IrregularossificaIon• HeterotopicossificaIon• TendondesiccaIon• Muscleandjointcontractures• Nerveinjury

RehabFollowingaBurn

•  ImmediatepriorityisLIFEpreservaIonandwoundcoverage•  Doesnotprecludeaggressiverehab

•  UrgentneedforimmediateandaggressivepaIentspecificrehab

•  AtrophyofskeletalmuscleaspartofthecatabolicstateoftheburnpaIent•  CatabolismdecreasesleanbodymassandmusclestrengthwhichareessenIalforADLs

•  ShortTermGoal•  PreserveROMandfuncIonalabiliIes

•  LongTermGoal•  ReturntoindependentlivingandtrainforcompensaIonsoffuncIonallosses

PainManagementinRehab

Becomfortablewithaprocessthatneverends,butwhichcanbringmanymomentsofreliefforthepaIentandsaIsfacIonforthecaregiver.

PainManagementAnxietyandPsychiatricIllnessesItching

80to100%ofpaIentsChronicissueMedicaIons

Non-pharmacologicalLasertherapyMassagetherapyCompressiongarments

“PosiIonofComfortIsthePosiIonOfContracture”

BurnScarContracture1-4daysTendonsandTendonSheaths5-21daysAdapIveMuscleShortening2-3weeksLigamentandJointCapsule1-3months

ReprintedwithpermissionfromBurnCareandRehabilitaIonTodayRegRichard,PTandMarlysStaley,PT

BurnRehabGoals•  IncreasefuncIonalindependenceandrangeof

moIon•  Minimizepain•  ProvideconInuityofcareandconsultaIon•  Limitcontracturedevelopment•  Facilitatereturntoindependentlivingandhelpthe

paIentcompensateforanyfuncIonallosses.•  TherapyshouldbepaIentspecificandstartas

soonaspossibleaSeradmission.

Therapeu8cPlan

AcuteStage:•  PosiIoning–withorwithoutsplints

•  RangeofMoIon•  ReduceeffectsofedemaandimmobilizaIon

• MaintainfuncIonaljointmoIonandmusclestrength

Sub-AcuteStage:•  RangeofMoIon•  FuncIonalacIviIes(mobility,

ADLs,strength/enduranceacIviIes)

•  HomeprogrameducaIon•  SplinIng(PRN)•  AdapIveequipment(PRN)•  Facilitatecommunity

reintegraIon

“It’sComplicated”

•  EvenwhenburnpaIentshaveassociatedtraumaorgraSs–itisimportanttodoasmuchtherapyasallowed.

• MayrangejointsnotcrossedbynewgraSs,rangewithinallowedlimitaIons,etc…–Alwaysdothemostthatyouareallowed!

Therapeu8cExercise

• ReducetheeffectsofedemaandimmobilizaIon• MaintainfuncIonaljointmoIonandmusclestrength•  StretchthescarIssue• ReturnthepaIenttotheopImalleveloffuncIon

StrengthandEndurance

Severely burned patients frequently spend hours daily on their rehabilitation, including stretching, strengthening, ambulation, activities of daily living, and pre-work skills.

Ac8vi8esofDailyLiving

• DirectlyrelatedtotheirwoundhealingandresultanthypertrophicscarcontractureformaIon.• Parry(2010)reportedthat“scarcontracturecancausesignificantimpairmentandfuncIonaldeficits”.•  ScarcontracturesaredirectlylinkedtodecreasedphysicalfuncIon,occupaIonalrolelimitaIon,painanddecreasedqualityoflifefortheburnsurvivor.

TherapyTechniques

ROM–HelpfulHints

•  With upper extremity range of motion, stretching should be done distal to proximal.

•  UE Extensor tightness leads to difficulty making a fist. May need muscle relaxation techniques combined with stretching to obtain full ROM.

•  Keep elbow straight with shoulder ROM•  Don't forget about pronation and supination.•  Take away pillows – for patient's with anterior neck burns•  Passive and active facial exercises to achieve function ROM•  For full lower extremity range - you must range the ankle with the hip at neutral and the knee in FULL extension.

•  Patients should be discouraged from sleeping with knees flexed or with a pillow under their knees.

SustainedStretching• Gentle,sustainedstretchismoreeffecIvethanmulIplerepeIIvemovementstogainlengthinburnedIssue• EffecIvestretchingcausesblanching•  IfmulIplejointsareinvolved–stretcheachseparatelythenstretchtheskinasawholeunit• PassiverangeistheprimaryfocusunIlfullROMachieved

Resis8veROM• Manualormechanicalresistanceisappliedtoamovement• TradiIonalweights,theraband• Manualresistanceprovidedbythetherapist• Hold,release,stretch

MassageandMyofascialTechniques• Performovernon-burnedareasofmuscleinserIonororigin• WorktowardIghtorscarredarea•  Increasemobilityofskin,muscle,andunderlyingIssues•  IncreasesROMbyelongaIngmuscleandskin

Inpa8entRehaborCommunityBasedTherapy

•  LimitedamountsofaROM–thepaIentcandoaROMWITHOUTyourhelp.TherapyImeshouldbedevotedtothethingstheycannotdoalone.•  Passivestretch•  ResisIveROM• Myofascialtherapy•  SplinIng•  PaIent/caregivereducaIon

• BurnSurvivorswillonlyachievemaximalrecoveryifthepaIentisconsistentwiththerapyANDwithhomeprogramexercises.

BurnWoundHealing• WoundshealbyscarformaIontoreplacedestroyedIssue• DeeperburnsandwoundsthattakelongertohealareatgreatestriskofscarformaIon

HypertrophicScars• Definedasearlyas1790• Raised,erythematous,pruriIcandinelasIcmassofIssue•  IfleSuntreated,canleadtocontractures,funcIonalimpairment,discomfort,cosmeIcproblems

Microscopicviewofnormalcollagen

versusHTS

ScarManagement

ScarMassageGoal:SoSeningorremodelingbyfreeingadheringfibrousbandsIncreaseselasIcityofscarsIncreasesjointmobilityAlleviatesitchingDesensiIzaIonIncreasesscarpliability

CompressionGarments

• Customgarmentsaremeasuredwhenwoundclosureisachieved(ifwoundclosurewas>21days)• Usuallyfirstpost-dischargevisit• Manufacturedin~2weeksandfitduringaclinicvisit• Mustwear23hours/day(2sets)• Re-measureevery~3months• Wear1-2years(unIlscarsaremature)

AcIveScar Compression

BlanchingDecreasedBloodFlow

DecreasedO2inTissue

DecreasedCollagenProducIon

RightShoulder4/23/09

RightShoulder5/18/09

Reconstruc8on• ASertherapyandcompressionhavebeenuIlized• ShouldbedelayedunIlrecoveryfrominiIalphaseofinjury• RestoraIonofdeformiIesthatimposefuncIonallimitaIonsshouldbeaddressedbeforecosmeIcs

DisabilityEvalua8on

• Respiratory• Musculoskeletal•  Skin• DecreasedcoordinaIon,strength• Contractures• Garments(maylimitworkability)• Anxiety

• Heat/ColdIntolerance•  SunlightSensiIvity• PAIN• NeuropathicPain•  Itching• ChemicalsensiIvity• ChangesinsweaIngpa$ern• PTSD

PsychologicalRecoverya-eraBurnInjury

Suppor8ngBurnSurvivorsOutpaIent

Physical/Work/School/Society/RelaIonshipsEmoIonal/PTSD/Anxiety/FlashbacksVisiblescars/Hiddenscars/Hypertrophicscars/Contractures

Loss/Grief/Depression/Anger/Loneliness/Poorself-esteem/

Challenges

AmputaIons/ProstheIcs/Contractures/

Appearance

DisabiliIes

EmoIons

Suppor8ngBurnSurvivorsConInualAdjustment

Dry/SensiIve/Painful/Ta$ooofTrauma/Revisions

Stares/Awareness/Namecalling/Bullying/IsolaIon/LossofIdenIty

Scars

Stayhidden/Denial/Lifestylechanges/IsolaIon

Visual

Hidden

Suppor8ngBurnSurvivors[SUR·VI·VOR]Defini8on:

Someonewhoperseveres,someonewithgreatcourageandstrength,atrueinspira8ontoothers

CampSunshineAges:4-16(Campers)Youngerthan4:•  ParentsreceivesupportfromSOARvolunteers

•  EarlyinformaIononCampSunshinebeforedischarge

YoungAdultEventsAges:16-23•  Y.A.RatCampSunshine•  JuniorStaff/CIT/VITrolesatCampSunshine

•  Y.A.Conference(Tulsa)

AdultSurvivorGroupAges:23+•  YearlyFallRetreat•  MonthlyDinners•  CampCounselor•  BuildingaSupportGrouponFacebook

•  SOARSupporterTraining•  WBC

TheThreePiecePuzzle ProvidingalifeImeofsupport

Suppor8ngBurnSurvivorsCAMPSUNSHINE

Age4to16/10%fullthicknessinjury/scarring/disability/HandsandfaceOpportunitytobewithothersurvivors/counselingwithanacIvity/achievesocialacceptance/camper–counselorpairing

IAFFCampinDC/PhoenixSocietyPEGgrant/AngelFacesRetreat/YoungAdultConferenceWiseFoundaIonChangeChallenge

Criteria

APFF–payrolldeducIonandfundraisers/totallyfree/volunteers

Goals

Funding

OpportuniIes

24th Camp Sunshine August 2015 August 1991 with 6 campers!

IAFFCampinWashingtonD.C.

Angel Faces A Soft Place to Fall, a solid Foundation for Growth

Howhascamphelpedyoucopewithyour

burnexperience?“I’vebeena

bletomeet

peoplejustlikemeandcampgivesme

courageandstrengthtotake

onanother

year.”

Howdoyoufeelaboutyourscarsnow?“Is8llstruggleeverydayaboutmyscarsbutthemorecampIreceivethebe^erIfeelanddealwithmyselfesteem.”

JuniorStaff17-18YearsofAgeCounselorinTraining18-23YearsofAgeVolunteerinTraining18-23YearsofAgeFullCounselororVolunteer23yearsofageandabove

“Seeingthestrengthofthese

childrenand

knowingthatIhaveplayeda

partintheirlives

isimmeasurable”

“IhopeImakeadifferenc

ein

theirlivesliketheydo

mine!”

“ItposiIvelyimpactsallthecampersandbooststheirself-confidenceandhelpsthemrealizetheyaren’tlimitedtowhattheirskinandscarsshow”

Suppor8ngBurnSurvivorsYoungAdultRetreat

Age16to23years/Campa$endanceorgreaterthan20%fullthicknessinjuryAvoidsagingout/YoungAdultConference/WiseFoundaIonscholarship/PhoenixPEGscholarship/

Selfimage/RelaIonships/MoneyManagement/SocialMedia/ApplicaIon-Interviewskills/Goalsetng

Criteria

ConInuewithCampa$endanceprograms/Meetbehavioralrequirements/Actasrolemodels/TransiIontoCounselor

OpportuniIes

ExpectaIons

Development

First Camp Sunshine Young Adult Event August 2013 August 2015 with 12 Young Adults!

PhoenixEducaIonGrantP.E.G.

YoungAdultConference

Suppor8ngBurnSurvivorsSOAR–SurvivorsOfferingAssistanceinRecovery

BurnSurvivor/Mature/Stable/Acceptance/Compassionate/ReadyApplicaIon/Profile/Interview/Fulldaytraining

PhoenixSocietyPrograms/WorldBurnCongress/PEG/Survivor–FamilyDinners/Camp/Retreat

Criteria

Consents/Match/Arrangement/Followup/EvaluaIon

Training

Visits

OpportuniIes

First SOAR Training October 2011 Repeated in 2012 and 2014!

Suppor8ngBurnSurvivorsAdultRetreat

Age23andabove/Greater20%FT–Hands–Face/WoundshealedIndependent/MedicalHistoryCommunicaIon/Acceptance/Support/TransiIon/

PhoenixPrograms/FamilyFacebookGroup/Discussions/MoIvaIonalSpeaker

Criteria

Grants/Fundraisers/DonaIons

Goals

Funding

OpportuniIes

First Adult Retreat March 2012 November 2015 with 30 Survivors!

2013

“This was one of the best experiences of my life because you share your experience with others

who can truly grasp and understand” “We were on automatic pilot – one

day at a time. Once you come to the Retreat, you find out that the folks

here have been through what you’re going through – it gives you

a sense of relief…”

“You have support and encouragement to find your dream”

Burninjuriesarelifechanging.Burnscarswillneverfullygoaway.Butthroughconsistenttherapy,scarmanagementandmedicalcare,burninjuriesdonothavetobedebilitaIng.ItisourjobtohelptheburnvicImbecomea

burnsurvivor!