Physiotherapy Trauma Talks
In Physiotherapy Trauma Talks we discuss the key roles that physiotherapists and other healthcare practitioners play in the management and rehabilitation of patients with traumatic injury. Experts in trauma care offer their insights about in-hospital patient care and post-discharge follow up service delivery. New research in the field of trauma care and rehabilitation is shared to provide answers to your questions.
Physiotherapy Trauma Talks
Burns Part 3: Physiotherapy's Vital Role in Burn Recovery with Moira Wilson
Whether you're a physiotherapy student, practicing clinician, or healthcare professional working with burn patients, this episode offers targeted, evidence-informed approaches to optimize outcomes. Refresh your knowledge about the role of positioning, manual hyperinflation, stretching, progressive mobilisation, and the 'physio pause' management strategy in patient management.
Link to paper that was discussed in this episode: doi: 10.4102/sajp.v78i1.1543
Podcast website: https://physiotherapytraumatalks.buzzsprout.com
Book: Cardiopulmonary Physiotherapy in Trauma: An Evidence-based Approach’ published by World Scientific: https://doi.org/10.1142/13509
Hi there, fellow physiotherapists. I am Helene van Aswegen, your host for Physiotherapy Trauma Talks, where we discuss everything related to trauma care. So if you are passionate to learn more about physiotherapy in the field of trauma to ensure that you provide the best possible care for your patients, then this is the right podcast series for you. Good day and welcome back to all our listeners. Thank you for joining us for the discussion today on physiotherapy management of patients with burn injury. If you enjoy this episode, please use the link in the show notes to send us a kind message and also remember to click on the link to the podcast website where you can read more about my guests. So for today's discussion, I'm joined again by Moira Wilson. Moira is a returning guest to the podcast and Moira works at Malt Park Net Care Hospital in Johannesburg. Moira, thank you for joining me again for this discussion.
Speaker 2:It's my pleasure, Helene Happy to help.
Speaker 1:Moira, in our previous episode you mentioned that your team provide the lead physiotherapy service to the trauma ICU and that you have an eight-bedded Burns ICU. Would you mind just explaining to our listeners what type of services are provided to patients admitted to the Burns ICU by the different team members?
Speaker 2:We're very fortunate in Mill Park Hospital to have lots of different members assisting us. So we have, obviously. We have physiotherapists, we have occupational therapists, we have speech therapists, we have orthotists, we have social workers, we have psychologists. We've got a very wide range of people that can assist these patients. The MDT really works well in the burns and trauma setup in Mill Park Hospital.
Speaker 1:That's great to hear. When patients are admitted or when they sustain burn injuries, they lose the main protective barrier, the skin, and are therefore at risk of infection. What does infection control entail in your unit?
Speaker 2:When we come into the unit we change out of our day-to-day scrubs and we put on separate scrubs. Each patient is in a separate cubicle and then there's white aprons outside some of the cubicles and there's yellow aprons outside some of the others. The yellow apron patients got positive infections so they might be your longer stay patients. So we would see the patient, the white aprons first. We start with the patients who are less likely to be infected. Stethoscopes are cleaned between every patient. Strict hand washing before and after every patient. Once you're in that cubicle with your apron and your gloves, you don't come back out. If you need to come back out, you take your gloves off, you leave your stethoscope, your apron comes off and then you go out if need be. So very, very strict bare below elbow nothing. No artificial nails, jewellery nothing below your elbow no artificial nails, jewellery, nothing below your elbow.
Speaker 1:So, despite the fact that it's such strict infection control, I'm sure that you managed to contain the spread of infection quite well in the unit. In your experience, what type of causes are there to patients sustaining burn injuries and being admitted specifically into your unit, and how seriously injured are these patients?
Speaker 2:It's a mixture of hot water burns, I would say, and a lot of industrial burns and electrical burns. So we basically have a lot of patients coming in from all over the place with severe electrical burns, all the way up to 75-80% full thickness burns. Yes to hot water burns.
Speaker 1:I would say that's the two most common injuries that we see in Mill Park burns. I remember we did a research project in your unit that was published in 2022, a retrospective record review, in which we did find that majority of the patients admitted were males and in their mid to late 30s, and they had around 31 to 32 percent burns, but the range of that was also much higher, which is similar to what you just said that some of them may have up to 75% body surface area involvement. How large is the physiotherapy team that works with you in the burns unit and could you maybe just explain, in the acute phase of the patient's admission, what is your priorities of care for these patients?
Speaker 2:So usually there's two physios in the burns unit. There's a senior physio, which would be myself, and one of the more junior physios. There's always two of us in the burns unit. Basically, if it's a ventilated patient, then the main priority would be the chest. If the patient's non-ventilated, then a lot of education right from day one what our role is, why we're there, what we're going to do, how we do it. So it just depends exactly how the patient's presenting. But we get a lot of big bad burns. So I would say the majority are ventilated patients. So then we would start with them, get consent obviously, take a sputum sample as a baseline and then chest physio to clear the chest and improve the oxygenation, and then passive movements to the limbs and turning and positioning and keeping the patient as well as possible.
Speaker 1:Would your management be any different if the patient had inhalation injuries? Is there any difference in your approach to the patient with inhalation burns versus those that you're just trying to prevent the onset of complications?
Speaker 2:prevent the onset of complications. Well, usually with the inhalation burns they tend to have a lot more secretions compared to just a normal. A large burn that was ventilated, so your inhalation ones would be would have more secretions, especially after around the second or the third day when you start to get sloughing of the epithelial layer and then they really become very, very productive. So I would say they're more productive than than the other type.
Speaker 1:Yeah, so are there specific physiotherapy treatment interventions for the chest that you tend to use more than others?
Speaker 2:We use a wide gamut of techniques depending if they've had, if they've got, wounds over their chest, burn wounds over their chest. It's not very comfortable to be doing hands-on stuff, so then we would use MHI just to get some increased tidal volume. It depends each patient's assessed on their own merits and we decide. But we use a wide gamut of physiotechnics at our disposal.
Speaker 1:So MHI meaning manual hyperinflation, or ambibagging as we used to call it many years ago. Yeah, okay, and then when would you start consulting with an orthotist to get splints made for the patients? When does that start?
Speaker 2:We generally start from day one, because we found out in years gone past that the resting position of a person's foot is in plantar flexion. So we get resting foot splints basically day one or day two, even if the legs are not burnt. If it's going to be a longish term patient, then we get those legs up into dorsiflexion so that when it's time to start mobilising the patient then the TAs are nicely stretched and there's not a problem, because we've had some cases way in the beginning where we get them up and they're a bit on their tippy toes. So we've learned very, very early on to get those. Even with passive movements the best is passive movements plus the resting foot splints.
Speaker 1:So for the patient in your unit that is more sedated and not able to cooperate much, your physiotherapy approach would be more therapist driven, regarding the chest therapy and also management of joint range of motion through passive movements and things when the patients are a little bit more awake and able to start cooperating. How does your approach to patient care change?
Speaker 2:When the patients are still ventilated. We find positioning quite important. So if there's anterior neck burns we don't let the pillows be in the patient's neck. We do it two hours off on the flat on the bed, and then the nurses don't particularly like patients not to have a pillow, but we explain to them we need that stretch on the anterior neck. We position the arms even in the ventilated patients because often supination is the first movement. We found that goes. Often the position is pronated on the bed so we often take them up into a supination. Once the patients are more able to cooperate, then we're more active. We do quite a lot of combined movements. So we would do elbow extension, wrist extension, finger extension, stretching the web, stretching the thumbs. So it's a much more active. But positioning is extremely important even from day one.
Speaker 1:Yeah, and I think as the skin starts to repair itself from the burn injury, there's a huge risk of stiffness that develops. Are there any specific stretching exercises that you teach your patients? I know that in our book you referred to the big five, or would you mind to just elaborate on that a little bit?
Speaker 2:We find with patients, patients, if you give them too many exercises they get them all mixed up. So we stick to a few which would be like the hallelujah stretch, get them up into full flexion of the shoulder. And then the prayer stretch is quite important and to get wrist extension you have to get wrist extension, finger extension and thumb and get some abduction at the same time as that. So we use a prayer stretch quite a lot and then, like I said, supination we find is the first movement to go. We're not really quite sure why, but we push active supination. But lots of combination-type movements are important. We use the wall quite a bit, we make them climb the wall, we put them in abduction and then we turn away from them to get the pecs stretched and the elbows stretched, the wrists stretched, fingers stretched, stretch the web spaces as well.
Speaker 1:Do you find that in patients who have had burns to the lower extremities that they need walking aids when you start getting them up and moving out of bed, and what type of walking aids would you use?
Speaker 2:Generally they do. Obviously we start sitting on the edge as soon as we can and up into standing. We sometimes have a pulpit walker that we use quite a bit. If it's a big patient or the patient's particularly been in for a long time and deconditioned, we would use the pulpit walker. When we put them on the pulpit walker then the physios are free to control the knees and the hips and things like that. Then we move them very quickly on from pulpit down to rollator, normal walker crutches and off. So we push them through quite quickly, yeah.
Speaker 1:And do you involve strength training in these patients? Would you mind just elaborating on that a little bit?
Speaker 2:We start strength training while they're in bed. We often use water bottles just for a bit of a weight and we make them do that as part of their routine. We do that quite a lot as well, because they lose a lot of muscle bulk as well, these patients. They become very weak.
Speaker 1:Are you restricted at all with regards to the type of equipment that you can bring into the burns unit to facilitate rehabilitation with the patients? No, things like TheraBands, for instance.
Speaker 2:No, no, we're not restricted. Obviously, the TheraBand would be single use, so you would give that patient his TheraBand, you wouldn't be passing it around. All the other patients we can can take in what we like and then, as long as we wipe it down when we're finished, we use I was using a broom handle the other day for the patient to get to get full, full a flexion elevation of the shoulder. Now we're not restricted.
Speaker 1:Okay, right, um during the Okay Right During the patient's journey, they obviously need a lot of attention. With regards to wound care. Some patients need to go to theatre for debridement or escherotomy. What specific precautions do you take when those patients come back from theatre with regards to what you can and can't do during rehabilitation?
Speaker 2:Your escherotomy and your fasciotomy is normally done very early on in the journey. That's quite an emergency procedure and they would do that within the first day. Usually Later on they would do the debridements. What we use quite a lot, helene, is what I've coined as a physio pause. So if the patient's had a rather deep debridement by this time you know the patient well. I'm talking about the awake patient now. You know them well, you've got a rapport with them.
Speaker 2:They've gone in for a fairly deep debridement in the morning. In the afternoon they're very painful. Then we would go to them and say we're doing a physio pause this afternoon. We're going to give you a gap this afternoon. We're back on tomorrow morning. You've had a big, big surgery, just rest this afternoon and we start again. But we coin it as a physio pause so that even in the note keeping we write physio pause. So the doctors know it's a voluntary thing that we've done. We're not just ignoring the patient but we're taking cognizance of the potential pain post-surgery of the patient. You've got to get them on your side. Pain post-surgery at the patient You've got to get them on your side. You've got to get buy-in from these patients. It can't be an authoritarian. You're doing it and that's the end of it.
Speaker 2:You've got to buy in and let's try this. Let's try that. You've got to seem to be part of the solution, Okay.
Speaker 1:What is the operating procedures in your unit with regards to patients who have had skin grafts? How long does the physio pose last for?
Speaker 2:Depends where the skin graft was. We generally teach the students to not move one joint above and one joint below. That's what we generally teach them. What's happening now is, helene, we're seeing quite a lot of the grafted patients being vacced on top of the skin graft and some of the docs are quite happy to carry on moving with that vac top of the skin graft and some of the doctors are quite happy to carry on moving with that vac on over the skin graft at a much lower, a much lower pressure. Okay, but it depends on the doctor. Some of them don't want the limb moved at all and others will let you move the shoulder or the fingers, depending on where the graft is. Usually you would leave it for five days and then you would recommence.
Speaker 1:Yeah, and just to clarify, the vac is the negative pressure vacuum dressings that are applied. Yes, okay, do your doctors ever use artificial skin substitutes as wind dressings, and what? How does that change your physiotherapy?
Speaker 2:yes, they do approach the user. They use a artificial skin called biobrain quite a lot and on superficial burns normally they take them, they debride them and they biobrain them to allow that wound matrix to start healing up. Then we're not allowed to move that limb for five days as well. So, it behaves like a skin graft. If they're biobrained, they wouldn't be allowed to mobilize. If the arms are done, we can get them out of bed, but we wouldn't be allowed to move the limb itself.
Speaker 1:Yeah, I think working in the burn setup or setting, you often have patients who have a prolonged stay in the ICU. And coming back to that publication that we had in 2022, we found that the average length of stay in the ICU was around 17 days and the average stay in the hospital was more than a month for many patients. So, with that in mind, can you talk a little bit about your approach to patient care together with a dietician? How important is nutrition to what you do with your patients?
Speaker 2:Nutrition is absolutely vital, absolutely vital. When we see the patient ourselves, we obviously check all the bloods and we can see if the sodium's low or whatever's wrong. We can see what's happening with the patient. But we do after we've had a session of physio with the patients. We will give them one of their fresh even drinks or something, because they say that's the best uptake is after they've done some strength training, to give them one of their shakes. Yes, so we do that with the patients.
Speaker 1:Yes, okay, yeah so, in your experience working in the burns ICU, what type of complications are the most common that you would see in your patient?
Speaker 2:population, mainly, I would say, the ventilated patients maybe a bit of atelectasis at times, further on down the line, some contractures, I would say. So obviously we try our hardest not to let contractures develop. So we'd put the patients through, even sometimes going to theatre with the patients and putting the patients through a full range. If it's a child or if it's someone that we're really struggling with that's battling a bit to cope with the physio, then we would go into theatre with them and put the limb through a full range and the doctors are quite happy about that.
Speaker 1:Okay. Yeah, I suppose the atelectasis is something that you could manage quite well with ambivagging as part of your patient approach if they're still intubated, and out-of-bed mobilisation for those that are spontaneously breathing.
Speaker 2:Yeah, we move them out very quickly on the edge of the bed into the lazy boy walking. Yeah, we move them very, very quickly. We've even got an outside area that we're able to get them outside, which is quite nice, and we take them out there for some fresh air. There's some ramps there and there's steps, so it just adds variety to the treatment rather than being in the hospital and you're kind of limited equipment wise.
Speaker 1:Yeah, so use the outside area quite a lot okay, I suppose one main predictor of patient outcome is the patient's willingness to participate in rehabilitation. You mentioned earlier in the discussion that you take time to explain to them from early on what your role as the physiotherapist is and why you need to do certain things to help them to have a better outcome. And we know that pain is quite a large complication of burn injury. Is there any education that you do with the patients regarding pain management strategies that they could use?
Speaker 2:We use quite a multimodal approach, because the burn patients have got background pain and then they've got procedural pain as well, so they've always got a bit of pain. And then when the nurses come along and do the dressings or the physio comes along and wants to do a physio, the pain increases. So we would either get I personally don't like them to have something for pain before I start, I prefer to do the physio then say if you need something, afterwards we'll get the nurse to give you something, but it's to be cognizant that it is a very painful thing. Yeah, and just to like be on their side. Helene and we're in this together and we're going to get you through. And, yes or no, it's a wee bit tight, but let's just try and push a wee bit yeah.
Speaker 1:Okay, what about advice regarding skin care, especially when things have started to yield and they're about to go home? What advice do you give them?
Speaker 2:we start that once they're awake and talking, we talk about sun care. We talk about and using a factor 50 sunblock stay out of the sun. We teach them to to look out for the three hours like hypertrophic scarring, because it sometimes comes as long as a one year, 18 months, after the actual burn. So we tell them look out for the three R's, the red roppiness raised scar, and that needs to be. You need to get back to the doctor to keep an eye on that if it starts to come. So yeah, and basically just to keep the long sleeves, long pants, stay out of the sun. Yeah, bathing every day, not rubbing hard, because they do sometimes blister for a bit, you know afterwards when the skin is still quite friable. So we warn them not to scrub themselves, just pat themselves dry. We start that talking very early on so that they're wearing hats when they're outside.
Speaker 1:We start that once they're awake and cognizant. Yeah, I just want to come back a little bit to the dynamics of your patient population. I remember in that retrospective record review we did, we saw that many patients had burn injuries due to hot water into the face, on the neck and the upper limbs and I was wondering if you can maybe just share with our listeners what rehabilitation you do with regards to the face.
Speaker 2:The face is very important, I think sometimes, Helene, it's overlooked, so that the neck and the face kind of together. You know the neck has especially the anterior structures of the neck. They contract quite easily. So we did speak earlier about that. We keep the pillow out and we put the patients through, even when they're ventilated. We put them through full range of of neck movements and then we also make them make sure their eyes close, we open their mouths to try and try and prevent microstomy on the edges of their mouth. When they're awake we let them chew chewing gum so they get that movement. We do facial exercises, even put our fingers in their mouth and work, work the mouth that way if need be, and make sure the eyelids are closing and open and the face is very much part of it, because that's your face to the world.
Speaker 1:Yes, yeah, and I suppose closing of the eyelids is so important for the health of the eyes and maintaining optimal vision and the stretches of the mouth to allow them to be able to open and close adequately to eat.
Speaker 2:We use those spatulas. If the mouth is battling to get a little bit open, we would tape some spatulas together and make the patient do self-stretching with the spatula to open the teeth. The eyes you can tape closed as well if you're battling to get full eye closure.
Speaker 1:Yeah, and then the last reference to the study we did together. We found that by the time patients are discharged home, many of them still haven't regained optimal joint range of motion in the affected areas. Most of them had fair muscle strength, not good muscle strength, and although most of them were fair muscle strength, not good muscle strength, and although most of them were independent with the activities of daily living and mobilisation, only a third of them were able to climb stairs easily. Is there any type of post-discharge physiotherapy follow-up that you provide to these patients?
Speaker 2:A lot of our patients come from far and wide so we don't have a lot of patients coming back for check-up. We do try and get them an outpatient appointment wherever they are and just do a note just to tell the physio we do stay, we do stares on every single trauma and burns patient when they're in Mill Park before they leave.
Speaker 1:But obviously they do need to keep themselves active and push a little bit cardiovascularly yeah okay, yeah, because Moorpark Hospital is a level one trauma centre, so your catchment area for patients is quite broad, it's very broad and oftentimes international as well.
Speaker 2:International burdens, yeah, international burdens.
Speaker 1:Yeah, Mwira. Are there any last thoughts that you would like to share with our listeners, particularly the junior physios that may not be so experienced in the field of burn care?
Speaker 2:I had a patient the other day whose elbow flexion was quite limited and we were kind of stuck. We were kind of stuck on like 90 degrees and I gave her my pen and I said to close your eyes, take that pen to your mouth. That's all I want you to do take the pen to your mouth, but close your eyes. We find if we give them something to work towards, they can do it. If you just say, take your thumb to your mouth, seems like they can't do it. But if you say take that pen or the fork, it seems that it seems much easier. But with their eyes closed as well okay, so guided, guided like yes guided exercise, yeah, or even even like marks on the wall.
Speaker 2:Helene, if we're struggling with elbow shoulder elevation, we'll. We'll put a tape on the wall and say right, we're dating it. By next week, we want you a little bit higher. And use that visual reinforcement for them. It seems to work well, rather than just stand and say, lift your arm up.
Speaker 1:Okay, moira. Thank you so much for sharing those balls of wisdom with our audience. I want to encourage people who are listening to this recording that if you have any questions, you can put those questions in the link in the show notes and we'll review them and respond. And for those of you that want to read more about the research that we published from the Burns Unit, I'll put the link to the paper in the show notes and, of course, there's the link to the book that we wrote and that Moira was a co-author for, regarding physiotherapy management of patients with burn injuries. So thank you for listening and we hope to see you again soon, moira. Thank you. Thank you, helene. Thank you.
