C u r re n t Co n c e p t s Bu r n

R ehabilitat ion, Par t I I

Long-Term Recovery
Heather Dodd, OTR/La, Sandra Fletchall, OTR/L, CHT, MPAb,
Carrie Starnes, LRT/CTRS, CCLSa, Keith Jacobson, MPTa,*

KEYWORDS
 Burn  Rehabilitation  Scar  Exercise  Coping  Psychosocial adjustment  Recreation therapist
 Child Life specialist

KEY POINTS
 Range of motion can be preserved through splinting and scar contracture management.
 Maximal independence after burn injury can be gained through exercise and activities of daily living
training.
 Child life specialists and recreation therapists specialize in nonpharmacologic management of pain
and anxiety to aid in psychosocial recovery following burn injury.

OUTPATIENT MANAGEMENT OF SCAR therapy (RT) aid in the continuum of care that pa-
CONTRACTURES tients need to succeed and return to their life goals.
Rehabilitation from a burn injury begins acutely
within minutes of admission to the hospital but HYPERTROPHIC SCARS
can continue for weeks, months, and years. Outpa-
tient care is essential to the success of burn survi- From the time of wound closure, clinicians can
vors. Studies show that the prevalence of scar often predict the potential for hypertrophic scar-
contracture at discharge is high, around 40% to ring. Family genetics increase the likelihood of
55%, thus showing a need for optimal continued developing hypertrophic scarring but not as
rehabilitation and reconstructive care.1 The focus much as the overall time of wound healing. Litera-
of care continues on minimizing hypertrophic scar ture indicates that the time to heal directly corre-
and contracture formation; improving flexibility, lates to the propensity to form hypertrophic scars
strength, and endurance; ensuring proper skin (HSs), with those healing in 14 to 21 days having
and scar management techniques; and promoting a 30% incidence of HSs and those more than
independence in normal daily activities, including 21 days with a 78% incidence.3 HSs can affect
self-care and social and recreational pursuits. people’s ability to fully engage in their days.
This long-term rehabilitation phase may in- Neuropathic pain, itching, pruritus, and stiffness
clude reconstructive surgeries and lifelong services create barriers in burn patients’ levels of function,
for contractures being exacerbated by patients’ including work and recreational activities.4 Ther-
growth and aging.2 Outpatient therapy services, apy services can offer scar modalities and pres-
plasticsurgery.theclinics.com

including occupational, physical, and recreational sure garment therapy to help in decreasing these
symptomatic restraints.

Disclosure: The authors have nothing to disclose.

a
Rehabilitation Therapy Services, NC Jaycee Burn Center, 101 Manning Drive, CB #7600, Chapel Hill, NC 27599,
USA; b Burn Rehabilitation, Firefighters Burn Center, 890 Madison Avenue, TG 043, Memphis, TN 380103, USA
* Corresponding author. UNC Hospitals, NC Jaycee Burn Center, 101 Manning Drive, Chapel Hill, NC 27514.
E-mail address: [email protected]

Clin Plastic Surg 44 (2017) 713–728

http://dx.doi.org/10.1016/j.cps.2017.05.013
0094-1298/17/Ó 2017 Elsevier Inc. All rights reserved.
714 Dodd et al

Through the use of manual scar management or needed, other commercial garments may be
compression garment therapy, 2 main goals are measured and fitted to the patient by the therapy
achieved: restricting the flow of blood to the scar team. These products have a high-grade
area and inhibiting growth of the HSs by control- compression of about 30 to 45 mm Hg and can
ling collagen synthesis by limiting access to blood be used for longer durations because the prod-
supply, oxygen, and nutrients.5,6 Scars create ucts are of higher quality (ie, Mediven, Jobst, Bio-
increased tension and restriction for passive or concept). It has been noted by patient reports
active movement, which influences the patient’s that there is a significant improvement in ery-
ability to resume preburn activities. The burn reha- thema when placed in higher mercury garments,
bilitation team can manage all the components of such as 25 to 45 mm Hg, as opposed to the
so-called scar wars by introducing, educating, lower-level compression, as their wounds prog-
and providing the tools needed to enhance ress in healing. Depending on the funding source
patients’ quality of life. of the patient, custom burn garments for any part
of the body can be measured by the outpatient
therapists and obtained through a company
SCAR MANAGEMENT
specializing in burn-specific garments. If funding
Pressure Garment Therapy
is not available for custom burn garments,
Literature continues to question the efficacy of consider the use of more affordable garments
pressure garment therapy in treating HSs (Fig. 1). for the trunk or extremities, such as athletic-
Although used as long ago as the early 1800s, pres- style garments (Table 1).
sure garments were not used prophylactically or to Assessment tools such as the Vancouver Scar
treat HSs until the early 1970s, based on observed Scale, which is a clinician’s tool to examine
increase rate of maturation.5 The use of compres- pigmentation, pliability, vascularity, and height of
sion garments is currently standard among burn scarring, or the Patient and Observer Scar Assess-
centers to treat HSs because of its “non-invasive ment Scale can aid in understanding the positive
characteristics and presumed desirable treatment results the use of pressure garment therapy can
effects with few associated complications.”4 provide.7,8 Having patients’ personal input on their
As wound size decreases and tensile strength progress or personal assessment of their pain,
of the graft or conservative healed skin wounds stiffness, and pruritus of their HSs can guide clini-
occur, pressure to the hands can progress from cians in altering the use of or need for change in
Coban wrap to temporary pressure gloves, with mercury pressure of the garments. Studies have
a recommended pressure of 15 to 20 mm Hg. Up- shown that with the use of compression, the height
per and lower extremity compression can prog- of the HSs can flatten and improve by 92%.3
ress from Ace wraps to the use of commercial For burn wounds that are deeper or those that
Tubigrip or Demigrip, which also tend to vary in require autografting, scar tissue may require 9 to
pressure from 15 to 20 mm Hg. Once a patient’s 18 months to reach full maturation. The use of
wounds are well healed, and no dressings are pressure garments decreases the hydration of
the scar, reducing the neovascularization and ac-
celerates the remission phase of the postburn
reparative process.6 With the use of pressure
garment therapy until this scar tissue maturity is
achieved, it minimizes edema, provides a method
of scar tissue pliability, and assists with reeduca-
tion of abnormal sensory responses.
Patients with burns may require the use of
compression garments for 2 years or more,
depending on the depth of the injury and the
vascular symptoms, which may fluctuate
throughout the rehabilitation and maturation
phases. Some burn centers recommend wearing
compression garments as much as 23 hours a
day for 12 months. It is important that patients
have continued contact with the therapy team to
Fig. 1. Hypertrophic scarring following a burn to the reassess and monitor potential need for changes
dorsal left hand. The efficacy of pressure garment to the garments. Family and patient education is
therapy for treating hypertrophic scar has been essential regarding the rationale for the use of
questioned. pressure during the acute phase of the burn, as
 Burn Rehabilitation: Long-Term Recovery 715

Table 1
Affordable options for compression garments should be considered when funding for custom burn
garments is not available

Trunk Garment Options Corsets/Spanx/girdle Abdominal binders 15 cm (6”) Ace wrapping

Upper and Lower Sliders/biker shorts/ Basketball/football Weight-lifting/golf gloves
Extremity Compression compression shorts sleeves

well as frequently throughout the rehabilitation thick moisturizing cream, such as Eucerin or Ceta-
phase, to ensure compliance. phil, helps to softening the skin before direct
Clinicians should take into consideration both manual massage. The technique of scar massage
the pros and cons of pressure garments (Table 2) should be to apply a slow, prolonged pressure to
when assessing patients and their primary areas of tension or thickness, emphasizing areas
needs. Although pressure garment therapy has of a potential or contracted joint. It is suggested
been shown to aid in reducing HSs, other as- that patients complete massage 3 times a day
pects of outpatient therapy, such as exercise, for 5 minutes, especially in an area of HSs, while
splinting, and reconstructive surgery, allow an the joint is in full extension and the scar contrac-
optimal level of function and cosmesis to be ture is at its fullest pull or tension. Massage tech-
achieved.9 niques create a force and mechanical change in
the direction and pull of the scar tissue that seems
to create a disruption of the fibroblasts. Patients
Scar Massage
report a decrease of pain and pruritus with the
The use of scar massage in addition to pressure use of massage techniques.11 A reduction of
garment therapy can effectively increase the pain with the use of massage techniques could
aesthetic appearance of HSs, increase movement be attributed to the release of dopamine, which
of scar contractures, and decrease hypersensitiv- is obtained through firm pressure. Often patients
ity and neuropathic pain. The use of massage ther- are hypersensitive to deep scar massage so tech-
apy or therapist-assisted manual elongation niques of desensitization should also be intro-
techniques has frequently been used in individuals duced. Simple techniques such as touching or
with firm, nonelastic scar tissue or scar bands. A rubbing areas with different textures ranging from
literature review of numerous studies found some cotton balls to terry cloth towels, as well as just
evidence for the benefit of massage therapy.10,11 having the patient touch the newly healed skin,
Studies show that daily scar massage may prevent can aid in sensitivity and normalizing touch.
and improve HSs by improving scar-related pain,
pruritus, pliability, and thickness.10 Therapists Silicone
should include education of scar management
techniques as soon as burn wounds are closed Scar tissue can be further influenced by the thera-
and not at risk for skin breakdown or abrasion. A pist with the use of silicone gel or silicone gel
sheets. In the current practice guidelines for the
use of silicone, it is recommended for use with
Table 2 immature scars that have a high potential of devel-
Clinicians should consider the pros and cons of oping HSs.12 The process of positive scar influ-
the use of pressure garment therapy when ence through the application of silicone has been
addressing a patient’s rehabilitation needs described as hydration and occlusion, which
seems to reduce the activity of fibroblasts and
Pros Cons collagen development.10,11 Silicone can be used
Decreased edema Costly under an Ace wrap or pressure garment. Guide-
Decreased neuropathic Overheating
lines recommend that the silicone extends 5 mm
pain beyond the margins of the scar. The silicone wear-
ing time should begin at 1 to 2 hours, and, if there
Increased pliability Unattractive
is no development of skin reaction or pruritus, then
Flattening of HSs/ Wound breakdown/
should increase daily until 23 hours a day is
increased tissue blistering
aesthetics
reached. To further minimize skin problems, the
silicone must be removed, with the area of appli-
Increased psychosocial Family compliance/
cation and the silicone washed and dried thor-
health adherence
oughly several times a day.12 For selected
716 Dodd et al

patients, the ability to tolerate the silicone is poor if Patients who sustain burn injuries can experi-
their home environment or work place has high ence diminished activity performance caused by
temperatures and humidity; for these patients it the sequelae of immobilization, ventilator depen-
may be limited to a few hours daily. The incidence dence, and the burn-related catabolic response.
of skin maceration and contact dermatitis in- Hypermetabolism following a burn injury can result
creases in this type of environment and should in loss of muscle mass, leading to rapid-onset
be monitored. muscle fatigue. During this phase, individuals
Silicone products come as a gel or hydrogel attempting to complete activities of daily living
sheet and also as a silicone spray, which can be (ADL) must perform at a higher percentage of their
more costly. There are also over-the-counter op- maximal effort. The predicted age-appropriate
tions of silicone that can be purchased by patients resting energy expenditure following a burn injury
who are not able to purchase because of financial remain increased by 20% to 100% for months to
strain (Box 1). Most insurance companies do not years.14–16 The burn-induced catabolic response
cover the expense of silicone and this becomes can persist from 9 months to 3 years after the
an out-of-pocket expense for the patient and burn, resulting in an impaired ability of the individ-
family. ual to effectively resume preburn activities.14–16
Studies show that the use of silicone gel sheet or Burn injury causes protein synthesis and muscle
spray with compression garments and pressure atrophy to occur at the site of the injury as well as
garment therapy alone for 1 year were associated distant to the injury.15 A 2016 survey of individuals
with significant improvement of the Vancouver with larger percentage burns found that more than
Scar Score and the subscores for pliability, height, 30% identified muscle weakness and more than
pruritus, and vascularity at the 18-month end 50% reported fatigue.17 In addition, patients with
point.13 If patients can be provided with scar man- an average length of stay of 15 days, indicating
agement tools, such as compression therapy, scar small percentage burns, also had muscle weak-
massage, and silicone, there is an increased likeli- ness greater than the matched controls.14 Pulmo-
hood of returning back to their normal lives at a nary function following a burn injury has been
quicker rate. identified as being decreased compared with the
patients’ age-related peers. Pulmonary function
THERAPEUTIC EXERCISE IN THE LONG-TERM has been found to remain decreased for months
REHABILITATION PHASE to years following a burn, regardless of the pres-
ence of an inhalation injury.18 During the first
During the outpatient rehabilitation phase of re- 2 years following the burn injury pulmonary change
covery, patients with burns may go through count- may be identified as having an obstructive pattern,
less physical and emotional changes. Once home, and later develops into a restrictive pattern.18
patients begin to experience both functional and In recent years, an effort has been made to
social consequences from the burn injury, all of determine whether a structured resistive exercise
which have a direct effect on the motivation to program could benefit patients who have sus-
remain compliant with therapy recommenda- tained a burn injury. From the work and research
tions.2 Before discharge from the acute setting, a completed to date, it is recommended that individ-
patient’s strength and endurance may be uals more than 7 years of age should be evaluated
adequate for independence in daily living. Once for strength and cardiovascular performance.19
home, fatigue may be a major barrier to success. When assessments indicate the individual is below
Because of this a continued rehabilitation program norms for the individual’s age group, a structured,
and open communication with the therapy team supervised resistance and/or aerobic program
must continue after discharge. should be implemented.19 Following participation
in a structured supervised resistive exercise
Box 1 program, individuals reported an improvement in
Affordable silicone options should be health-related quality of life equal to their nonin-
considered when gel sheet, hydrogel sheet, or jured counterparts. Although Storch and Kruszyn-
silicone spray are not available to the patient ski20 did not specifically study the effects of an
exercise program on individuals following a burn,
Swimmer’s ear wax
they focused on individuals admitted to an inten-
Nipple pads for breast-feeding mothers sive care unit (ICU) and found similar positive ef-
Prosthetic liners fects of psychosocial improvements. Storch and
Over-the-counter (drug store) silicone Band- Kruszynski20 indicated that physical exercise pro-
Aids grams can contribute to improvements in cogni-
tive function; specifically, memory, concentration,
 Burn Rehabilitation: Long-Term Recovery 717

and focus. With a structured resistive exercise colleagues,14 whereas Porter and colleagues16
program for individuals with burn injury, an in- provide a 6-week program for those with less
crease in protein synthesis also produced an in- than 60% TBSA and a 12-weeks program for
crease in muscle size and lean body mass, those with more than 60% TBSA. Although most
regardless of age or gender.15,16,18,21 of the outpatient resistive exercises programs are
In the first 6 to 8 weeks of an exercise program, 3 days a week for 30 minutes, the length of the
improved efficiency in neural recruitment patterns, session is influenced by the patient’s decondi-
which contributes to increase in muscle power, tioned status. For patients transferred to an inpa-
was observed. Muscle hypertrophy occurs during tient rehabilitation program, portions of the
the 12 to 16 weeks of the resistive program.15 resistive exercise program can be initiated if active
The use of propranolol in children resulted in movement of the body area is within functional
improved maximal oxygen uptake (VO2) compared limits. The author’s program places patients in an
with a group that received only a resistive-only elongation, movement, endurance, and progres-
program. However, the use of this beta-blockade sive resistive program within 24 to 48 hours
with adults is associated with negative out- following burn hospital discharge for 2 to 4 hours,
comes.19,20,22 For children and adults, more im- 3 days a week, with no harmful events occurring.
provements were noted when an anabolic agent, The length of the program is based on the patient’s
such as oxandrolone, was used in conjunction s preburn activity level; for those needing to return
with the exercise program.15,19 to competitive employment/work, the program
In “Practice Guidelines for Cardiovascular may be up to 12 to 16 weeks.
Fitness and Strengthening Exercises Prescription Outpatient treatment activities are similar to
after Burn Injury,”19 it is recommended that children those used during the inpatient rehabilitation
to receive a structured exercise program for up to phase, but their intensity and frequency increase.
12 weeks and adults from 6 to 12 weeks. However, Scar management techniques such as massage
current research has not extended beyond and elongation continue but there is a greater
12 weeks and the potential for benefits remains un- focus on strengthening, and ADL independence
known. For children less than 7 years of age, an in- is essential as well. Because scar management is
crease in movement of elbows and knees was more successful during the early stages of wound
recorded when their programs included both music maturation, limitation in self-care ability can be
exercise and rehabilitation compared with rehabili- resolved if appropriate treatments are imple-
tation only. Both programs resulted in greater im- mented. Performing basic self-care activities,
provements than no structured therapy.16 such as donning compression garments or work-
For patients with less than 15% total burn sur- ing on applying lower body clothing, can also be
face area (TBSA) with unhealed burn wounds, an effective and meaningful way to increase
participation in an exercise program produced strength, endurance, and coordination. It is impor-
positive effects on pain reduction, muscle tant not to introduce adaptation tools early, such
strength, and movement without harm to the heal- as ergoreachers or built-up handles, without first
ing process.21 With the use of handheld dyna- applying compensatory techniques because burn
mometry, the greatest minimal detectable patients’ scar contractures are relative to the
difference in muscle strength was with static grip amount of accommodation that is provided to
strength and the least was in the deltoids. The the pattern of scar.2
study reported that the biceps and quadriceps
strength increased in a linear trajectory with biceps
Positioning/Splinting
at 0.1 kg/d and quadriceps at 0.18 kg/d. Static
hand grip strength decreased between day 1 and Once scars mature in the rehabilitation phase, the
3 by 1.76 kg/d; however, between day 4 and 6 it need for splinting and preventive positioning
increased by 1.13 kg/d.21 decrease but there are times when a scar contrac-
Research work performed to date has shown ture is so advanced that prevention of further loss
that patients involved in a structured exercise of motion is the next therapy goal. When a patient
resistive program versus those who are not require is compliant with postdischarge management and
fewer invasive surgical procedures; at 6 months has access to the use of preventive tools such as
they have greater aerobic capacity, muscle splints, further surgical reconstruction can often
strength, and lean body mass, and return to work be avoided. During the long-term phase of rehabil-
sooner.15,16 Resistive programs could begin on itation, scar maturation occurs but range of motion
an inpatient basis, although many are established gains can still be achieved with the use of
after discharge. A work-to-tolerance program for home exercise program (HEP) and progressive
12 weeks is suggested by de Lateur and splinting23; research has shown that splinting
718 Dodd et al

alone can be more effective in reversing scar con- involved in both before and after management
tractures more rapidly than all other interventions of reconstruction to prevent tissue reshortening.
in this phase.24 Because of the extended duration of the
Static and/or dynamic splinting can be effective long-term rehabilitation phase and associated
as a corrective force to exert or stretch the tight scar maturation, it is common to alternate the
tissue or correct an existing contracture. Static use of static, static-progressive, and dynamic
splints can be used during rest or sleep to maintain splints as range of motion and surgical needs
the range of motion that is achieved throughout change.13
the day with dynamic splinting and the HEP. Burn survivors require intensive therapy ser-
Splints should be fabricated to have the wrist in vices through the acute phase and throughout
a neutral 10 to 15 of extension, metacarpopha- the long-term rehabilitation phase to regain inde-
langeal (MCP) joints at 70 to 90 of flexion, and pendence to manage their physical changes.
the thumb in a combination of radial and palmar There are psychosocial repercussions of abnormal
abduction at the carpometacarpal, and MCPs at visible scarring and it is clear that improving scar
full neutral extension (very similar to positioning aesthetics promotes adjustment and return to
in the acute phase). participation in age-appropriate occupations.8
Dynamic splinting works on the biomechanical Addressing not only the physical dysfunction but
principle of increasing tissue creep by applying a also the psychosocial limitations created by the
constant force to progressively lengthen the tissue injury, and understanding how these affect pa-
over time using rubber bands or pulleys (Fig. 2). tients’ self-image and motivation, is critical for
Studies show that increased tissue length occurs optimal healing.
in a manner similar to the increase that occurs dur-
ing the use of tissue expanders in burn reconstruc- THE ROLE OF THE CHILD LIFE SPECIALIST AND
tion.25 Although custom dynamic splinting may be RECREATION THERAPIST IN PSYCHOSOCIAL
time consuming, this is preferred compared with RECOVERY AFTER BURN
static splints to enhance functional gains.
Postoperative positioning of skin grafted Child Life (CL) and RT services are beneficial when
areas or reconstructed tissue is implemented ac- working with patients and families who have expe-
cording to physician’s orders; however, the rienced a burn injury. Both services help patients
development and implementation of positioning and families find positive coping techniques and
programs are core components of burn thera- ways to adjust to the effect of the burn injury. CL
pists’ job responsibility.26 No matter the extent specialists (CLSs) work with pediatric patients
of surgical reconstruction that a patient may and their siblings, as well as the children of adult
require, it is essential that the therapy team is patients. The purpose of CL is to promote coping
through therapeutic play, medical support, and
education of all children involved, which is accom-
plished by promoting positive coping and self-
expression as they relate to hospital experiences
(Fig. 3). CLSs work closely with patients and fam-
ilies to establish rapport and foster a safe environ-
ment in the hospital.
RT uses recreation and leisure as a path to
recovery in the emotional, cognitive, physical, so-
cial, and leisure/recreation domains (Fig. 4). An
import aspect of recovery is the return to commu-
nity and social settings. RT uses the patient’s
support system and interests to motivate and
encourage the patient in meeting goals, including
coping/adjustment, nonpharmacologic pain man-
agement, exercise, range of motion, expression
of emotion, peer support, and community/work/
school reentry.
Fig. 2. This dynamic metacarpophalangeal flexion Within the burn service, CL and RT are impor-
splint is based on the biomechanical principle of tissue tant to all aspects of care. This therapist’s institu-
creep. In this example, rubber bands apply a constant tion (NC Jaycee Burn Center) uses both RT and
force in an effort to progressively lengthen restrictive dually certified RT/CLSs to meet the needs of all
tissue of the dorsal fingers and hand. patients on the burn service.
 Burn Rehabilitation: Long-Term Recovery 719

Fig. 3. CL provides play opportunities to build Fig. 4. Recreation therapy uses patient leisure inter-
rapport, establish trust, and provide normalization ests to motivate and encourage patients to meet their
during hospitalization. goals.

Coping with Stressors in the Critical Phase of Coping, Anxiety, and Stressors in the Acute
Recovery Phase of Recovery
Immediately after injury and admission to the ICU, As patients progress in their healing and recovery,
patients and family are often faced with stressors they can become more aware of what is
arising from the unknown and a lack of familiarity happening around them. It is at this time that pa-
with the ICU environment. Educating patients tients may first develop concerns regarding the
and their families on the mission of the burn center impact that their injuries have on daily life, and
and the complex nature of burn care is an impor- not only for their own lives but also those of their
tant part of this initial phase of the recovery pro- families. This time is the acute phase of recovery
cess. At this time, patients may be partially or when feelings of anger, guilt, anxiety, depression,
completely sedated for medical procedures. The acute stress disorder, and posttraumatic stress
burn staff take into consideration the effects that disorder may become evident. Patients in the
medication can have on cognition and orientation. acute phase of recovery may also have concerns
In addition, ICU delirium can occur during this regarding sleep disturbances, including night-
period and can manifest emotionally and behavior- mares and insomnia, as well as grief related to
ally. Allowing patients to begin learning coping their injuries.27 These feelings can make it difficult
skills during the acute phase starts with speaking for patients and families to adjust to treatment and
to them as if they were awake and informing hospitalization, resulting in withdrawal and social
them on what is occurring. Consistency in this isolation. These psychological effects are more
approach is important because patients’ levels of prevalent among those who have sustained
awareness may wax and wane. Reality orienta- burns.28 Anxiety and stress may be more evident
tions as well as visual and verbal cues provide a with patients in this phase as patients become
sense of normalcy and consistent reminders for more aware of their injuries. As patients’ strength
critically ill patients. Coping can be improved by and mobility improve it should be expected that
having a supportive family. they will become more aware of the specific
720 Dodd et al

physical limitations caused by their injuries. These from a stressor. These patients were more recep-
limitations can be a source of anxiety and stress. In tive to learning nonpharmacologic coping tech-
addition, patients in this phase may undergo daily niques, such as diaphragmatic breathing, guided
dressing changes and multiple surgeries. Patients imagery, and conversation during invasive pro-
may also receive extensive therapies for range of cedures.31 Both coping styles can easily be adapt-
motion, splinting, and ambulation. ed to the needs of the patient by observing the
Stress is the feeling of tension or strain in the patient’s involvement in care and treatment. Treat-
mind or body and can be interpreted by patients ment should be provided by meeting the patient
in different ways. Stress can also affect how a per- and using the patient’s preferred coping style in
son interacts with other people. For example, order to achieve the best possible outcome.32
some may find it easier to lash out or to socially The process of assisting patients with burn injuries
isolate. The feeling of stress is considered a to adjust to their hospitalization, injury, and treat-
normal reaction to the types of change or circum- ment can be difficult for both the patients and their
stances associated with a burn injury. Finding families.
healthy ways to reduce and manage stress is Burn injuries often result in scarring, leaving
important so that the body and mind can heal. patients and families struggling to adjust to the pa-
Depression is another psychological condition tients’ appearance and acceptance of their in-
that may affect patients in the acute phase after juries. Patients with scarring on any part of the
burn injury. Patients may have guilt related to the body can have difficulty with accepting their in-
injury and/or the burden it places on the family. juries. As in any traumatic event, burn injuries
This feeling of guilt increases the risk for depres- may trigger negative feelings, including fear of
sion. Depression can occur in patients with a rejection, loss of love, and loss of appreciation. It
burn of any size and, the development of depres- is important to remember that some patients dur-
sion does not always relate to the site or size of ing this phase also have questions and concerns
burn injury.29 Additional factors that may also related to healing and body image. Age-
play a role in depression include level of social appropriate education is a valuable and important
support, presence of actual and/or perceived resource for psychosocial adjustment of patients
pain, TBSA, and the location of the injury. with burn injuries and their families.
Pain is an important element of the recovery Social support systems are a key factor in help-
process. According to Wiechman,30 “it is useful ing patients adjust to injury and hospitalization.
to understand the psychological factors that can Research strongly suggests that social support
exacerbate pain.” It is beneficial to associate the has an impact on the long-term outcome of adjust-
relationship between psychological conditions ment to injury for not only the patient but the fam-
(anxiety, stress, depression, and so forth) and the ily. Din and colleagues33 noted that, “findings
person’s perception of pain. Its impact and effect verified that when social support is provided to
on coping for patients with burn injuries can be the burn patient he or she feels himself valuable,
compromising to recovery. which is related to reducing the stress and other
Patients tend to have one of 2 types of coping psychological problems.”
styles. The approach-type patients seek informa- Peer support is another valuable resource avail-
tion related to their care and hospitalization and able to some patients with burn injuries. Providing
tend to take an active role in their wound care patients and families with a support network of
and treatment. In a 2011 study, it was suggested other burn survivors who have hands-on experi-
that patients with this type of coping style gener- ence of what it is like to go through such a trau-
ally do not use distraction techniques during in- matic event has been reported as helpful in
vasive procedures because they tend to avoid adjusting to life with a burn injury. Studies show
situations that require them to relinquish control.31 that providing peer support can help provide op-
Essentially, providing information for the approach portunities for increased self-esteem, improved
type provides a sense of control over the situation. quality of life, and decreased feelings of isolation.
The study also goes on to report that patients us- When patients speak to other burn survivors it
ing this coping style are more likely to be receptive can be an empowering experience resulting in
to education related to surgery, healing, and body positive outcomes that can provide comfort and
image.30 The second type of coping is referred to foster healing.34 Burn survivors can benefit from
as the avoidant type. This style tends to lean to- peer support to create a sense of reassurance,
ward cognitive avoidance and relinquishing con- hope, and inspiration during the course of burn
trol when considering the injury and procedures. recovery.
Patients using this type of coping style tend to Patients who are recovering from a burn injury
find success with distraction to divert attention vary greatly in their readiness to receive peer
 Burn Rehabilitation: Long-Term Recovery 721

support. This peer support may occur during the peer support to meet the needs of the patient
acute phase of recovery or after hospitalization. and family. Patients and families are provided op-
It is important that CLSs and RT as well as other portunities to learn about their medical experi-
burn staff monitor patient readiness for peer sup- ences, including operating room preparation and
port and make referrals when appropriate. Peer information on facial and donor site healing
support can also be provided to family members (Fig. 5). Patients and families are encouraged to
at any time during a patient’s hospitalization. use nonpharmacologic coping techniques in addi-
Peer supporters in this facility are at least 1 year tion to pharmacologic interventions for pain and
after injury and are part of the Phoenix Society Sur- anxiety management. Some of these techniques
vivors Offering Assistance in Recovery (SOAR) are discussed here.
program. Peer supporters may not only be burn
survivors but also family members, burn care staff, Diaphragmatic breathing
and firefighters, among others. Diaphragmatic breathing is a type of relaxation
By learning to use positive coping techniques breathing that uses the diaphragm. The result is
during the acute phase of injury, patients can miti- slow, even, and deep breathing. Benefits of this
gate some of the detrimental effects of stress and technique include decreased pain, decreased
anxiety. CL and RT provide support to patients heart rate, decreased anxiety, decreased muscle
and families no matter what phase of recovery tension, decreased stress, and a slowing of respi-
they are in. Interventions are determined and ration (Fig. 6).
assessed in the 5 domains in the following ways.
Guided imagery
Guided imagery is a skill that can be used to help
Emotional Domain
relax mind and body. In guided imagery, the imag-
The goals of the emotional domain are to establish ination and 5 senses are used to take the mind to
positive coping, support, and well-being. CL/RT a place where the person would rather be. Benefits
encourages expression of emotion through con- of this technique include decreased stress,
versation, journaling, education on healing, and improved sense of control, decreased anxiety,

Fig. 5. Progressive facial burn wound healing. This example was taken from an iBook created by RT/CL for the
purpose of educating patients on the healing process of facial burns.
722 Dodd et al

Fig. 6. Patient education handout provided as a part of diaphragmatic breathing instruction. This material is pro-
vided in other languages.

improved sleep, improved concentration, and the coherent heart rhythms naturally emerge due
decreased pain (Fig. 7). to positive experience, or through the self-
activation of positive emotion.” This coherence
Emotional self-regulation and coherence can be gained by using paced breathing tech-
McCraty and Zayas35 report that “psychophysio- niques, thus linking the breathing and heart
logical coherence is used in the context of when rhythms in the brain. These techniques can be
 Burn Rehabilitation: Long-Term Recovery 723

Fig. 7. Guided imagery patient education handout provided to patients. This handout is also available in other
languages.

used in the moment to create the shift in and the ability to regulate and maintain compo-
coherence. “The use of these techniques typi- sure (Fig. 8).
cally shift the user’s physiology into a more
coherent and balance functional state with re-
Cognitive Domain
flected in the patterns of the heart’s rhythm.”35
These techniques and increased coherence can The goal of the cognitive domain is to promote
lead to feeling of calmness, positive emotion, medical understanding of injury, treatment, and
724 Dodd et al

Fig. 8. (A) This patient’s coherence is at a low level at baseline. (B) The same patient’s coherence at a higher level
after engaging in an Emotional Self Regulation session.

hospitalization. In addition, nonpharmacologic Medical play/procedural support

coping techniques to assist with pain and anxiety CLS and RT work to meet the need of pediatric pa-
are taught. CLSs and RT specialists meet the tients, siblings, and children of adult patients on
cognitive needs of patients with burn injury and their learning style and adapt information and sup-
their families through education on many levels. port to their level. By providing education through
Two primary areas of education are nonpharma- age-appropriate medical play and reinforcement
cologic coping techniques and body image. through written material, educational tools become
Handouts can provide detailed information for vital aspects in the healing of pediatric patients.36
patients regarding body image and healing, non- LeRoy and colleagues37 state that, with preproce-
pharmacologic coping techniques, as well as dural preparation of children with congenital heart
preparation for treatment and support for pro- disease, the following are possible outcomes:
cedures and therapies. Some facilities use elec- “reduced anxiety for patients and family mem-
tronic books, apps, or published books on bers/caretakers; improved patient cooperation
healing after burn injury. Educational materials and adjustment during and between medical pro-
also assist patients with learned coping strate- cedures, enhanced post-procedure recovery,
gies, discharge planning, and community reentry increased sense of mastery and self-control for pa-
(Box 2). tients and family members/caretakers, enhanced
 Burn Rehabilitation: Long-Term Recovery 725

Box 2
Summary of hospital-specific education materials and subject matter created by recreational therapy/
child life that are available for patients and families.

Educational materials for patients and families

 Electronic prep book for this institution used by CL and RT
 Areas
- Inpatient operating room
- Outpatient operating room
- Bronchoscopy Laboratory
- Vascular intervention radiology
- Pediatric hematology/oncology clinic
 Procedures
- PICC (peripherally inserted central catheter) line
- Computed tomography scans
- MRI scans
- PET scans
- Burn dressing change
 Silvadene
 Bacitracin and Adaptic
 Negative-pressure wound therapy
- Burn donor sites
 Thigh
 Back
 Scalp
- Facial healing
 Printed materials
 Nonpharmacologic coping techniques (available in English and Spanish)
- Diaphragmatic breathing
- Guided imagery
- Autogenics
- Progressive muscle relaxation
- Stress management
- Mandalas
- Journaling
 Preparation
- Helping Burns Heal.An Adventure for Kids with Burns
 Video
 Nonpharmacologic coping techniques
- Diaphragmatic breathing
- Progressive muscle
- Guided imagery
726 Dodd et al

trust between patients, family members/care-  Exercise

takers and healthcare providers, and improved  Recreation/leisure
long-term emotional and behavioral adjustment in  Therapeutic play
patients and family members/caretakers.” The
study further details that successful coping is not Social Domain
measured by lack of distress but by the event being
perceived as manageable. Pediatric patients who The goals addressed in the social domain include
engage in medical play and procedural preparation encouraging acceptance of the burn injury and
have a better understanding of their treatments integration into community. CLSs and RT special-
and injuries. The children also tend to understand ists encourage patients to maintain social contacts
and cope better with daily treatment and proced- with friends and family throughout the hospitaliza-
ures (Fig. 9). In addition, pediatric patients who tion. Social support can also come in the form of
seek information about their care tend to cope bet- psychotherapy, peer support, and support groups.
ter with hospitalization.37 CL can use written mate-  Peer support
rial, apps, iBooks, and publications to educate  Community reintegration
patients on procedures and treatment. Educational  School reentry
resources combined with medical play, procedural
preparation, demonstration, and sequences are
Recreation and Leisure Domain
imperative in coping with treatment after a burn
injury.38 Goals addressed in this domain include providing
patients with opportunities to maintain or gain
Nonpharmacologic coping techniques healthy leisure interests after a burn injury. CL
Nonpharmacologic coping techniques were dis- and RT meet the recreation and leisure needs of
cussed in the context of the emotional domain. patients through individualized interests and play.
Physical Domain  Therapeutic play: “When children feel less
fearful about their hospitalization, they experi-
The goal of this domain is to promote the return to
ence greater emotional well-being and less
the patient’s preinjury level of function. In meeting
psychological distress. Therapeutic play inter-
the needs of patients with burn injuries, CL/RT en-
vention addresses improvement in the child’s
courages patients by incorporating the patient’s
affect, anxiety symptoms, level of distress,
interests to maintain and/or gain a functional
depression symptoms, regression, aggres-
range of motion and to increase endurance. CL/
sion, and fear, as well as enhances a child’s
RT can cotreat with occupational therapy and
ability to cope.”39
physical therapy to meet the needs of each pa-
 Individual interests
tient. Cotreating often promotes the connection
between the physical recovery and other aspects
of recovery, including emotional and leisure New technology and its use in recreational
aspects. therapy
A 2006 study by Haik and colleagues40 concluded
that “the use of virtual reality (VR) helps motivate
patients to practice movements in a repetitive
manner, thereby improving their condition, an
achievement that is not easy to attain vis-à-vis
conventional therapy.” The benefits of virtual real-
ity and other nontraditional forms of therapy may
appeal to not only the pediatric population but
also adults. This appeal is partly to the result of
VR allowing people to engage in activities they
enjoy without the added stress on their bodies
that the actual activity might cause.41 It has been
observed that “the game may be virtual, but the
physical exertion is very real.”42 The Sony PlaySta-
Fig. 9. Children who engage in medical play and pro- tion II Eye Toy has been used for the rehabilitation
cedural preparation have a better understanding of of patients with burn injuries during intensive occu-
their treatment and injury. Medical play also pro- pational and physical therapy. It has been
motes coping with daily treatment and adjustment observed that the Sony Eye Toy allows patients
to their hospitalization. to “.immerse himself or herself in an alternate
 Burn Rehabilitation: Long-Term Recovery 727

and pressure therapy on posttraumatic hypertrophic

scars. J Burn Care Res 2010;31:448–57.
8. Yildiz N. A novel technique to determine pressure in
pressure garments for hypertrophic burn scars and
comfort properties. Burns 2007;33:59–64.
9. Carr-Collins JA. Pressure techniques for the preven-
tion of hypertrophic scar. Clin Plast Surg 1992;19:
733–43.
10. Khansa I, Harrison B, Janis J. Evidence-based scar
management: how to improve results with technique
and technology. Plast Reconstr Surg 2016;138(3
Suppl):165S–78S.
11. Anthonissen M, Daly D, Janssens T, et al. The effects
of conservative treatment on burn scars: a system-
Fig. 10. VR allows patients to engage in activities atic review. Burns 2016;42(3):508–18.
without adding additional stress to their bodies. It 12. Nedelec B, Carter A, Forbes L, et al. Practice guide-
can provide opportunities for active range of motion, lines for the application of nonsilicone or silicone
coping/adjustment, and nonpharmacologic coping. gels and gel sheets after burn injury. J Burn Care
Res 2015;36:345–74.
13. Steinstraessar L, Flak E, Witte B, et al. Pressure
reality while undergoing treatment, thereby
garment therapy alone in combination with silicone
reducing pain and discomfort he or she experi-
for the prevention of hypertrophic scarring: random-
ences.”40 In a conventional VR study it was shown
ized controlled trial with intraindividual comparison.
that “therapeutic exercise plays a key role in the
Plast Reconstr Surg 2011;128(4):306–13.
prevention of permanent impairments caused by
14. De Lateur BJ, Shore WS. Exercise following burn
burn scar contracture”.43 VR was used as an alter-
injury. Phys Med Rehabil Clin N Am 2011;22:347–50.
native but effective nonpharmacologic pain con-
15. Grisbrook TL, Elliott CM, Edgar DW, et al. Burn-
trol technique. This study recognized “meaningful
injured adults with long term functional impairments
reductions in pain (i.e. >30%) when they per-
demonstrate the same response to resistance
formed passive ROM exercises while in VR, even
training as uninjured controls. Burns 2013;39:680–6.
when used on multiple occasions”43 (Fig. 10).
16. Porter C, Hardee JP, Herndon D, et al. The role of ex-
ercise in the rehabilitation of patients with severe
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