Rehabilitation Options after Experiencing a Severe Hand Burn
Article written by: William Scott Dewey, Pt, CHT. Mr. Dewey has practiced as a Physical Therapist for 17 years. He became a Certified Hand Therapist in 2001 and has been treating burns since 2004. Mr. Dewey has published several textbook chapters on hand and burn rehabilitation and has articles published in Journal of Burn Care and Research, Burns, Journal of Trauma and Journal of Hand Therapy. He currently serves as the Program Manager for the Burn Rehabilitation department at the U.S. Army Burn Center at Fort Sam Houston, Texas.
Disclaimer: The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.
Recent medical and prosthetic advances have resulted in many options designed to maximize functional outcomes after sustaining a severe hand burn. Although it is great to have options, determining which options are best for an individual can be overwhelming. The intent of this article is to review rehabilitation considerations to help with this decision making process.
The primary rehabilitation goal following a burn is to maximize range of motion (ROM) of the affected area. The best time to increase the ROM is when the scar is still maturing. Scar begins forming within days after injury and can continue to form for years. Although immature scar is thicker than mature scar and will tighten if adequate stress is not applied, it is actually more capable of lengthening – making ROM gains more possible. Unfortunately, the scar lengthening process can be uncomfortable at times. This increase can be accomplished by persistent exercise and/or wearing splints, casts or other devices as recommended by your therapist. A key principle to remember is that stress applied to lengthen a scar should not be too intense. The duration of the stress is also an important factor – a little bit of stress for a long period of time is more important than a lot of stress for a few minutes or seconds. This is the primary reason why wearing splints or other devices consistently can be successful for regaining motion.
There are many types of splints that are commercially available through your therapist. Some therapists can also fabricate splints specifically for you, these customized versions can usually be remolded or adjusted to account for changes in motion. Splints should hold the affected area so the scar tissue is being lengthened. Splints that hold one position are called static splints. Once the scar grows sufficiently, the splint may need to be adjusted to accommodate for this lengthening. This process is called serial splinting. Serial casting is a similar procedure that uses casting material.
Splints that allow or provide motion when wearing them are also an option for increasing scar length. These splints are classified as either dynamic or staticprogressive splints, depending on the design mechanism used. These types require frequent adjustments by your therapist as ROM increases are achieved. Although they can be more work for the therapist and more cumbersome for the patient to wear, dynamic or static-progressive splints have been shown to be very effective for increasing ROM. In addition to providing a long duration stress, they also allow the patient to control the intensity of the pull.
Generally speaking, initial attempts to increase ROM should include exercise and wearing static splints as needed. If adequate ROM gains are not being achieved through these two means than dynamic or static-progressive splinting should be attempted. A combination of all of these techniques should be continued until a plateau with progress is noticed. Once all of these options have been exhausted, you should speak with your rehabilitation professional to decide what options you may have. Unfortunately, if a scar is not promptly lengthened, then underlying muscles, tendons and joints can become tight as well. It is important to determine what is causing the ROM restriction. Your therapist can help with this determination and adjust your rehabilitation plan based on these findings.
Other important considerations are strength and sensation, the ability to feel. Both of these are controlled by nerve function, and dysfunction of either of these may impact your rehabilitation treatment and outcomes. Early recognition of any strength or sensory loss is important so that appropriate interventions can be considered by rehabilitation and medical personnel. Therapists can test for strength and sensory loss as part of their evaluation and consult with the physician for further testing if that is necessary. The more detailed nerve tests performed by physicians can help determine the prognosis of either sensory or strength return. The potential of sensory or strength return should be considered when deciding how to proceed with rehabilitation or other options.
If you are unable to achieve full ROM or you have significant strength loss, there are devices available that may help compensate for these deficits. Your therapist can advise you on which devices may benefit you and provide instruction on how to use this equipment.
Finally, if any type of amputation has occurred or is being considered, it is very important to coordinate efforts between the therapist, prosthetist and physicians. If an amputation has occurred, therapists can assist with shaping of the residual limb and preparing this area for tolerating a prosthesis. The sooner this is done, the sooner a patient can be fit for a prosthesis. Specific exercises can also be prescribed by your therapist based on what type of prosthesis you may receive. These exercises can help condition the proper muscles to help with improving prosthetic control.
Although splint use was discussed earlier, there is another type of splint that some therapists may be able to fabricate to compensate for a loss of strength or loss of digits. These functional splints may substitute movement that your body is unable to produce or they can provide length resulting from a loss of digits. This type of splint can serve as a temporary device to help prepare for a prosthesis or it can be used in place of a prosthesis if one is not available.
In summary, it is very important to communicate your desires to your therapist. Your therapist can assist with developing a plan to maximize your function. Rehabilitation efforts can also include coordination with other disciplines to achieve the best possible outcome.