Occupational Therapy’s Role Working with the Burn Patient Population
Depending on the severity of the case, burns can be the root of all-encompassing disruption in a patient’s life. We’re talking about physical, emotional, and psychological trauma that can last a lifetime. Burns can also exacerbate other comorbidities that patients may have been living with prior to their newly acquired injuries.
Burns are potentially life-threatening and life-altering injuries, and occupational therapy plays a vital role in patients’ recovery periods. This article is going to walk you through some basics regarding burns, how burns impact function, and what the OT evaluation and intervention process could look like.
Consider the Following Scenario
Cynthia is a 34 year-old female who was admitted to the hospital after an accident outside of her home. She stepped out of her house for a smoke break and was wearing an oxygen nasal cannula on her face. She forgot to turn off the oxygen and remove the cannula prior to lighting her cigarette. The combination of the oxygen flow and the lighter resulted in 2nd and 3rd degree burns across roughly 50% of her face and neck.
Upon admittance, doctors determined that she would need immediate surgery and respiratory care as well as rehabilitative care and wound management later down the road. Cynthia also has paranoid schizophrenia, lives alone, and has had previous accidents in the past some of which resulted in hospitalization.
Types of Burns: How Burns are Measured
Depending on the source, many medical entities have broken down burn severity into four stages of degrees:
1st degree burns (superficial): Pain and reddening of the outer layer of skin called the epidermis.
2nd degree burns (partial thickness): Damage to the first and second layers of skin, the epidermis and the dermis. This includes blistering, redness, and swelling.
3rd degree burns (full thickness): Damage past the epidermis and dermis tissue layers; this includes white or blackened, charred skin that may have loss of sensation.
4th degree burns: Damage deep enough to impact muscle, fatty tissue, and bone; nerve endings are damaged or destroyed so there is complete loss of feeling at the burn site.
First and second degree burns usually heal on their own, but 3rd and 4th degree burns require immediate medical attention (WebMD, 2020).
Types of Burns’ Healing Duration
According to Stanford Healthcare (2020), any burn is a result of an energy transfer to the body. Physiological changes, such as the extent of cell death, are dependent on the type of burns the body incurs. The most common is thermal, or heat (i.e. hot metals, scalding liquids, flames, etc.).
Other types of burns include radiation, chemical, and electric contact. Superficial burns can often heal in a matter of a few days. Moderate-to-severe burns, especially those that require reconstructive surgery or skin grafts, may take up to a few months to several years to fully heal (NHS, 2020).
What Areas of Function Can Burns Impact?
Burns that require extensive medical attention cause much more than just cosmetic damage. Depending on the type, the severity, the size, and the location of the burn(s), any or all areas of function can dramatically change:
- Basic activities of daily living: dressing, toileting, showering, hygiene, feeding, etc.
- Instrumental IADLs: household management, childcare, financial management, community errands, etc.
- Social participation
- Community integration and participation
- Work and/or school obligations
- Hobbies, sports participation, volunteer work, etc.
Burn injuries can be the source of extensive hospital stays, multiple surgical operations, and prolonged rehabilitation which means resuming a normal life at home may not be readily attainable for a long time.
What Should OT Focus on in the Initial Evaluation?
Let’s back up a few steps in order to put the occupational therapy evaluation into better perspective. Think about three things: the population in which you work with (kids, adults), the setting where you work (acute care, skilled nursing, outpatient, etc.), and the type of diagnoses you tend to address.
Are you working in a specialty burn center with a multi-disciplinary team to treat burn injuries specifically? Or are you employed at a facility that admits a wide variety of patients? All of these factors should be considered prior to you entering the patient’s room for the initial evaluation.
Once you have greeted the patient, consider gathering the following information:
- Pain Levels: At rest, with activity, pain description (inflamed, stinging, etc.) and the specific bodily locations.
- Medical History: This should include hospital information regarding the burn injury, the location, the severity, the type of burn, and the percentage of damage. Gather any and all information about prior treatment for the burn including wound care, reconstructive surgery, grafting, and precautions (i.e. limited to no range of motion, no weight-lifting, etc.).
- Patient Goals: First and foremost, have an open and honest discussion about what the patient would like to accomplish in OT. At the end of scar management, stretching, and contracture prevention, have them contemplate what (and how well) they functionally would like to perform at the end of their rehabilitative journey.
- ROM/MMT: If range-of-motion and manual muscle testing are permitted, gather baseline measurements for what the patient can currently perform.
- Cognitive/Psychological Assessment and History: If you recall earlier in the article, we mentioned in our case study that Cynthia had a diagnosis of paranoid schizophrenia. Cognitive and mental capacities often play a role in how burn injuries occur and whether the patient will adhere to current and future interventions. Collect patient history information and current performance levels in cognition and safety awareness.
- Activities of Daily Living: Gather detailed information about how the patient is performing relevant activities of daily living, currently and prior to injury. This should include general activities as well as activities of importance or interest to the patient.
What are some OT intervention strategies that are commonly used for burn patients in occupational therapy?
Tailor your occupational therapy interventions to meet your individual client’s functional needs. For example, a small child attending elementary school will have drastically different goals compared to an elderly patient living in a group home.
OT interventions for burn injuries can include (but are not limited to):
The primary limitation that comes with burns and the healing process is pain. Thus, it is essential to make pain management a main driving force behind OT intervention. Techniques may include education and training in lifestyle modification and compensatory strategies to change movement and participation in order to reduce overall pain with functionality.
Energy Conservation Techniques
Healing from a burn injury as well as side effects from medications and respiratory injuries can be exhausting. OT can work on helping patients incorporate ways to slow down and to prioritize activities throughout the day. Read this My OT Spot post about energy conservation techniques.
ADL Training and Management
ADL management can include adaptations to hygiene routines while waiting for burn injuries to heal. Additionally, OT can work on helping patients adhere to new skin and wound care/hygiene routines to promote rapid healing.
Range-of-motion and Scar Management
OT can develop therapeutic exercise regimens that emphasize full joint range and stretching of the skin to reduce the long-term effects of scarring.
Part of intervention may include managing swelling tissue with compression programs in order to minimize infection and to increase skin integrity.
Splinting and Contracture Management
For severe burn injuries, OT can create a regular splinting program combined with appropriate range-of-motion and stretching regimens to prevent contractures.
Cognitive and Psychosocial Interventions
If burn injuries are a result of self-harm or mental illness, OT can address psychosocial needs to promote adherence to healing strategies and overall functional safety.
Community Re-Integration Training
This could include employment, volunteer work, social opportunities, transportation use, and all sorts of community-related activities. Functioning in a community setting after a burn injury can also come with some emotional difficulty that OT can appropriately tackle.
Along with standalone interventions, OT should expect to work side-by-side with additional disciplines including wound care, nursing, respiratory care, physical therapy, psychology, and social work in order to promote the patient’s recovery.
Burn injuries can have long-term, devastating effects on a person’s life. As you can see, occupational therapists are well-equipped to step in and provide optimal rehabilitation for these patients in order to get them back on track.
Burns (2020). WebMD. https://www.webmd.com/pain-management/guide/pain-caused-by-burns#1.
Different Types of Burns (2020). Stanford Healthcare: Stanford Medicine. https://stanfordhealthcare.org/medical-conditions/skin-hair-and-nails/burns/types.html.
Recovery: Burns and Scalds (2020). NHS. https://www.nhs.uk/conditions/burns-and-scalds/recovery/.
Educative article on OT management of burns