Burn Interventions

Elisa Dick & Jessica FongOCCT 630May 2, 2013

Pain Management & OTPF

• Preoccupation with pain affects every area of the OTPF, thus hindering client from further pursuing occupations• Areas of occupation: ADLs, rest and sleep• Client factors: Body function• Context & Environment: Virtual reality

• Relief from preoccupation with condition and pain• Aim is to be less burdened by pain • Focus on other aspects of life that they would like to

participate in

Biopsychosocial Frame of Reference

• Biological: how illness stemmed• Psychological: thoughts, emotions, behaviors that can

influence negativity • Social factors: SES, culture, religion, technology are

intertwined and play a significant role in human functioning in the context of disease or illness

• BPS utilized within OT scope of practice when treating burn patients• Validates client’s pain, promotes linkage with environment,

includes family and workplace, and views client holistically (Moon, McDonald, & Van den Dolder, 2012)

PharmacologicalNot within OT scope of practice, but should be familiar with different interventions • Opiod analgesics (primary; oral or IV): low cost,

familiar, manageable, convenient, efficient, potent• Non-opiod analgesics: ex. NSAID’s, acetaminophen.

Low cost, familiar• Anxiolytics: provided for patients who have high

anxiety or high baseline scores for pain• Anesthesia: should only be used for limited

duration; general anesthesia over long periods of time is costly

Non-pharmacological• OTs can implement these as long as client wants to participate• Diversion: rooted in the anatomy and physiology of attention

and perception of pain; designed to distance patient away from the source of pain • Distraction: additional stimuli, i.e. Music, movies, conversation• Imagery: visualization or and relaxing imagery

Non-pharmacological (cont’d)• Virtual Reality: costly, requires

OT to be familiar and have knowledge• Immersing patients in

computer-generated environment

• Allow patient to interact in a new place, diverting attention away from pain

• SnowWorld: game designed for burn patients; patient is in an ice world and they shoot snowballs at different targets

Non-pharmacological (cont’d)Hypnosis: extensive training and costly• Used prior/after wound care• Alters client’s state of consciousness, allows for perception of pain

to be altered• Requires more planning, well-controlled environment, and strong

client-therapist rapport

Relaxation techniques• No-cost• Transferable• Lower arousal and muscle tension, which can heighten pain• Diaphragmatic breathing: chest breathing• Progressive muscle relaxation: alternately tensing and relaxing a

series of muscles

Practical Considerations

Pharmacological interventions• More costly (especially anesthesia)• Insurance companies may not reimburse everything• Requires attention from doctors• Not in the scope of OT

Non-pharmacological• Easier to learn and teach• Easier for client to do independently as they heal• No/low cost (except for virtual reality & hypnosis)• Client-centered

Client/Caregiver Training & Education

Pharmacological• OT can only be aware of the type of interventions

the client is using and help to track progress/side effects of client• OT can help educate client/family on side effects of

medication

Non-pharmacological• OT can educate client and family on benefits of

techniques and emphasize the fact that many of these can be done independently

Precautions & Contraindications

Pharmacological• Allergies• Client’s personal beliefs or choices• Oral consumption or IV

Non-pharmacological• Client-centered

Range of Motion (ROM)

ROM and the OTPF

ROM will improve all domains of occupational engagement• Areas of occupation: ADLs, etc.• Client factors: Body function• Performance skills: Motor & Praxis

Positive Effects of ROM• Increasing ROM improves functional capacities• Increased independence with ADLs• Prevent or lessen potential contractures• Educates client to become proactive

Biomechanical Frame of Reference• Biomechanical: remediation or improvements in strength,

ROM, or endurance• ROM exercises stretch tissues including skin, fascia, and

muscles to increase the client’s range of motion

Timing of TreatmentAcute phase:

• Medical clearance for ROM exercises is usually 4-5 days post-op• Perform during dressing change to see condition of wound and graft

status- clients may have multiple surgeries, so it’s important to assess current status

• May be done on a client in a coma or under conscious sedation• Time with pain medication for increased tolerance

Rehabilitation Phase: Therapy is more occupation-based, such as placing groceries on a high shelf

• Will need to carefully document progress for reimbursement

Methods to Increase ROM• Passive stretching: for a weak or unconscious client• Active-assist stretching: increase ROM while engaging the client’s

strength• Active stretching: client does movement independently• Functional ROM:

• In the acute phase, brushing hair and eating can be done in bed• More stable clients can perform hygiene at the sink and work on

dressing• Rehabilitation phase can incorporate more occupation-based

activities like placing groceries on a high shelf

Performing ROM Stretches• Knowledge of joint anatomy and biomechanics• Materials: gloves, possibly a gown and face mask• How far to passively stretch? Watch for whitening of tissue

• Motion will depend on the location and severity of the burn

Client/ Caregiver Education• Self-exercise: • instruct client on exercises they can safely do independently • Post handouts provide pictures and instructions in a noticeable

location to increase adherence• Inform the client, family, and caretakers of the importance of

exercises to increase ROM and prevent contractures

Important Considerations

• Contraindications• Grafting post-op • Fractures• Dislocated joints• Ruptured tendons or ligaments• Unstable vital signs

• Consider the client’s health and mental status • Inhalation injuries will decrease aerobic capacity and can make

vitals unstable• Pain tolerance: time therapy with medications

Client/ Caregiver Resources

Resources to help burn survivors and their families cope:www.spiegelburnfoundation.comwww.phoenix-society.orghttp://nwburn.org/

List of support groups by state: http://www.burnsurvivor.com/supportgroups.html

ReferencesGrisbrook, T.L., Reid, S.L., Edgar, D.W., Wallman, K.E., Wood, F.M., Elliott, C.M. (2012).

Exercise training to improve health related quality of life in long term survivors of major burn injury: A matched controlled study. Burns, 38(8) 1165-1173. doi:10.1016/j.burns.2012.03.007

Moon, M., McDonald, R., Van den Dolder, J. (2012). Occupational therapy for pain management in the compensation setting: Context and principles.

Occupational Therapy Now, 14.5. Retrieved from http://www.caot.ca/otnow/sept12/context.pdf

Pessina, M.A., & Orroth, A.C. (2008). Burn injuries. In Occupational therapy for physical dysfunction (6th ed., pp. 1244-1263). Baltimore, MD: Lippincott, Williams & Wilkins.

Weichman, A.S., Patterson, D.R., Sharar, S.R., Mason, S., & Faber, B. (2009). Pain management in patients with burn injuries. International Review of Psychiatry. (21)6, 522-530. doi: 10.3109/09540260903343844

Wright, P.C. (1984). Fundamentals of acute burn care and physical therapy management. Physical Therapy, 64, 1217-1231.