The role of physical therapy in burn care management is critical and usually begins when the child is in the ICU. Megan Clark, Supervisor of Burn Physical Medicine at the Joseph M. Still Burn Center at Doctors Hospital says the challenge of caring for children is the fact that they are still developing, growing and learning.
“Not only do we need to ensure that the child can maintain movement and range of motion, but we must also be sure to preserve the motor skills they have learned, such as walking and feeding themselves, so they don’t regress and have to learn these skills all over again.”
Under a traditional therapy model, typically the physical therapist works with the patient on standing and walking—anything from the waist down—and the occupational therapist focuses on the patient’s body from the waist up, such as using his arms and hands. The burn team’s approach is a bit different. Each discipline rotates on a weekly basis, working closely together in addressing the full physical / mobility needs of the child. Each is able to make recommendations such as whether splints are needed, whether the patient is ready to walk, or whether crutches or a walker is needed to assist with ambulation.
Therapy with the pediatric patient requires a progression of activities that focus on movement and range of motion. The therapist closely monitors the child’s joints, muscles and skin to make sure nothing tightens to limit function, which ultimately inhibits independence. During each therapy session beginning from the first, the child is assisted with movement and stretching; daily pain medication helps control her pain to make this possible.
According to Clark, it is common to treat toddlers who have burned the palms of their hands from touching a hot surface. As the palm heals, the skin tends to shorten and contract, drawing the fingers into a fist. For some patients, the best approach is a surgical procedure to cut the skin and release the tightening. For others, a compression glove is used to prevent contracture by keeping the palm open and straight.
Compression therapy is useful for deep burns in keeping the scars flat and preventing a thick scar from forming. A variety of compression garment can be utilized, including shirts, pants, socks, sleeves, gloves and masks. “In a child, the scar can continue to change for a year following the burn, so compression therapy can last equally as long,” Clark says. Young children tend to try to take the glove off, so a compression sleeve may be used instead. To keep the child in a functional position, a splint or cast also may be used in conjunction with, or instead of, the compression garment.
When possible, a special gel sleeve—either infused with mineral oil or with a silicone base—is worn up to 23 hours per day to keep the burn scar soft and moist. The sleeve is utilized alone or under the compression garment and helps improve movement by making the child more comfortable and minimizing the tight feel of the healing tissue. If a gel sleeve is not in use, lotion must be applied to the scar tissue numerous times throughout the day.
Immersion in a whirlpool is a commonly used therapeutic intervention when the burn is healing. The jets and warm water help stimulate circulation and facilitate debridement of loose dead skin. For young children, it can double as fun tub time with floating rubber ducks and other toys.
“Our main concern is mobility and range of movement. In other words, helping the child to develop towards independence,” says Clark. “Parents don’t fully understand how important physical therapy is because they don’t have the clinical understanding of what the end result needs to be and what it takes to get there given the ongoing growth and development of the child.”
She says that because parents don’t differentiate between pain and discomfort, they won’t stretch and move him or her as much as a therapist would for fear of hurting their child.
Clearly, physical and occupational therapy are essential for any burn patient’s recovery. Appropriately managing a child’s healing process, however, takes a considerable amount of planning, persistence, and patience combined with expert knowledge of the human growth process.