REHABILITATION OF BURN PATIENTS IN THE BURN UNIT

Brcit A.

University Medical Center, Ljubljana, Yugoslavia

SUMMARY. Early surgery of the bum wound, especially primary tangential excision, creates favorable conditions for effective early rehabilitation. A team for rehabilitation was organized to follow the patient from admission, during hospitalization and after discharge. The members are: surgeon, nurse, physio- and occupational-therapist, psychologist, dietitian, school teacher, play therapist, social worker and cosmetologist. For major bums, treatment in the Rehabilitation Centre follows discharge, although regular controls by the rehabilitation team are continued. Every patient is supplied with compressive garments (gloves, mask) or splints and conformers which are individually produced by the occupational therapist during treatment in the unit. Reconstructive operations are performed because of both functional and psychological needs. In children early reconstruction is often necessary in cases of development and growth impairment. The role of the family in the process of reintegration in normal life is obvious not only in children but also in adults. Bum Units should organize their own rehabilitation team and cooperate with Rehabilitation Centres, as in the present situation they have limited knowledge of specific burn rehabilitation.

The application of generally adopted surgical principles in the treatment of bum wounds has been introduced relatively late. The active surgical approach to the bum wound was finally recognised by the majority of surgeons treating bums in the last five years. The conventional methods of local treatment, especially in deep bums with late separation of necrotic tissue and grafting, cannot prevent infection and fibrosis of burned tissue and surrounding tissues.
Our Bum Unit in Ljubljana started to treat bums systematically by primary excision in 1966. It was a long, sometimes difficult process and the contributions of Zora Janzekovic, Mirko Derganc and Franjo Zdravic were remarkable. From the vast experience of operations we developed our principles and philosophy of the primary tangential excision of bums.
Advantages of primary tangential excision for rehabilitation:

1. Preservation of tissue by tangential or "calibrated" excision. During the operation it is possible to see in a clean wound viable and nonviable tissue and to recognize the amount of destroyed tissue. On this basis an appropriate skin cover is chosen (even free flap, if necessary)
2. Primary and early closing of the bum wound and elimination of infection
3. Absence of pain stimuli after excision and grafting 4) Short period of immobilization with early mobilization after operation.

A rehabilitation team was organized to improve and stabilize the good results of early surgery. The members are: surgeon, nurse, physio- and occupational -therapist, psychologist, dietitian, school teacher, play therapist, social worker and cosmetologist.

The treatment is started the day after admission with positioning. The goal is to prevent oedema and contractures. It is often necessary to maintain the desired position by splinting. If the patient is in good condition active exercises and ambulation is performed.

The majority of our patients are operated on the 3rd or 4th day after burning. We try to remove most of the burned tissue, 20-30%, even more, if possible. This period of about 5 days after the operation is very unfavourable for rehabilitation, and minor exercises are recommended in order to preserve the grafted areas. On the 7th day hydrotherapy is started by immersion and the take of grafts is evaluated. If most of the wounds are healed immersion hydrotherapy is continued every day; if there are open wounds of large necrotic areas shower spray is used every day to facilitate exercises and to prepare the patient for the next operation.

Healed and grafted areas are sensitive and fragile and blisters and pruritus very often develops.
Patients are shown and taught how to clean, lubricate and massage the new skin. They are encouraged to develop independence in everyday activities.
The possibility of scar development and hypertrophic reactions are discussed with the patient or the family and the necessity stressed for continuous pressure on these areas. Splinting is necessary especially during the night - the position of comfort is the position of contracture.
Splints, conformers, masks, gloves and other compressive garments are produced immediately during treatment in the Burn Unit. It is not necessary to have expensive materials and equipment. Plaster splints are very simple to produce. Elastic material for pressure garments is commercially available. With an ordinary sewing machine excellent gloves and masks can be produced by the occupational therapist in the Unit.
Especially for children the school teacher and play therapist are very important during hospitalization to keep their minds busy and active. It is necessary to teach children how to use compressive garments or splints, which they very often dislike.

The burn team keeps in contact with the patient after discharge through regular out-patient clinical care.
There are problems of reintegration at school, work or even in the family and consultations with the psychologist are needed. Short hospitalization time is very important and in our Unit we developed a simple rule: hospitalization time should be equal to the percentage of burned area (e.g. 30% burn requires 30 days' hospitalization time).
The role of the surgeon is to recognize contractures which hinder rehabilitation and to perform early release. This is especially important in the hands. Of no less importance are aesthetical disfigurements (face) which are to be corrected for psychological reasons. For minor disfigurements which cannot be corrected surgically the cosmetologist is able to help the patient.

Our experience is that every Burn Unit has to organize its own rehabilitation team and keep in close contact with patients, as in the present situation Rehabilitation Centres have only limited knowledge of specific burn rehabilitation.

RÉSUMÉ. L'intervention chirurgicale précoce en cas de brûlure, surtout l'excision tangentielle primaire, crée les conditions favorables pour une rééducation précoce et efficace. Nous avons organisé une équipe de rééducation pour suivre le patient à partir du moment de l'hospitalisation, pendant la période du traitement et après la sortie. Les membres de l'équipe sont: le chirurgien, l'infirmier, le physiothérapeute et le thérapeute occupationnel, le psychologue, le diétécien, le maître d'école, le thérapeute du jeu, l'assistant social et le cosmétologue. Dans le cas des brûlures graves, le traitement continue au Centre de Rééducation après la sortie, bien que l'equipe de rééducation continue à effectuer des contrôles réguliers. Tout les patients reçoivent des vêtements compressifs (gants, masque) ou des prothèses orthopédiques fabriquées individuellement par le thérapeute occupationnel. Les opérations de reconstitution sont effectuées pour les exigences soit fonctionnelles soit psychologiques. Chez les enfants il faut souvent effectuer une reconstitution précoce en cas de comprimission du développement ou de la croissance. Le rôle de la famille dans la réintégration du patient à la vie normale est évident, soit pour les enfants, soit pour les adultes. Les Centres des Brûlés doivent organiser en manière autonome leurs équipes de rééducation; ils doivent en outre coopérer avec les Centres de Rééducation puisque actuellement ils ont une expérience limitée de la rééducation spécifique des brûlés.