COLLEGE OF

PHYSICAL THERAPY

Integumentary Condition
Burn COLLEGE OF
PHYSICAL THERAPY

• Etiology (Thermal, Chemical , Electric, Radiation)

• Scald Burns (MC)
• Male (53%) > Female (45%)
• Under 4 ; Children with Disability

-Author/s (Year)
 COLLEGE OF
PHYSICAL THERAPY

-Author/s (Year)
Pathophysiology COLLEGE OF
PHYSICAL THERAPY

• Zone of Coagulation (most

contact with heat source)
• Zone of Stasis have decreased
blood flow and respond to
resuscitation to save viable tissue
• Zone of hyperemia wherein the
cells have sustained the least
damage and should recover within
10 days.
 COLLEGE OF
PHYSICAL THERAPY

Phases of Wound Healing

Inflammatory Proliferative Remodeling

Phase Phase Phase

Organization of
Granulation the collagen
Vascular
Epithelization tissue
Exudate
Contraction of Increase tensile
Reparative strength of
the wound site
tissue
-Author/s (Year)
 COLLEGE OF
Inflammatory Phase PHYSICAL THERAPY

• Vascular period
• Hyperemia
• Change of cellular filtration
and cell permeability
 COLLEGE OF
Inflammatory Phase PHYSICAL THERAPY

• Vascular period
• Local edema (tumor)
• Warmth (callor)
• Erythema (rubor)
• Discomfort (dolor)
 COLLEGE OF
Inflammatory Phase PHYSICAL THERAPY

• Exudate Stage
• Serous (Blister)
• Purulent (Pus)
• Fibrinous (Clotting)
• Hemorrhagic (Bleeding)
 COLLEGE OF
Inflammatory Phase PHYSICAL THERAPY

• Exudate Stage
• A fluid passes through
the walls of the vessel
into adjacent tissue or
spaces to help deposit
fibrin and leukocytes
 COLLEGE OF
Inflammatory Phase PHYSICAL THERAPY

• Reparative Stage
• Damaged cells are
replace
• True healing begins
• Phagocytosis
(polymorphonuclear and
monocytes)
 COLLEGE OF
Proliferative Phase PHYSICAL THERAPY

• Granulation
• Epithelization
 COLLEGE OF
Proliferative Phase PHYSICAL THERAPY

• Overlaps with inflammatory

phase
• A bed of granulation tissue
forms gradually over the
surface of the wound and the
epithelial margins begin to
migrate toward the center of
the wound on top of this
granulation bed
 COLLEGE OF
Maturation/Remodeling Phase PHYSICAL THERAPY

• Characterized by the
organization of the
collagen tissue into
a more definitive and
finite pattern
 COLLEGE OF
Maturation/Remodeling Phase PHYSICAL THERAPY

• wound contracts
• occurs by a complex interaction
of extracellular materials and the
fibroblasts
• Contraction: the reduction of
the size of the wound by the
inward movement of the
tissue and the surrounding
skin
 COLLEGE OF
PHYSICAL THERAPY

EXAMINATION AND EVALUATION OF

PEDIATRIC BURN
Physical Therapy Goal COLLEGE OF
PHYSICAL THERAPY

• To assist with burn wound management,

• To maintain or increase active and passive ROM,
• To manage soft tissue contours,
• To maintain and increase strength and endurance,
• To promote normal development and function,
• To inhibit loss of motion, deformity, hypertrophic scarring, and
contractures.

-Author/s (Year)
History Examination COLLEGE OF
PHYSICAL THERAPY

• Date of injury
• Mechanism of injury,
• What the child was wearing
• What was done immediately at the scene prior to emergency services
arriving
• What medical or surgical interventions the child has had
• Circumstances of the injury and the pattern of the burn will assist the team in
ruling out child abuse.
• Fluid resuscitation after burn

-Author/s (Year)
 System Review for Burn Patient COLLEGE OF
PHYSICAL THERAPY

-Author/s (Year)
 System Review for Burn Patient COLLEGE OF
PHYSICAL THERAPY

-Author/s (Year)
Pain Assessment COLLEGE OF
PHYSICAL THERAPY

• Wong Baker FACES

• FLACC
• A score of 3 requires analgesic intervention
• A score of 7 requires narcotics intervention

-Author/s (Year)
Sensation COLLEGE OF
PHYSICAL THERAPY

• Ability to detect touch or pain at the burn site indicates

the depth of the burn.
• Lack of normal sensation (Precaution in barefoot walking)

-Author/s (Year)
Mobility/Gait COLLEGE OF
PHYSICAL THERAPY

• If the patient is allowed to mobilize, examine the level of independence with

transfers in and out of bed and a chair, and with ambulating.
• With lower extremity burns, the child may have an antalgic gait, and may
need an assistive device.
• Following grafts, the child may have pain/ limitations at the donor sites,
which are frequently on the upper legs, thus impeding mobility and gait.
• During the scar maturation phase, truncal and leg scars may inhibit normal
walking or running patterns.

-Author/s (Year)
Functional Ability COLLEGE OF
PHYSICAL THERAPY

• How impairment cause reduce in physical

function on the child.

-Author/s (Year)
 COLLEGE OF
PHYSICAL THERAPY

CLASSIFICATION OF BURNS
Extent of Burn COLLEGE OF
PHYSICAL THERAPY

• Total Body Surface Area (TBSA)

-Author/s (Year)
Extent of Burn COLLEGE OF
PHYSICAL THERAPY

• Rule of Nines
• The head represents 9%, each arm is 9%, the
anterior chest and abdomen are 18%, the posterior
chest and back are 18%, each leg is 18%, and the
perineum is 1%. For children, the head is 18%,
and the legs are 13.5% each.

-Author/s (Year)
 COLLEGE OF
PHYSICAL THERAPY

-Author/s (Year)
Extent of Burn COLLEGE OF
PHYSICAL THERAPY

• Lund and Browder Chart

• This is a more accurate method, especially in children,
where each arm is 10%, anterior trunk and posterior
trunk are each 13% and the percentage calculated for the
head and legs varies based on the patient’s age.

-Author/s (Year)
 COLLEGE OF
PHYSICAL THERAPY

-Author/s (Year)
COLLEGE OF
PHYSICAL THERAPY
 Extent of Burn COLLEGE OF
PHYSICAL THERAPY

• Palmar Surface
• For small burns
• The patient's palm surface (excluding the fingers)
represents approximately 0.5% of their body surface area
• The hand surface (including the palm and fingers)
represents about 1% of their body surface area.

-Author/s (Year)
 COLLEGE OF
PHYSICAL THERAPY

-Author/s (Year)
 Depth of Burn Injury COLLEGE OF
PHYSICAL THERAPY

• The actual depth of injury may not be accurately or easily

determined on the first day, even by the most experienced
clinician
• Clothing of victim
• Age (thinner skin for younger patient)

-Author/s (Year)
 COLLEGE OF
PHYSICAL THERAPY

-Author/s (Year)
Superficial burns (First Degree) COLLEGE OF
PHYSICAL THERAPY

• Involve only the epidermis

and are warm, painful, red,
soft and blanch when
touched.
• Heals without scar formation
or discoloration
• Usually, there is no blistering.
• A typical example is a
sunburn.
Partial thickness burns COLLEGE OF
PHYSICAL THERAPY

• Extend through the epidermis and

into the dermis.
• The depth into the dermis can vary
• Superficial partial thickness 2nd
degree burn (epidermis and papillary
dermis) heals in 2 weeks or less
• Deep partial thickness (reticular
dermis); insensitive to light touch,
painful to pressure; 3-6 weeks
Partial thickness burns COLLEGE OF
PHYSICAL THERAPY

• These burns are typically very

painful, red, blistered, moist,
soft and blanch when
touched.
• Examples include burns from
hot surfaces, hot liquids or
flame.
Full-thickness burns COLLEGE OF
PHYSICAL THERAPY

• Extend through both the epidermis

and dermis and into the
subcutaneous fat or deeper.
• These burns have little or no pain,
can be white, brown, or charred
and feel firm and leathery to
palpation with no blanching.
• Will not heal without skin grafting
• These occur from a flame, hot
liquids, or superheated gasses.
 COLLEGE OF
Scar Formation
PHYSICAL THERAPY

Collagen synthesis in the wound Scar maturation for most children

Collagen formation begins within
and such activity returns to a is approximately 12 to 18
24 hours of the burn injury.
normal pace by 6 to 12 months months

the processes of
hypertrophy and
contraction can
be controlled or
corrected by
nonsurgical
approaches, such
as pressure, splinting,
and ROM exercises

-Author/s (Year)
Scar Hypertrophy and Contraction COLLEGE OF
PHYSICAL THERAPY

Hypertrophic scar Keloid

-Author/s (Year)
 COLLEGE OF
PHYSICAL THERAPY

MANAGEMENT
 COLLEGE OF
PHYSICAL THERAPY
American Burn Association
(Recommendation for specialized burn unit)

• Partial-thickness burns greater than 10% TBSA

• Burns of the face, hands, feet, genitalia, perineum, or major joints
• Full-thickness burns in any age group
• Electrical burns
• Chemical burns
• Burn injury in patients with pre-existing medical disorders that could
complicate management
• Burns in children at a hospital without qualified personnel or equipment
• Burn injury in patients that will require special social, emotional, or
rehabilitative intervention.

-Author/s (Year)
Preventive Measures COLLEGE OF
PHYSICAL THERAPY

• Lowering water heater temperature settings to 120° F or lower

• Keeping cords to coffee pots and cups with hot liquids out of reach of young
children
• Keeping young children in a safe place during food preparation and serving
• Turning pot handles toward the back of the stove and cooking on rear
burners when possible
• Supervising children in the bathtub and testing bath water with a liquid
crystal thermometer before placing the child in the tub

-Author/s (Year)
Preventive Measures COLLEGE OF
PHYSICAL THERAPY

• Keeping young children in a safe place when using appliances such as a

clothes iron or curling iron, and allowing these items to cool while out of the
reach of children
• Discouraging the use of infant walkers
• Placing safety caps on electrical outlets
• Teaching children that matches are tools, not toys
• Teaching older children and adolescents about: (1) the dangers of high-
voltage wires and (2) the dangers of and safe use of gasoline and other
flammable liquids
• Teaching children about the dangers of fireworks

-Author/s (Year)
Minor burns which you plan to treat can
be approached using the “C” of burn COLLEGE OF
PHYSICAL THERAPY
care:
• Cooling - Small areas of burn can be cooled with tap water or saline
solution to prevent progression of burning and to reduce pain.
• Cleaning – Mild soap and water or mild antibacterial wash. Debate
continues over the best treatment for blisters. However, large blisters are
debrided while small blisters and blisters involving the palms or soles are left
intact.
• Covering – Topical antibiotic ointments or cream with absorbent dressing or
specialized burn dressing materials are commonly used.
• Comfort – Over-the-counter pain medications or prescription pain
medications when needed. Splints can also provide support and comfort for
certain burned areas

-Author/s (Year)
Nutrition COLLEGE OF
PHYSICAL THERAPY

• Normal serum albumin is 3.5 to 5 g/dL.

• Normal serum prealbumin levels range from 16 to 40
mg/dL (>16 mg/dL malnutrition)
• The half-life of prealbumin is 2 to 3 days, thus making it a
good predictor of nutritional status

-Author/s (Year)
Pain Management COLLEGE OF
PHYSICAL THERAPY

• Background pain, which was relatively constant from the time of injury
through the initial healing period.
• Procedural pain, which was described as burning or stinging during wound
cleansing and dressing changes, and often included significant anxiety and
distress.
• Breakthrough pain, which was worsening of background pain either due to
a decrease in blood levels of analgesia and may require additional
medication or use of a patient controlled analgesia (PCA) pump

-Author/s (Year)
Pain Management COLLEGE OF
PHYSICAL THERAPY

NON PHARMACOLOGIC PHARMACOLOGIC

• Cognitive behavioural therapy
• Relaxation training
• Hypnosis
• Guided imagery;
• Biofeedback
• Distraction
• Art, music, and play therapies
• Multi modal Distraction
• Opiates have been proven useful
in alleviating burn pain. Can cause
itching
• Benzodiazepines are effective for
anxiety control.
• Ketamine, a dissociative
anesthetic, is also widely used to
provide comfort and has an
amnesic effect so the child does
not have memory of the painful
procedure

-Author/s (Year)
Pain Management COLLEGE OF
PHYSICAL THERAPY

• Morphine appeared to be the “gold standard” for

medicating the child before, during, and after a painful
procedure

-Author/s (Year)
 Multimodal Distraction COLLEGE OF
PHYSICAL THERAPY

-Author/s (Year)
Wound Care COLLEGE OF
PHYSICAL THERAPY

• Room temperature should be at least 86° F to minimize heat loss and lower
the metabolic rate of the child.
• Whirl pool
• Air drying
• Silvadene (MC antibacterial)
• Mafenide acetate (Sulfamylon)-eschar penetration
• Contact layer (Exu-Dry, Conformant, Xeroform, and Adaptic)

-Author/s (Year)
Secondary dressings COLLEGE OF
PHYSICAL THERAPY

• Acticoat dressing (gram – and

+ bacteria infection)
• AQUACEL Ag Hydrofiber is a
moisture-retentive topical
dressing used in the acute
management of burns
Skin Grafting and Replacement COLLEGE OF
PHYSICAL THERAPY

• Skin replacement is the application of healthy skin onto

the wound bed and includes autograft and allograft.
• Skin substitute is a mixture of cells or tissues that
replaces skin autograft or allograft and is usually
temporary or used in two-stage procedures

-Author/s (Year)
 COLLEGE OF
PHYSICAL THERAPY

-Author/s (Year)
Autograft COLLEGE OF
PHYSICAL THERAPY

• Autograft is achieved by harvesting the patients’ healthy skin and is

the current standard of care in burn surgery.
• Full-thickness skin grafts (FTSGs) or split-thickness skin grafts
(STSGs).
• Thicker grafts, therefore, have a better cosmetic and functional
outcome.
• Graft survival depends on the diffusion of nutrients and oxygen from
the wound bed known as imbibition.
• Inosculation then follows when the blood vessels of the graft and
from the wound bed grow together to make end-to-end contact.
• Neovascularization occurs when new blood vessels grow from the
wound bed into the graft.

-Author/s (Year)
Xenograft COLLEGE OF
PHYSICAL THERAPY

• Porcine-derived products are most commonly used but

put patients at risk for invasive infections if left in place
for more than a few days.
• Best used for temporary coverage of superficial partial-
thickness burns and less so for deep partial-thickness
and full-thickness burns due to infection risks.

-Author/s (Year)
Whirlpool (Benefits) COLLEGE OF
PHYSICAL THERAPY

• Help remove the old topical antimicrobial agent

• To clean the wound, to help superficially debride the
wound (through the effect of the agitator)
• To increase circulation to promote wound healing
• To provide an environment for exercise.

-Author/s (Year)
Whirlpool (Disadvantages) COLLEGE OF
PHYSICAL THERAPY

• It can spread infection

• It can increase the length of time required for a dressing
change
• It can increase cost (because of the additional personnel
required to perform the procedure and clean the
equipment)
• It can increase edema (especially if a limb is placed in a
dependent position),
• Children may find it traumatic,

-Author/s (Year)
 COLLEGE OF
Position, Casting and Splinting
PHYSICAL THERAPY

-Author/s (Year)
Pressure Garments and Orthosis COLLEGE OF
PHYSICAL THERAPY

• Pressure levels for these garments should be 24 mm Hg or above and

applied for a minimum of 12 months.
• Pressure garments are worn for 23 hours a day, allowing removal for
bathing/skin care.
• Pressures over 24 mm Hg occlude vessels, which leads to hypoxia and
fibroblast degeneration and altered collagen synthesis
• Flexible neck orthosis that allows circumferential pressure to the neck to
assist increasing ROM and is easier to fabricate than traditional
thermoplastic splints

-Author/s (Year)
Massage and Scar Mobilization COLLEGE OF
PHYSICAL THERAPY

• Massage of scar tissue and skin grafts helps maintain

motion by freeing restrictive bands and increasing
circulation.
• Massage may also be helpful in decreasing itching

-Author/s (Year)
Exercise COLLEGE OF
PHYSICAL THERAPY

• AROME and PROME

• Aerobic exercise for inhalation injury
• Strength training

-Author/s (Year)
Resources COLLEGE OF
PHYSICAL THERAPY

• Tecklin, Alexander , Pediatric Rehabilitation

• Guidelines on Burn Care American Burn
Association

-Author/s (Year)