SUMMARY. The rehabilitation of the elderly burned patient presents a series of problems, which are considered in this paper. These problems are both physical and psychological and any rehabilitation programme must take them into account. The Palermo Bums Centre has a two-phase protocol, for the hospitalization period and for the long post-discharge period. The first of these prescribes appropriate posture training, early mobilization and intensive occupational therapy. In the second phase, on discharge, patients are assigned to one of three distinct groups according to their age and condition. The ultimate objective is the maintenance of muscular strength, the prevention of articular stiffness and postural vices, and the strengthening of motor function. The various phases are described, always bearing in mind the particular physical and psychological limitations of the elderly.

From the point of view of prognosis and functional recovery, the bum trauma is probably the most serious injury that can affect elderly persons. In such patients, even if the burns are not extensive, the treatment for psychophysical rehabilitation is of fundamental importance in order to guarantee a good quality of residual life. The programme of recovery is complicated by a series of physiological and psychological factors (1).
Although the age of retirement from work does not necessarily coincide with an actual physical or psychological incapacity, the elderly person has certain functional and reactive limits that must be ana-lysed and borne in mind when a rehabilitation programme is being drawn up.

The physicalfactors (2, 3, 4) that exert a negative influence on recovery are: paramorphism of the lower limbs, senile kyphosis, limitation of articular excursion and motor activity, chest deformation and neuromotor deficit.
To these must be added a number of transformations of the general physical state, varying between the normal and the pathological ' such as cardiocirculatory, pulmonary and renal modifications and hydro ele c trolytic imbalances which render the patient liable to easy tiredness and to the formation of oedema and neuromotor conditions interfering with normal movements and walking.
The psychological factors (1) to be considered are: the normal deterioration of intellectual capacity, reduction or cessation of interest, loss of an active role, the frustration of ideals - all these conditions induce patients to be uncooperative and even to refuse therapy because of the inevitable pain it causes.
For good recovery to be possible it is therefore indispensable to prepare appropriate psychological care, which during hospitalization has to be provided by professional operators who will act as family substitutes and create a comfortable and reassuring atmosphere.
Elderly persons who have had an accident are terrified that it may happen again; they lose confidence in their physical capacity, even if they are in fact still fit, and they attempt to prevent all efforts to help them to return to an autonomous life, prefe rig instead a complete but not always justified condition of protected dependency. For these reasons it is the task of other family members to assist the patient on dismissal from hospital to return to his or her normal routine, with all the risks that this may involve.

The preparation of a valid "personalized" programme of rehabilitation treatment has to be preceded by a careful anamnesis in order to assess previous motor limitations, the presence of degenerative diseases, pre-existing deformities, pain phenomena, intellectual level and psychological disturbances, together with the family and economic background and the patient's previous social relations (1,2,5,7).
The rehabilitation programme in our Department is divided into two phases: the first to be followed during hospitalization and the second after discharge.
For hospitalized patients the protocol is articulated as follows:

1. Appropriate posture training in order to reduce oedema and in particular to prevent the adoption of antalgic positions which in the elderly may become irreversible.
2. Early mobilization of all body segments whether affected by the burn or not. This practice is based on some fundamental rules:
   do not fatigue the patient, provoke as little pain as possible, and perform only short but frequent sessions. It is important to inform patients of the purposes of the therapy, which they tend to refuse because of the pain it causes. Mobilization will help to reduce pressure sores and articular problems. The prevention of ulcers is guaranteed by continuous posture change, by water- and air-beds and by hammocks which with their rotating sides help to change the patients' position easily and ainlessly (Figs 1, 2). The patients are encouraged to get up from their beds as soon as possible, with the aid of elastic bandaging of the limbs. This helps to maintain capillary tone, to reduce osteoporosis due to immobilization, to facilitate renal function, to improve puh-nonary ventilation, to maintain muscular tone and above all to restore the patients' confidence in themselves and their recovery (Figs. 3, 4).
   The prevention of articular problems (3, 4, 5, 6) is effected by means of exercises of physiokinesis therapy in all its aspects: passive, active, active assisted and resistance, both in bed and in the swimming-pool or gymnasium.
   Hydrotherapy produces particular beneficial effects and is well tolerated because the patients are immersed in water and can perform their exercises with less physical effort and are therefore more willing to co-operate.
   In the final period of hospitalization, rehabilitation coming and different from that of intensive care where the patient has long been kept in isolation, and it will allow him to re-establish contact with the outside world and prepare him sychologically for his discharge and his return to the family, Elderly patients are often unwilling to return home either because they are afraid they will not receive adequate care and support from their family or because they begin to look upon themselves as being permanently ill and requiring special care. They therefore believe that the hospital environment is where they will best be protected.
3. Full-scale occupational therapy (5): physical activity is one of the most important and effective methods of care and rehabilitation in the elderly., it is the final goal of all mobilization and rehabilitation activity and of all psychophysical stimulation. Physical activity provides a pleasant way for elderly patients to fill the emptiness that they may feel in their existence. Manual activity performed with common everyday objects and instruments will assist in the recovery of their personal autonomy (Fig. 5).

Fig. 1 Fig. 2 Fig. 3 Fig. 3 Fig. 4

Recreational pastimes such as basketwork, carpet making, drawing and painting, together with card therapy is performed in the gymnasium. This games, bingo, etc., all serve to stimulate the environment is new to the patient: it is wel attention and above all to help socialization.
On discharge the rehabilitation phase is completed by placing the patients in one of three groups, depending on their age and their physical and psychological conditions (7).
Group I generally contains patients aged between 65 and 70 years of age who are still fit and who present none of the factors that are considered to interfere with recovery.
Patients aged between 70 and 75 who are still motivated by particular social and/or working interests are put in Group 11, while Group III is composed of persons aged over 75 years who present reduced or no interest, accentuated by the burn illness and immobility.
Group I patients are taken through the final phase of the rehabilitation protocol, which consists of the continuation of physiokinesitherapy for a few months until the time comes to programme the surgical phase for the functional and aesthetic correction of scarring.
For Group 11 patients we recommend a protocol of occupational therapy directed at maintaining personal autonomy and self-sufficiency in all daily activities.
In the case of Group 111 patients, family members are informed as to the procedures they should follow and the treatment to be given to the patient in the home environment.

The particular psychological and physical conditions of the elderly person who has suffered burn injuries and has to go through functional recovery treatment play an important part in the preparation of the rehabilitation programme and in its realization.
The treatment must begin early, it must be intense and long-term (it may in fact become permanent), and it must involve all body areas whether affected by the bum or not, with the objective of maintaining muscular strength, preventing articular stiffness and postural vices, and strengthening motor function.
The whole procedure must of course take into account the physical and psychological limitations inevitably present in the elderly.

RESUME. La réadaptation des patients brûlés âgés présente une série de problèmes que les auteurs considèrent. Ces problèmes sont de nature physique et psychologique et tout programme de réadaptation doit en tenir compte. Le Centre des Brûlés de Palerme a un protocole à deux phases, pour la période de l'hospitalisation et pour la longue période de la convalescence. La première phase prescrit des exercises appropriés pour la posture, une mobilisation précoce et une thérapeutique occupationnelle intensive. Dans la deuxième phase, après le renvoi de l'hôpital, les patients sont divisés en 3 groupes, selon l'âge et la condition physique. Le but final est le maintien des forces musculaires, la prévention de la rigidité articulaire et les vices de posture, et le renforcement de la fonction motrice. Les auteurs décrivent les différentes phases, en tenant toujours compte des particulières limitations physiques et psychologiques du patient âgé.

BIBLIOGRAPHY

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