Burn Interventions

1. Burn Interventions Elisa Dick & Jessica FongOCCT 630 May 2, 2013

3. 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

4. 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)

5. Pharmacological Not within OT scope of practice, but should be familiar with different interventions • Opiodanalgesics (primary; oral or IV): low cost, familiar, manageable, convenient, efficient, potent • Non-opiodanalgesics: 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. Precautions & Contraindications Pharmacological • Allergies • Client’s personal beliefs or choices • Oral consumption or IV Non-pharmacological • Client-centered

12. Range of Motion (ROM)

13. 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

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

15. 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

16. Timing of Treatment Acute 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

17. 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

18. 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

19. 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

20. 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

21. Client/ Caregiver Resources Resources to help burn survivors and their families cope: www.spiegelburnfoundation.com www.phoenix-society.org http://nwburn.org/ List of support groups by state: http://www.burnsurvivor.com/supportgroups.html

22. References Grisbrook, 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.