Symposium on Burns
Rehabilitation Following Burn Injury Robert H. Bartlett, M.D.,* E'lane Wingerson, O.T.R., M.P.A.,t Shirley Simonton, O.T.R.,+ Patricia A. Allyn, R.N.,§ Sue Martinez, R.N.,II and Steven D. Feinberg, M.D.**
Burn survival statistics can be misleading. After the surface has healed and the donor sites are epithelized, the patient is discharged home; but the job of burn care is only half over. From the time of admission the goal of therapy must be to minimize ultimate disability by improving those factors that can be improved, and by helping the patient to adjust to those that cannot. Any burn, from an 80 per cent flame burn to a small scald injury of the hand or face, can result in serious disability. Although much has been written about methods in burn rehabilitation,3, 6, 10 the actual results of such treatment are rarely recorded. Since the incidence of disability after burns is not known, the relative importance of causes of disability cannot be determined. The purpose of this paper is to describe one approach to burn rehabilitation and to examine its results.
PATIENTS AND TREATMENT PROTOCOL From January, 1972 to July, 1977we treated 3023 patients for burns and related injury: 1240 patients with major burns were hospitalized and 1783 patients with smaller injuries were managed as outpatients. One third were children under 12 years old. Ninety-one patients died. All surPresented in part to the American Burn Association, 1974 and 1976. "Professor of Surgery, University of California at Irvine; Director of Burn Center, and Chief, Division of General Surgery, Medical Center, University of California at Irvine, Orange, California tDirector, Division of Occupational Therapy, University of California at Irvine, Orange, California !Occupational Therapist, University of California at Irvine, Orange, California §Head Nurse, Burn Center, University of California at Irvine, Orange, California "Nurse-Clinician, Burn Center, University of California at Irvine, Orange, Califurnia **Assistant Professor of Physical Medicine and Rehabilitation, University of California at Irvine; Physical Medicine Consultant to Burn Center, Medical Center, University of California at Irvine, Orange, California Supported in part by a grant from the Hearst Foundation and donations to the UCI Bum Center Fund.
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vivors were followed until they returned to their pre-burn functional (physical, psychological, and socioeconomic) status, or until disabled status could no longer be improved. Follow-up on these 2932 patients was over 99 per cent. Many of these patients had minor injuries that healed promptly and did not pose significant risk of disability. There were 695 patients considered to have potential rehabilitation problems. This includes all the patients who had not returned to their pre-burn functional status three months after the injury. All of these patients were treated jointly by Burn Center nursing staff, the Department of Surgery, and the Department of Physical Medicine and Rehabilitation (largely through its Division of Occupational Therapy). Forty-five patients had permanent or unusually prolonged disability; 33 were adults and 12 were children under the age of 12. These 45 patients represent 1% per cent of the entire patient population, 3.7 per cent of inpatient admissions, and 7 per cent of patients with potential rehabilitation problems. Methods of functional management are necessarily interrelated with other methods of burn care. Principles of management in our Center are reported elsewhere. I, 4, 11 The surface is managed by thorough cleaning daily in a large tank, sequential tangential debridement using ketamine anesthesia in the tank, and coverage with thin elastic occlusive dressings of fine mesh gauze impregnated with a topical antiseptic (usually silver sulfadiazene). Grafting is done on granulation tissue 18 to 20 days post burn. Neither systemic antibiotics nor isolation, aside from the occlusive dressings, is used. Positive caloric balance and zero weight loss is the goal in each patient. Usually this requires continuous feedings through gastric tubes in patients with extensive burns. In general, sheet grafts are used on face, hands, andjoints, and postage stamp grafts are used on other surfaces. Homografts and biologic dressings are used infrequently. Functional management during the acute phase begins on the first day. The creamy occlusive dressings relieve pain, and patients are encouraged to ambulate, eat,and carry out daily functions as independently as possible. This encourages full range of motion of all involved joints. Splinting and immobilization, formerly felt to be essential, 8 are not necessary. The only exceptions are the hand (discussed below) and the ankle, to which dorsiflexion splints are applied at night in patients with deep burns of the lower legs and feet. Care is taken to preserve tissue during the acute phase by avoiding pillows in patients with ear burns, doing escharotomies to improve extremity blood flow, and so forth. From the beginning the patient is assured that he will receive the best of care, but is warned that he must start adjusting to his new appearance. He is assured that he will regain his pre-burn status, but is advised that the patient is his own best therapist. Our protocol for hand management is described in detail elsewhere. 2 The proximal interphalangeal joints are held in full extension (usually by Kirschner wires) in severe burns. Active use and full range of motion of the metacarpophalangeal joints in the thumb and wrist are encouraged. When the patient is at rest the metacarpophalangeal joints are splinted in 90° flexion and the thumb is held in opposition and abduction. During grafting the metacarpophalangeal joints are completely immobilized with K wires and the arm is held in extension by skeletal traction. All pins
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and wires are removed seven days after grafting and full range of motion is achieved with active and passive exercise, stretching, and dynamic splints at night. After the surface is healed or grafted the real work offunctionalmanagement begins. Elastic pressure garments (Jobst) are used for all deep second and third degree burns for approximately one year. 20 Custom designed plastic splints are used to apply pressure in difficult areas such as the face, neck, and web spaces. Most patients have full range of motion of involved joints when the surface is healed. Contractures are prevented by active and passive range of motion exercises and topical pressure garments. If this is not successful, plastic night splints are added. Established contractures are treated with stretching and progressive splinting. 1s If contracture still occurs, or if stretching and splinting causes cracking and ulceration of the scar, operative release and grafting are advised. Reconstructive operations are delayed until the hypertrophic scar has matured (one year or more after burn), unless the scar is causing further damage (by exposing the cornea or causing joint subluxation, for example). Small exposed scars are excised. Moderate sized symptomatic scars may respond to topical steroid in the form of Cordran tape. Major resurfacing is rarely done except on the face. As outlined above, psychological rehabilitation is based on the premise that burn injury, although more visible, must be addressed as any other major injury or illness. The patient has the disorder; it might get better but it won't go away; meanwhile life will goon; the patient may have to adjust his life-style to accommodate his new condition. The normal periods of depression, the transient hostility toward the burn care team, the procrastination to avoid new social adjustments are all anticipated, and the patient is warned of these periods in advance. Although psychologists and psychiatrists are readily available to help with these mental adjustments, they are rarely needed. The Burn Center staff and burn patient alumni are the best psychotherapists for most patients. Finally, our rehabilitation program is strongly oriented toward return to work, school, or normal daily activities. Employers and teachers are encouraged to assist in the rehabilitation process by letting the patient return to his normal activity part-time or with reduced or modified workloads until further function is achieved. Patients are warned that numbness, tingling, heat sensitivity, tightness, weakness, itching, and ease of fatigue are all expected during the healing and maturation process. These subjective symptoms are annoying but not disabling. The best way to deal with them is to return to normal activity as soon as possible. This "hard line" philosophy often seems insensitive to those who do not deal with burned patients regularly, but it is, in our experience, an important factor in rehabilitation of the burned patient.
RESULTS Of 3023 patients, 2887 returned to their pre-burn socioeconomic status. Of 1240 inpatients with major burns, 91 died; 1783 patients with
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Table 1. Cause and Location of Disability Following Burn Injury PROBLEM AREA
CAUSE OF DISABILITY Tissue
Hand-
ADULTS
No.
Age
% Burn
33
34
Z6
24
9
15
38
25
8
7
7
30
43
5
2
2
31
6
2
9
35
30
9
12
6
42
9
Arm
Leg
Face
7
Other
6
Loss
Scars
Appearance
Subject.
Psycho.
6
14
9
10
1
2
3
1
8
1
2
4
1
Males Job-Related
Males Not job
1
related
Females Job-Related
2
Females Not job
6
6
2
7
7
7
8
5
5
2
related CHILDREN
6
minor burns were treated as outpatients. Forty-five patients (33 adults and 12 children) had permanent or prolonged disability. There were 695 potential rehabilitation problems. Twenty-four of the 45 disabled patients received financial compensation or had legal suits pending related to the burn injury. Sixteen of the 33 burn injuries in adults were not work-related. The average percentage burn in these 16 patients was 36 per cent (range from 16 to 80 per cent). The most common cause of burn was automobile accident, followed by flammable fluids. The major causes of disability were scars and contractures, tissue loss, and appearance. Seventeen adults were injured in the course of employment. The average percentage burn in this group was 15 per cent (range from 3 to 72 per cent). The most common cause of the injury was flammable liquids, followed by flash or explosion burns and hot grease. The most common cause of disability was subjective symptoms followed by scars and contractures. Twelve children were disabled. The average surface burn in children was 42 per cent (range from 10 to 80 per cent). The most common cause of disability was tissue loss and scar contracture followed by appearance. Two children are disabled as a result of hearing loss, probably secondary to topical neomycin cream administered in 1972. Most of the disabling burn injuries in children resulted from flammable liquids or house fires. Several patients experienced improvement in their socioeconomic status because of the burn injury. This includes patients who were addicted to drugs or alcohol before the injury but not after. It includes some patients who were severely depressed or suicidal but recovered healthy mental status, and some social derelicts who had all of these characteristics and recovered to become healthy contributing members of society. The home and family life of several children was improved as a result of families being reunited or the child being placed in a foster home.
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CASE REPORTS
Several difficult cases are presented to demonstrate problems in burn rehabilitation. CASE 1. A 56 year old woman sustained deep injuries over 20 per cent of the body surface involving both hands, chest, and thigh in a probable suicide attempt. She had been a nurse, but had not worked for several years because of depression and alcohol and drug abuse. All digits on the right hand were burned off, as well as the three ulnar digits on the left hand (Fig. 1A). She required amputation of the mid forearm and was fitted with an arm prosthesis (Fig. 1B). Influenced by the time and concern that many individuals spent in her behalf, she made a psychological recovery. She enjoys good mental health, lives alone independently, and works as a dressmaker. Although this patient had extensive tissue loss, she is not classified as disabled because she is working, supporting herself, and has achieved a better socioeconomic status than she had prior to the injury. CASE 2. A two year old child sustained 85 per cent burns, mostly full thickness, in a gasoline fire. Following grafting several Isoprene splints were used under Jobst pressure garments to prevent contractures. Some of this apparatus is shown in Figure 2A. Despite these measures she required releases of contractures of the neck and axilla (Fig. 2B). Five years later she has full range of motion of all joints and is a happy well adjusted child in school. This child is classified as permanently disabled on the basis of cosmetic appearance (Fig. 2C). Many scar revisions have been done, but final facial reconstruction awaits full bony growth of the skull. CASE 3. A 12 year old boy sustained 85 per cent burns, mostly full thickness, in an'automobile accident. Hands and face were severely involved with major tissue loss. Ten weeks after injury (Fig. 3A) the surface was healed but the rehabilitation problem was just beginning. Six years and many reconstructive operations later (Fig. 3B) he is attending college, plays the guitar, and leads an active social
Figure 1. Case 1. Functional status of this patient improved after burn injury, despite a hand prosthesis.
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Figure 2. Case 2. This two year old child sustained 85 per cent burns. A, Pressure garments and splints were worn after hospital discharge. B, Axillary releases were required. C, Facial scars require multiple revisions.
life. He is listed as permanently disabled on the basis of appearance and tissue loss, although he claimed no disability in a suit against the automobile manufacturer. This patient exemplifies the axiom that patience, time, and an optimistic outlook are the strongest allies of the reconstructive surgeon and the burn care team. CASE 4. A nine month old girl sustained burns of the face and right hand in a house fire (Fig. 4A). All the digits of the right hand were necrotic. Scars were treated with topical pressure and the right hand was reconstructed by excising the second metacarpal, making a prehensile metacarpal hand. At age six her appearance is satisfactory (Fig. 4B) and her hand is quite functional (Fig. 4, C and D). This patient is classified as permanently disabled on the basis of tissue loss. A combination of toe transplants and prosthetics may improve function and appearance of the hand in the future. CASE 5. This 10 year old boy developed large hypertrophic scars following flame burns to the back of the legs (Fig. 5A). Although he had normal gait and full range of motion, he was disabled by appearance, refused to be exposed or partici-
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Figure 3. Case 3. A. A 12 year old boy with scars following extensive bums. B. Six years later there is no functional disability, and further scar revision is planned.
pate in sports, and did poorly in school. Minimal improvement was achieved with topical pressure garments. Two years after injury the scars were excised and regrafted. Appearance improved (Fig. 5B) and he returned to normal social and academic performance. This child is listed as prolonged disability because of appearance and psychological factors. Major resurfacing rarely results in significant improvement and is usually discouraged. However these hypertrophic scars were particularly unsightly, and the final result was worth the additional morbidity of repeated operations. CASE 6. This man was burned with hot grease while working as a cook. Appearance was satisfactory (Fig. 6, A and B) and there was no limitation offunction. However the patient claimed total inability to work because of pain and tingling in the bum scars. This persisted despite revisions, topical pressure, and application of Cord ran tape (seen in the photographs). The patient was 60 years old at the time of injury and has retired on full lifetime disability because the injury was sustained in the course of his employment. Only the patient knows how significant subjective symptoms are. On the basis of experience with other patients with this extent of injury, however, we believe that permanent financial subsidy contributes to disability in patients such as this. CASE 7. This young man sustained full-thickness injury to the lower leg during the course of his employment. He had full range of motion and strength soon after grafting. He was advised to return to work, but claimed disability because of subjective symptoms. Outside consultants supported this claim and he did not return for follow-up for many months. One year after injury (Fig. 7) he was referred for re-evaluation and returned to work when disability subsidy was discontinued. This patient is listed as prolonged disability on the basis of subjective symptoms. Bum injuries to the legs and feet invariably cause unpleasant sensations when the patient stands. These can usually be partially alleviated by topical presure garments. Most patients with similar bums who do not receive financial subsidy find it possible to return to full activity despite these symptoms.
Figure 4. Case 4. A, Hand and facial bums were sustained in a house fire. B, Minimal l hypertrophic scaning following topical pressure. C and D, A metacarpal "hand."
Figure 5. Case 5. A, Hypertrophic scars caused disability. B , Appearance improved after removal of scars and grafting.
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Figure 6. Case 6. This patient claimed total disability because of scars on the forearm caused by burns sustained while working.
Figure 7. Case 7. This patient claimed total disability because of pain and tingling in this burn which was sustained while working.
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DISCUSSION The major socioeconomic loss caused by burn injury--disability during the acute phase treatment-is not addressed in this paper. Most patients have returned to full activity within a few months of the injury, but even that short interval adds up to over 100 man-years of disability in this series alone. Unless there are unusual circumstances (such as fullthickness burns of both hands), we consider three months the upper limit of expected disability ofpartial thickness injury and six months the upper limit of disability from full-thickness injury. Patients who exceeded those limits were listed as prolonged disability ("rehabilitation failures") in this review. It should be emphasized that the functional management program is interdependent on all other aspects of burn treatment program (Fig. 8). In our center, for example, elastic occlusive dressings are used to relieve pain and promote ambulation and independent activity. The use of occlusive dressings is best combined with daily thorough cleaning of the surface to prevent bacterial growth. Contraction and scarring are best prevented by early grafting. However the success of grafting, particularly in extensive injury, is best when grafts are placed on granulation tissue. By the same reasoning, final functional results will be best if infection does not occur in the bum wound. For these reasons we actively remove the eschar by tangential debridement beginning soon after injury. This presents an additional physiologic insult which is best met with positive caloric and nitrogen balance achieved by continuous gastric tube feedings. Any burn up to 50 per cent of the body surface area is usually grafted in a single operation, meeting the goal of total coverage without infection or contracture three to four weeks after the injury. This vigorous surface management protocol is, in tum, dependent upon the unique anesthetic agent ketamine. Thus each component ofthe bum care protocol depends on the others. The techniques offunctional management in a bum center PHYSIOLOGIC CARE
SURFACE CARE
INFECTION CONTROL
SURGICAL TECHNIQUES
l
I
PULMONARY
I
I
NUTRITION
I
POST GRAFTING PRESSURE + SPLINTS
OCCLUSIVE DRESSINGS
I
DEBRIDEMENT
FLUIDS
FUNCTIONAL CARE
J
I
I
HANDS
ACTIVITY
EARLY GRAFTING
CLEANING
I
I
J
BURN PATIENT Figure 8. Each aspect of bum care is interdependent on all other aspects. The functional management program depends on the method of surface care, which depends on the type of nutrition, which depends on debridement, and so forth.
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that treats the surface by exposure and spontaneous eschar separation, for example, would have to be considerably different than those described here. For these reasons some aspects of this program are considerably different than those described in the literature. 5 • 12. 14. 17 Immobilization of joints in anti-contracture positions during the acute phase (prior to grafting) is unnecessary, and in fact may be detrimental. Skeletal traction is occasionally helpful for immobilization during skin grafting but severely limits activity otherwise and is not used during the acute phase. Fluidfilled beds, special mattresses, and radiant warmers are not necessary when occlusive dressings are used and may lead to maceration and infection. These dressings minimize topical evaporation, eliminating the need for high temperature and high humidity environment, improving the psychological and physical climate for the burn center staff and patient. Keeping the surface clean, debrided, and covered eliminates the need for bacterial isolation precautions. Friendly faces rather than masks, frequent direct contact with the family, and unlimited activity by the patient are significant factors in avoiding psychological complications. Positive blood cultures occur in 4 per cent of our patients. We have rarely seen periarticular calcification, and we have never encountered major gastrointestinal bleeding; we consider these to be complications of sepsis, not burns. The major exception to the policy of full activity and joint function during the acute phase is in management of the burned hand. Proximal interphalangeal flexion contracture and extensor tendon rupture can be avoided with anti-claw splinting,13 but these splints can slip, particularly in the extensively burned patient who has more immediate problems elsewhere. This has led to the protocol of early internal fixation of proximal interphalangeal joints in full extension during the acute phase. This technique, combined with metacarpophalangeal skeletal fixation during grafting, has been quite successful in salvaging hand function in our experience. The techniques and results of that protocol are described in detail elsewhere. 2 Primary excision and grafting essentially eliminate the acute phase, and gives excellent cosmetic and functional results. This is particularly true in the hand. 19 Primary excision is indicated in localized areas of uniformlydeep injury in patients who are physiologically stable. In our experience, approximately 10 per cent of hand burns meet all of these criteria, but results of primary excision are excellent in these patients. With some exceptions (Case 3, Fig. 3), the patient will complete the acute phase with no contractures. Dobbs and Curreri reported early results of a daily stretching and exercise program in a large consecutive series. Seventy-two per cent of their patients had full range of motion of all joints 30 days after discharge. 7 However, a vigorous program of active and passive exercise, stretching, and topical pressure must be followed to maintain satisfactory joint function. At this stage, anti-contracture splints worn during night and rest periods are extremely helpful. This may be cumbersome and uncomfortable (Case 2, Fig. 2A) but can avoid contracture and the need for release and reconstructive operations in
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many cases. Night splints are worn until hypertrophic scars begin to soften (about six months) and topical pressure garments are worn until the scar is mature (about one year). In addition to collagen molding, symptomatic relief from pain and itching afforded by topical pressure garments is significant. Scar contractures may occur despite all the measures listed above. The areas most commonly affected are those most difficult to splint and exercise-the neck, the axilla, the anterior chest. Although any release or reconstructive operation is best delayed until the scar is mature, we proceed promptly to those procedures whenever contracture is limiting joint function (Case 2, Fig. 2B). Patients who are referred with established contractures ofthe elbows, knees, wrists; etc. often respond well to a program of stretching and progressive splinting with topical pressure as described by Willis and Larson. 15 This technique usually obviates the need for release operations in those areas. The principles of topical pressure and splinting apply to the face as well as the rest of the body. Custom made devices and ingenuity are combined by the Department of Occupational Therapy to treat or prevent eyelid, lip, and mouth contractures. Exposure of the sclera and mild tearing may be tolerated for several months while the scar matures, but persistent conjunctivitis is best treated with eyelid release and grafting. Rehabilitation following major facial burns depends heavily on the experience and skill of the reconstructive surgeon. An optimistic but realistic approach to psychological care cannot be overemphasized. 6 If the patient is warned in advance about the usual psychological low points, and gets to know patients with more severe injury who have successfully negotiated those crises, few psychological problems occur. It is our policy to conduct all follow-up visits in the midst of the inpatient burn center activity, and to admit all patients for reconstructive procedures into the Burn Center. The practice has several psychological effects. Patients in the acute phase see that others with more severe injuries have survived, and, in general, are doing well. They see that the burn center staff follows patients for months or years. They realize from the beginning that others have found it possible to adjust satisfactorily to altered function or appearance. Patients returning for follow-up visits see this same spectrum of gradual recovery in other returning patients, while being reminded that the worst days of the acute phase are over. Most important, the burn center staff regularly sees the final satisfactory results of their intensive efforts, although they may not be apparent until months or years after the injury. Based on this experience, nurses, physicians, and therapists gain the perspective that gives both practicality and optimism to their care of other acute phase patients. Most of our staff remains stable over a period of years, although it would be difficult to keep nurses for more than a few months if their experience were limited to acute phase care only. Causes of prolonged or permanent disability listed in Table 2 provide some insight into how rehabilitation might be improved. Tissue loss, scars, and unpleasant appearance are inevitable consequences of some injuries. These causes of disability may be minimized by early grafting,
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skin tissue culture, free composite grafts, and other reconstructive techniques, but will always present a problem. The amount of surface burn was less and the amount of subjective complaints was greater in adult patients who were injured in the course oftheir employment. Many of these individuals brought suits related to the burn injury against their employer or other individuals. In our follow-up clinic we often see patients who have been free of symptoms for a year or more after injury suddenly complain of a multitude of physical problems. This syndrome is common enough to be easily recognized, and inquiry usually elicits the fact that the patient has been advised to file a suit or that his case is about to go to court. All of these factors, often occurring in patients with minor injuries such as Cases 6 and 7, suggest that financial compensation or reward, when combined with the personality of certain individuals, is a major cause of disability following burn injury.
CONCLUSION Of 3023 consecutive burned patients treated at UCI Burn Center, 98% per cent returned to their pre-burn socioeconomic status. This represents 95 per cent of the inpatient adInissions and 93 per cent of 695 patients with potential rehabilitation problems. This is considerably better than rehabilitative results for other major illness, 9,18 and suggests that the time, effort, and dollars expended during acute phase burn care are well spent. The functional management protocol depends on other aspects of burn management. Using the protocol outlined here, most ofthe cumbersome splinting and positioning techniques recommended for acute phase care have been found unnecessary. Financial subsidy is a major cause of disability in adults; tissue loss is the major cause of disability in children. ACKNOWLEDGMENTS
The results reported in this paper are due to the efforts of the nurses, physicians, and therapists of the VCI Burn Center. Major contributions have been made by Drs. David Furnas, Bruce Achauer, and Jerome Tobis. We are grateful to our patients and their families for their help, persistence, and understanding.
REFERENCES 1. Achauer, B. M., Allyn, P., Furnas, D. W., et a!.: Pulmonary complications of burns: The major threat to the burned patient. Ann Surg., 177:311, 1973. 2. Achauer, B. M., Bartlett, R. H., Furnas, D. W., et al.: Internal fixation in the management of the burned hand. Arch. Surg., 108:814, 1974. 3. Baebel, S., Bulkley, A. L., and Shuck, J. M.: Physical therapy for burned patients: Low budget effectiveness. Phys. Ther., 52:1289, 1973. 4. Bartlett, R. H., Allyn, P. A., Medley, T., et al.: Nutritional therapy based on positive caloric balance in burn patients. Arch. Surg., 112:974, 1977. 5. Birch, J. R., Eakins, B., Gosen, J., et a!.: Musculoskeletal management of the severely burned child. Canad. Med. J., 115:583, 1976. 6. Chang, F. C., and Herzog, B.: Burn morbidity: A followup study of physical and psychological disability. Ann. Surg., 183:34,1974.
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7. Dobbs. E. R.. and Curreri. P. W.: Burns: Analysis of results of physical therapy in 681 patients. J. Trauma. 12:242, 1972. 8. Evans, E. B., Larson, D. L., Arston, S., et al.: Prevention and correction of deformity after severe burns. SURG. CLIN. NORTH AM., 50: 1361, 1970. 9. Feigenson, J. S., McCarthy, M. L., Greenberg, S. D., et al.: Factors influencing outcome and length of stay in a stroke rehabilitation unit. II. Comparison of 318 screened and 248 un screened patients. Stroke, 8:657, 1977. 10. Feller, I., Jones, C. A., Koepke, G., et aL: The team approach to total rehabilitation ofthe severely burned patient. Heart and Lung, 2:701, 1973. 11. German, J. C., Wooley, T. E., Achauer, B. M., et al.: Porcinexenograph burn dressings: A criticalre-apprai.saL Arch. Surg., 194:806,1972. 12. Hales, M.: Physical treatment and rehabilitation of burns. Physiotherapy, 63 :5,157,1977. 13. Koepke, G. H., Feallock, B., and Feller, I.: Splinting of the severely burned hand. Am. J. Occup. Ther., 17:147,1963. 14. Koepke, G. H.: The role of physical medicine in the treatment of burns. SURG. CLIN. NORTH AM., 50:1385, 1970. 15. Larson, D. L., Abston, S., Evans, E. B., et al.: Techniques for decreasing scar formation and contractures in the burned patient. J. Trauma, 11 :807, 1971. 16. Larson, D. L., Abston, S., Willis, B., et aL: Contracture and scar formation in the bum patient. Clin. Plast. Surg., 1 :653, 1974. 17. Larson, D. W., Evans, E. B., Abston, S., et aL: Skeletal suspension and traction in the treatment of burns. Ann. Surg., 168:981,1968. 18. Leon, A. S., and Blackburn, H.: Exercise rehabilitation of the coronary heart disease patient. Geriatrics, 32 :66-68, 73-76, 1977. 19. Moncrief, J. A., Switzer, W. E., and Rose, L. R.: Primary excision and grafting in the treatment of third-degree burns of the dorsum of the hand. Plast. Reconstr. Surg., 33:305, 1964. 20. Willis, B.: The use of orthoplast isoprene splints in the treatment of the acutely burned child: Further report. Am. J. Occup. Ther., 24:1, 1970. Burn Center University of California, Irvine 101 City Drive South Orange, California 92668
Rehabilitation Following Burn Injury Robert H. Bartlett, M.D.,* E'lane Wingerson, O.T.R., M.P.A.,t Shirley Simonton, O.T.R.,+ Patricia A. Allyn, R.N.,§ Sue Martinez, R.N.,II and Steven D. Feinberg, M.D.**
Burn survival statistics can be misleading. After the surface has healed and the donor sites are epithelized, the patient is discharged home; but the job of burn care is only half over. From the time of admission the goal of therapy must be to minimize ultimate disability by improving those factors that can be improved, and by helping the patient to adjust to those that cannot. Any burn, from an 80 per cent flame burn to a small scald injury of the hand or face, can result in serious disability. Although much has been written about methods in burn rehabilitation,3, 6, 10 the actual results of such treatment are rarely recorded. Since the incidence of disability after burns is not known, the relative importance of causes of disability cannot be determined. The purpose of this paper is to describe one approach to burn rehabilitation and to examine its results.
PATIENTS AND TREATMENT PROTOCOL From January, 1972 to July, 1977we treated 3023 patients for burns and related injury: 1240 patients with major burns were hospitalized and 1783 patients with smaller injuries were managed as outpatients. One third were children under 12 years old. Ninety-one patients died. All surPresented in part to the American Burn Association, 1974 and 1976. "Professor of Surgery, University of California at Irvine; Director of Burn Center, and Chief, Division of General Surgery, Medical Center, University of California at Irvine, Orange, California tDirector, Division of Occupational Therapy, University of California at Irvine, Orange, California !Occupational Therapist, University of California at Irvine, Orange, California §Head Nurse, Burn Center, University of California at Irvine, Orange, California "Nurse-Clinician, Burn Center, University of California at Irvine, Orange, Califurnia **Assistant Professor of Physical Medicine and Rehabilitation, University of California at Irvine; Physical Medicine Consultant to Burn Center, Medical Center, University of California at Irvine, Orange, California Supported in part by a grant from the Hearst Foundation and donations to the UCI Bum Center Fund.
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vivors were followed until they returned to their pre-burn functional (physical, psychological, and socioeconomic) status, or until disabled status could no longer be improved. Follow-up on these 2932 patients was over 99 per cent. Many of these patients had minor injuries that healed promptly and did not pose significant risk of disability. There were 695 patients considered to have potential rehabilitation problems. This includes all the patients who had not returned to their pre-burn functional status three months after the injury. All of these patients were treated jointly by Burn Center nursing staff, the Department of Surgery, and the Department of Physical Medicine and Rehabilitation (largely through its Division of Occupational Therapy). Forty-five patients had permanent or unusually prolonged disability; 33 were adults and 12 were children under the age of 12. These 45 patients represent 1% per cent of the entire patient population, 3.7 per cent of inpatient admissions, and 7 per cent of patients with potential rehabilitation problems. Methods of functional management are necessarily interrelated with other methods of burn care. Principles of management in our Center are reported elsewhere. I, 4, 11 The surface is managed by thorough cleaning daily in a large tank, sequential tangential debridement using ketamine anesthesia in the tank, and coverage with thin elastic occlusive dressings of fine mesh gauze impregnated with a topical antiseptic (usually silver sulfadiazene). Grafting is done on granulation tissue 18 to 20 days post burn. Neither systemic antibiotics nor isolation, aside from the occlusive dressings, is used. Positive caloric balance and zero weight loss is the goal in each patient. Usually this requires continuous feedings through gastric tubes in patients with extensive burns. In general, sheet grafts are used on face, hands, andjoints, and postage stamp grafts are used on other surfaces. Homografts and biologic dressings are used infrequently. Functional management during the acute phase begins on the first day. The creamy occlusive dressings relieve pain, and patients are encouraged to ambulate, eat,and carry out daily functions as independently as possible. This encourages full range of motion of all involved joints. Splinting and immobilization, formerly felt to be essential, 8 are not necessary. The only exceptions are the hand (discussed below) and the ankle, to which dorsiflexion splints are applied at night in patients with deep burns of the lower legs and feet. Care is taken to preserve tissue during the acute phase by avoiding pillows in patients with ear burns, doing escharotomies to improve extremity blood flow, and so forth. From the beginning the patient is assured that he will receive the best of care, but is warned that he must start adjusting to his new appearance. He is assured that he will regain his pre-burn status, but is advised that the patient is his own best therapist. Our protocol for hand management is described in detail elsewhere. 2 The proximal interphalangeal joints are held in full extension (usually by Kirschner wires) in severe burns. Active use and full range of motion of the metacarpophalangeal joints in the thumb and wrist are encouraged. When the patient is at rest the metacarpophalangeal joints are splinted in 90° flexion and the thumb is held in opposition and abduction. During grafting the metacarpophalangeal joints are completely immobilized with K wires and the arm is held in extension by skeletal traction. All pins
REHABILITATION FOLLOWING BURN INJURY
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and wires are removed seven days after grafting and full range of motion is achieved with active and passive exercise, stretching, and dynamic splints at night. After the surface is healed or grafted the real work offunctionalmanagement begins. Elastic pressure garments (Jobst) are used for all deep second and third degree burns for approximately one year. 20 Custom designed plastic splints are used to apply pressure in difficult areas such as the face, neck, and web spaces. Most patients have full range of motion of involved joints when the surface is healed. Contractures are prevented by active and passive range of motion exercises and topical pressure garments. If this is not successful, plastic night splints are added. Established contractures are treated with stretching and progressive splinting. 1s If contracture still occurs, or if stretching and splinting causes cracking and ulceration of the scar, operative release and grafting are advised. Reconstructive operations are delayed until the hypertrophic scar has matured (one year or more after burn), unless the scar is causing further damage (by exposing the cornea or causing joint subluxation, for example). Small exposed scars are excised. Moderate sized symptomatic scars may respond to topical steroid in the form of Cordran tape. Major resurfacing is rarely done except on the face. As outlined above, psychological rehabilitation is based on the premise that burn injury, although more visible, must be addressed as any other major injury or illness. The patient has the disorder; it might get better but it won't go away; meanwhile life will goon; the patient may have to adjust his life-style to accommodate his new condition. The normal periods of depression, the transient hostility toward the burn care team, the procrastination to avoid new social adjustments are all anticipated, and the patient is warned of these periods in advance. Although psychologists and psychiatrists are readily available to help with these mental adjustments, they are rarely needed. The Burn Center staff and burn patient alumni are the best psychotherapists for most patients. Finally, our rehabilitation program is strongly oriented toward return to work, school, or normal daily activities. Employers and teachers are encouraged to assist in the rehabilitation process by letting the patient return to his normal activity part-time or with reduced or modified workloads until further function is achieved. Patients are warned that numbness, tingling, heat sensitivity, tightness, weakness, itching, and ease of fatigue are all expected during the healing and maturation process. These subjective symptoms are annoying but not disabling. The best way to deal with them is to return to normal activity as soon as possible. This "hard line" philosophy often seems insensitive to those who do not deal with burned patients regularly, but it is, in our experience, an important factor in rehabilitation of the burned patient.
RESULTS Of 3023 patients, 2887 returned to their pre-burn socioeconomic status. Of 1240 inpatients with major burns, 91 died; 1783 patients with
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Table 1. Cause and Location of Disability Following Burn Injury PROBLEM AREA
CAUSE OF DISABILITY Tissue
Hand-
ADULTS
No.
Age
% Burn
33
34
Z6
24
9
15
38
25
8
7
7
30
43
5
2
2
31
6
2
9
35
30
9
12
6
42
9
Arm
Leg
Face
7
Other
6
Loss
Scars
Appearance
Subject.
Psycho.
6
14
9
10
1
2
3
1
8
1
2
4
1
Males Job-Related
Males Not job
1
related
Females Job-Related
2
Females Not job
6
6
2
7
7
7
8
5
5
2
related CHILDREN
6
minor burns were treated as outpatients. Forty-five patients (33 adults and 12 children) had permanent or prolonged disability. There were 695 potential rehabilitation problems. Twenty-four of the 45 disabled patients received financial compensation or had legal suits pending related to the burn injury. Sixteen of the 33 burn injuries in adults were not work-related. The average percentage burn in these 16 patients was 36 per cent (range from 16 to 80 per cent). The most common cause of burn was automobile accident, followed by flammable fluids. The major causes of disability were scars and contractures, tissue loss, and appearance. Seventeen adults were injured in the course of employment. The average percentage burn in this group was 15 per cent (range from 3 to 72 per cent). The most common cause of the injury was flammable liquids, followed by flash or explosion burns and hot grease. The most common cause of disability was subjective symptoms followed by scars and contractures. Twelve children were disabled. The average surface burn in children was 42 per cent (range from 10 to 80 per cent). The most common cause of disability was tissue loss and scar contracture followed by appearance. Two children are disabled as a result of hearing loss, probably secondary to topical neomycin cream administered in 1972. Most of the disabling burn injuries in children resulted from flammable liquids or house fires. Several patients experienced improvement in their socioeconomic status because of the burn injury. This includes patients who were addicted to drugs or alcohol before the injury but not after. It includes some patients who were severely depressed or suicidal but recovered healthy mental status, and some social derelicts who had all of these characteristics and recovered to become healthy contributing members of society. The home and family life of several children was improved as a result of families being reunited or the child being placed in a foster home.
REHABILITATION FOLLOWING BUBN INJURY
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CASE REPORTS
Several difficult cases are presented to demonstrate problems in burn rehabilitation. CASE 1. A 56 year old woman sustained deep injuries over 20 per cent of the body surface involving both hands, chest, and thigh in a probable suicide attempt. She had been a nurse, but had not worked for several years because of depression and alcohol and drug abuse. All digits on the right hand were burned off, as well as the three ulnar digits on the left hand (Fig. 1A). She required amputation of the mid forearm and was fitted with an arm prosthesis (Fig. 1B). Influenced by the time and concern that many individuals spent in her behalf, she made a psychological recovery. She enjoys good mental health, lives alone independently, and works as a dressmaker. Although this patient had extensive tissue loss, she is not classified as disabled because she is working, supporting herself, and has achieved a better socioeconomic status than she had prior to the injury. CASE 2. A two year old child sustained 85 per cent burns, mostly full thickness, in a gasoline fire. Following grafting several Isoprene splints were used under Jobst pressure garments to prevent contractures. Some of this apparatus is shown in Figure 2A. Despite these measures she required releases of contractures of the neck and axilla (Fig. 2B). Five years later she has full range of motion of all joints and is a happy well adjusted child in school. This child is classified as permanently disabled on the basis of cosmetic appearance (Fig. 2C). Many scar revisions have been done, but final facial reconstruction awaits full bony growth of the skull. CASE 3. A 12 year old boy sustained 85 per cent burns, mostly full thickness, in an'automobile accident. Hands and face were severely involved with major tissue loss. Ten weeks after injury (Fig. 3A) the surface was healed but the rehabilitation problem was just beginning. Six years and many reconstructive operations later (Fig. 3B) he is attending college, plays the guitar, and leads an active social
Figure 1. Case 1. Functional status of this patient improved after burn injury, despite a hand prosthesis.
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Figure 2. Case 2. This two year old child sustained 85 per cent burns. A, Pressure garments and splints were worn after hospital discharge. B, Axillary releases were required. C, Facial scars require multiple revisions.
life. He is listed as permanently disabled on the basis of appearance and tissue loss, although he claimed no disability in a suit against the automobile manufacturer. This patient exemplifies the axiom that patience, time, and an optimistic outlook are the strongest allies of the reconstructive surgeon and the burn care team. CASE 4. A nine month old girl sustained burns of the face and right hand in a house fire (Fig. 4A). All the digits of the right hand were necrotic. Scars were treated with topical pressure and the right hand was reconstructed by excising the second metacarpal, making a prehensile metacarpal hand. At age six her appearance is satisfactory (Fig. 4B) and her hand is quite functional (Fig. 4, C and D). This patient is classified as permanently disabled on the basis of tissue loss. A combination of toe transplants and prosthetics may improve function and appearance of the hand in the future. CASE 5. This 10 year old boy developed large hypertrophic scars following flame burns to the back of the legs (Fig. 5A). Although he had normal gait and full range of motion, he was disabled by appearance, refused to be exposed or partici-
T REHABILITATION FOLLOWING BURN INJURY
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Figure 3. Case 3. A. A 12 year old boy with scars following extensive bums. B. Six years later there is no functional disability, and further scar revision is planned.
pate in sports, and did poorly in school. Minimal improvement was achieved with topical pressure garments. Two years after injury the scars were excised and regrafted. Appearance improved (Fig. 5B) and he returned to normal social and academic performance. This child is listed as prolonged disability because of appearance and psychological factors. Major resurfacing rarely results in significant improvement and is usually discouraged. However these hypertrophic scars were particularly unsightly, and the final result was worth the additional morbidity of repeated operations. CASE 6. This man was burned with hot grease while working as a cook. Appearance was satisfactory (Fig. 6, A and B) and there was no limitation offunction. However the patient claimed total inability to work because of pain and tingling in the bum scars. This persisted despite revisions, topical pressure, and application of Cord ran tape (seen in the photographs). The patient was 60 years old at the time of injury and has retired on full lifetime disability because the injury was sustained in the course of his employment. Only the patient knows how significant subjective symptoms are. On the basis of experience with other patients with this extent of injury, however, we believe that permanent financial subsidy contributes to disability in patients such as this. CASE 7. This young man sustained full-thickness injury to the lower leg during the course of his employment. He had full range of motion and strength soon after grafting. He was advised to return to work, but claimed disability because of subjective symptoms. Outside consultants supported this claim and he did not return for follow-up for many months. One year after injury (Fig. 7) he was referred for re-evaluation and returned to work when disability subsidy was discontinued. This patient is listed as prolonged disability on the basis of subjective symptoms. Bum injuries to the legs and feet invariably cause unpleasant sensations when the patient stands. These can usually be partially alleviated by topical presure garments. Most patients with similar bums who do not receive financial subsidy find it possible to return to full activity despite these symptoms.
Figure 4. Case 4. A, Hand and facial bums were sustained in a house fire. B, Minimal l hypertrophic scaning following topical pressure. C and D, A metacarpal "hand."
Figure 5. Case 5. A, Hypertrophic scars caused disability. B , Appearance improved after removal of scars and grafting.
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Figure 6. Case 6. This patient claimed total disability because of scars on the forearm caused by burns sustained while working.
Figure 7. Case 7. This patient claimed total disability because of pain and tingling in this burn which was sustained while working.
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DISCUSSION The major socioeconomic loss caused by burn injury--disability during the acute phase treatment-is not addressed in this paper. Most patients have returned to full activity within a few months of the injury, but even that short interval adds up to over 100 man-years of disability in this series alone. Unless there are unusual circumstances (such as fullthickness burns of both hands), we consider three months the upper limit of expected disability ofpartial thickness injury and six months the upper limit of disability from full-thickness injury. Patients who exceeded those limits were listed as prolonged disability ("rehabilitation failures") in this review. It should be emphasized that the functional management program is interdependent on all other aspects of burn treatment program (Fig. 8). In our center, for example, elastic occlusive dressings are used to relieve pain and promote ambulation and independent activity. The use of occlusive dressings is best combined with daily thorough cleaning of the surface to prevent bacterial growth. Contraction and scarring are best prevented by early grafting. However the success of grafting, particularly in extensive injury, is best when grafts are placed on granulation tissue. By the same reasoning, final functional results will be best if infection does not occur in the bum wound. For these reasons we actively remove the eschar by tangential debridement beginning soon after injury. This presents an additional physiologic insult which is best met with positive caloric and nitrogen balance achieved by continuous gastric tube feedings. Any burn up to 50 per cent of the body surface area is usually grafted in a single operation, meeting the goal of total coverage without infection or contracture three to four weeks after the injury. This vigorous surface management protocol is, in tum, dependent upon the unique anesthetic agent ketamine. Thus each component ofthe bum care protocol depends on the others. The techniques offunctional management in a bum center PHYSIOLOGIC CARE
SURFACE CARE
INFECTION CONTROL
SURGICAL TECHNIQUES
l
I
PULMONARY
I
I
NUTRITION
I
POST GRAFTING PRESSURE + SPLINTS
OCCLUSIVE DRESSINGS
I
DEBRIDEMENT
FLUIDS
FUNCTIONAL CARE
J
I
I
HANDS
ACTIVITY
EARLY GRAFTING
CLEANING
I
I
J
BURN PATIENT Figure 8. Each aspect of bum care is interdependent on all other aspects. The functional management program depends on the method of surface care, which depends on the type of nutrition, which depends on debridement, and so forth.
REHABILITATION FOLLOWING BURN INJURY
1259
that treats the surface by exposure and spontaneous eschar separation, for example, would have to be considerably different than those described here. For these reasons some aspects of this program are considerably different than those described in the literature. 5 • 12. 14. 17 Immobilization of joints in anti-contracture positions during the acute phase (prior to grafting) is unnecessary, and in fact may be detrimental. Skeletal traction is occasionally helpful for immobilization during skin grafting but severely limits activity otherwise and is not used during the acute phase. Fluidfilled beds, special mattresses, and radiant warmers are not necessary when occlusive dressings are used and may lead to maceration and infection. These dressings minimize topical evaporation, eliminating the need for high temperature and high humidity environment, improving the psychological and physical climate for the burn center staff and patient. Keeping the surface clean, debrided, and covered eliminates the need for bacterial isolation precautions. Friendly faces rather than masks, frequent direct contact with the family, and unlimited activity by the patient are significant factors in avoiding psychological complications. Positive blood cultures occur in 4 per cent of our patients. We have rarely seen periarticular calcification, and we have never encountered major gastrointestinal bleeding; we consider these to be complications of sepsis, not burns. The major exception to the policy of full activity and joint function during the acute phase is in management of the burned hand. Proximal interphalangeal flexion contracture and extensor tendon rupture can be avoided with anti-claw splinting,13 but these splints can slip, particularly in the extensively burned patient who has more immediate problems elsewhere. This has led to the protocol of early internal fixation of proximal interphalangeal joints in full extension during the acute phase. This technique, combined with metacarpophalangeal skeletal fixation during grafting, has been quite successful in salvaging hand function in our experience. The techniques and results of that protocol are described in detail elsewhere. 2 Primary excision and grafting essentially eliminate the acute phase, and gives excellent cosmetic and functional results. This is particularly true in the hand. 19 Primary excision is indicated in localized areas of uniformlydeep injury in patients who are physiologically stable. In our experience, approximately 10 per cent of hand burns meet all of these criteria, but results of primary excision are excellent in these patients. With some exceptions (Case 3, Fig. 3), the patient will complete the acute phase with no contractures. Dobbs and Curreri reported early results of a daily stretching and exercise program in a large consecutive series. Seventy-two per cent of their patients had full range of motion of all joints 30 days after discharge. 7 However, a vigorous program of active and passive exercise, stretching, and topical pressure must be followed to maintain satisfactory joint function. At this stage, anti-contracture splints worn during night and rest periods are extremely helpful. This may be cumbersome and uncomfortable (Case 2, Fig. 2A) but can avoid contracture and the need for release and reconstructive operations in
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many cases. Night splints are worn until hypertrophic scars begin to soften (about six months) and topical pressure garments are worn until the scar is mature (about one year). In addition to collagen molding, symptomatic relief from pain and itching afforded by topical pressure garments is significant. Scar contractures may occur despite all the measures listed above. The areas most commonly affected are those most difficult to splint and exercise-the neck, the axilla, the anterior chest. Although any release or reconstructive operation is best delayed until the scar is mature, we proceed promptly to those procedures whenever contracture is limiting joint function (Case 2, Fig. 2B). Patients who are referred with established contractures ofthe elbows, knees, wrists; etc. often respond well to a program of stretching and progressive splinting with topical pressure as described by Willis and Larson. 15 This technique usually obviates the need for release operations in those areas. The principles of topical pressure and splinting apply to the face as well as the rest of the body. Custom made devices and ingenuity are combined by the Department of Occupational Therapy to treat or prevent eyelid, lip, and mouth contractures. Exposure of the sclera and mild tearing may be tolerated for several months while the scar matures, but persistent conjunctivitis is best treated with eyelid release and grafting. Rehabilitation following major facial burns depends heavily on the experience and skill of the reconstructive surgeon. An optimistic but realistic approach to psychological care cannot be overemphasized. 6 If the patient is warned in advance about the usual psychological low points, and gets to know patients with more severe injury who have successfully negotiated those crises, few psychological problems occur. It is our policy to conduct all follow-up visits in the midst of the inpatient burn center activity, and to admit all patients for reconstructive procedures into the Burn Center. The practice has several psychological effects. Patients in the acute phase see that others with more severe injuries have survived, and, in general, are doing well. They see that the burn center staff follows patients for months or years. They realize from the beginning that others have found it possible to adjust satisfactorily to altered function or appearance. Patients returning for follow-up visits see this same spectrum of gradual recovery in other returning patients, while being reminded that the worst days of the acute phase are over. Most important, the burn center staff regularly sees the final satisfactory results of their intensive efforts, although they may not be apparent until months or years after the injury. Based on this experience, nurses, physicians, and therapists gain the perspective that gives both practicality and optimism to their care of other acute phase patients. Most of our staff remains stable over a period of years, although it would be difficult to keep nurses for more than a few months if their experience were limited to acute phase care only. Causes of prolonged or permanent disability listed in Table 2 provide some insight into how rehabilitation might be improved. Tissue loss, scars, and unpleasant appearance are inevitable consequences of some injuries. These causes of disability may be minimized by early grafting,
REHABILITATION FOLLOWING BURN INJURY
1261
skin tissue culture, free composite grafts, and other reconstructive techniques, but will always present a problem. The amount of surface burn was less and the amount of subjective complaints was greater in adult patients who were injured in the course oftheir employment. Many of these individuals brought suits related to the burn injury against their employer or other individuals. In our follow-up clinic we often see patients who have been free of symptoms for a year or more after injury suddenly complain of a multitude of physical problems. This syndrome is common enough to be easily recognized, and inquiry usually elicits the fact that the patient has been advised to file a suit or that his case is about to go to court. All of these factors, often occurring in patients with minor injuries such as Cases 6 and 7, suggest that financial compensation or reward, when combined with the personality of certain individuals, is a major cause of disability following burn injury.
CONCLUSION Of 3023 consecutive burned patients treated at UCI Burn Center, 98% per cent returned to their pre-burn socioeconomic status. This represents 95 per cent of the inpatient adInissions and 93 per cent of 695 patients with potential rehabilitation problems. This is considerably better than rehabilitative results for other major illness, 9,18 and suggests that the time, effort, and dollars expended during acute phase burn care are well spent. The functional management protocol depends on other aspects of burn management. Using the protocol outlined here, most ofthe cumbersome splinting and positioning techniques recommended for acute phase care have been found unnecessary. Financial subsidy is a major cause of disability in adults; tissue loss is the major cause of disability in children. ACKNOWLEDGMENTS
The results reported in this paper are due to the efforts of the nurses, physicians, and therapists of the VCI Burn Center. Major contributions have been made by Drs. David Furnas, Bruce Achauer, and Jerome Tobis. We are grateful to our patients and their families for their help, persistence, and understanding.
REFERENCES 1. Achauer, B. M., Allyn, P., Furnas, D. W., et a!.: Pulmonary complications of burns: The major threat to the burned patient. Ann Surg., 177:311, 1973. 2. Achauer, B. M., Bartlett, R. H., Furnas, D. W., et al.: Internal fixation in the management of the burned hand. Arch. Surg., 108:814, 1974. 3. Baebel, S., Bulkley, A. L., and Shuck, J. M.: Physical therapy for burned patients: Low budget effectiveness. Phys. Ther., 52:1289, 1973. 4. Bartlett, R. H., Allyn, P. A., Medley, T., et al.: Nutritional therapy based on positive caloric balance in burn patients. Arch. Surg., 112:974, 1977. 5. Birch, J. R., Eakins, B., Gosen, J., et a!.: Musculoskeletal management of the severely burned child. Canad. Med. J., 115:583, 1976. 6. Chang, F. C., and Herzog, B.: Burn morbidity: A followup study of physical and psychological disability. Ann. Surg., 183:34,1974.
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7. Dobbs. E. R.. and Curreri. P. W.: Burns: Analysis of results of physical therapy in 681 patients. J. Trauma. 12:242, 1972. 8. Evans, E. B., Larson, D. L., Arston, S., et al.: Prevention and correction of deformity after severe burns. SURG. CLIN. NORTH AM., 50: 1361, 1970. 9. Feigenson, J. S., McCarthy, M. L., Greenberg, S. D., et al.: Factors influencing outcome and length of stay in a stroke rehabilitation unit. II. Comparison of 318 screened and 248 un screened patients. Stroke, 8:657, 1977. 10. Feller, I., Jones, C. A., Koepke, G., et aL: The team approach to total rehabilitation ofthe severely burned patient. Heart and Lung, 2:701, 1973. 11. German, J. C., Wooley, T. E., Achauer, B. M., et al.: Porcinexenograph burn dressings: A criticalre-apprai.saL Arch. Surg., 194:806,1972. 12. Hales, M.: Physical treatment and rehabilitation of burns. Physiotherapy, 63 :5,157,1977. 13. Koepke, G. H., Feallock, B., and Feller, I.: Splinting of the severely burned hand. Am. J. Occup. Ther., 17:147,1963. 14. Koepke, G. H.: The role of physical medicine in the treatment of burns. SURG. CLIN. NORTH AM., 50:1385, 1970. 15. Larson, D. L., Abston, S., Evans, E. B., et al.: Techniques for decreasing scar formation and contractures in the burned patient. J. Trauma, 11 :807, 1971. 16. Larson, D. L., Abston, S., Willis, B., et aL: Contracture and scar formation in the bum patient. Clin. Plast. Surg., 1 :653, 1974. 17. Larson, D. W., Evans, E. B., Abston, S., et aL: Skeletal suspension and traction in the treatment of burns. Ann. Surg., 168:981,1968. 18. Leon, A. S., and Blackburn, H.: Exercise rehabilitation of the coronary heart disease patient. Geriatrics, 32 :66-68, 73-76, 1977. 19. Moncrief, J. A., Switzer, W. E., and Rose, L. R.: Primary excision and grafting in the treatment of third-degree burns of the dorsum of the hand. Plast. Reconstr. Surg., 33:305, 1964. 20. Willis, B.: The use of orthoplast isoprene splints in the treatment of the acutely burned child: Further report. Am. J. Occup. Ther., 24:1, 1970. Burn Center University of California, Irvine 101 City Drive South Orange, California 92668
