8.3 Burn Rehabilitation, Edema Management & CRPS

Burn Rehabilitation, Wound Care & Edema Management

Burn rehabilitation and wound care span the continuum from emergency life support to multi-year scar remodeling. Occupational therapy prevents debilitating contractures, preserves functional joint biomechanics, controls edema, and manages complex chronic pain syndromes through evidence-based interventions.

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1. Burn Depth Classification & Total Body Surface Area (TBSA)

Burn depth depends on the temperature, mechanism of injury, and duration of contact with the thermal, chemical, electrical, or radiation source.

+---------------------------------------------------------------------------------------------------+
|                               BURN DEPTH CLASSIFICATION MATRIX                                    |
+---------------------+---------------------+-----------------------+-------------------------------+
| Burn Classification | Anatomical Layers   | Clinical Appearance   | Sensation, Healing & Scarring |
+---------------------+---------------------+-----------------------+-------------------------------+
| **Superficial**     | Epidermis only      | Red, dry, no blisters | • Intact sensation / painful  |
| *(1st Degree)*      |                     | (e.g., mild sunburn). | • Heals 3–7 days; no scar.    |
+---------------------+---------------------+-----------------------+-------------------------------+
| **Superficial**     | Epidermis and upper | Bright pink/red, wet, | • Exquisitely painful         |
| **Partial-Thickness**| papillary dermis   | weeping, thin-walled  | • Heals 7–21 days             |
| *(2nd Deg Super)*   |                     | blisters; blanching.  | • Minimal potential for scar. |
+---------------------+---------------------+-----------------------+-------------------------------+
| **Deep Partial-**   | Epidermis and deep  | Mottled red/white, dry| • Reduced sensation / dull    |
| **Thickness**       | reticular dermis;   | surface, sluggish or  | • Heals 21–35 days; may graft |
| *(2nd Deg Deep)*    | hair follicles intact| absent blanching.    | • **High hypertrophic scar**  |
|                     |                     |                       |   **and contracture risk.**   |
+---------------------+---------------------+-----------------------+-------------------------------+
| **Full-Thickness**  | Epidermis, entire   | Leathery eschar, dry, | • Anesthetic / no pain to pin |
| *(3rd Degree)*      | dermis, subcutaneous| white, charred, brown;| • **Requires surgical**       |
|                     | tissue              | non-blanching.        |   **excision & skin grafting**|
+---------------------+---------------------+-----------------------+-------------------------------+
| **Subdermal**       | Complete destruction| Charred tissue, muscle| • Complete nerve destruction  |
| *(4th Degree)*      | of skin, fat, muscle| and bone exposed.     | • Requires flap coverage or   |
|                     | tendon, and bone    | (Electrical burns).   |   amputation; severe contract.|
+---------------------+---------------------+-----------------------+-------------------------------+

Total Body Surface Area: The Adult Rule of Nines

Therapists utilize the Rule of Nines to calculate the percentage of Total Body Surface Area (% TBSA) burned. For smaller or scattered patchy burns, the Palmar Method establishes that the patient's entire palm (including fingers) represents approximately 1% TBSA.

+---------------------------------------------------------------------------------------------------+
|                                 ADULT RULE OF NINES ALLOCATION                                    |
+---------------------------------------+-----------------------------------------------------------+
| Anatomical Body Region                | Total Percentage Total Body Surface Area (% TBSA)         |
+---------------------------------------+-----------------------------------------------------------+
| **Head and Neck**                     | 9% (4.5% anterior, 4.5% posterior)                        |
| **Anterior Trunk (Chest & Abdomen)**  | 18%                                                       |
| **Posterior Trunk (Back & Buttocks)** | 18%                                                       |
| **Right Upper Extremity**             | 9% (4.5% anterior, 4.5% posterior)                        |
| **Left Upper Extremity**              | 9% (4.5% anterior, 4.5% posterior)                        |
| **Right Lower Extremity**             | 18% (9% anterior, 9% posterior)                           |
| **Left Lower Extremity**              | 18% (9% anterior, 9% posterior)                           |
| **Perineum / Genitalia**              | 1%                                                        |
+---------------------------------------+-----------------------------------------------------------+
| **TOTAL ENTIRE BODY**                 | **100%**                                                  |
+---------------------------------------+-----------------------------------------------------------+

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2. Three Phases of Burn Rehabilitation

Burn care progresses through three distinct clinical phases: Emergent (0–72 hours), Acute (72 hours to wound closure), and Rehabilitation (wound closure to scar maturation).

Phase 1: Emergent Phase (0 to 72 Hours Post-Injury)

• Medical Priorities: Fluid resuscitation (Parkland formula), airway management, escharotomy monitoring, and pulmonary stabilization.
• OT Priorities: Edema control, early anti-deformity positioning, and fabricating protective orthoses.
• Anti-Deformity Positioning Matrix: Edema and myofibroblast activity pull healing tissues into positions of comfort (flexion, adduction, internal rotation), which rapidly leads to irreversible joint contractures. Anti-deformity positioning places tissues on stretch opposite the expected contracture vector.

+---------------------------------------------------------------------------------------------------+
|                         BURN ANTI-DEFORMITY POSITIONING & SPLINTING MATRIX                        |
+-------------------+-----------------------------------+-------------------------------------------+
| Anatomical Region | Typical Contracture Tendency      | Prescribed Anti-Deformity Position        |
+-------------------+-----------------------------------+-------------------------------------------+
| **Neck**          | Flexion / chin-to-chest           | • **Neutral to slight extension** (no     |
|                   | contracture                       |   pillow; neck conformer or collar).      |
+-------------------+-----------------------------------+-------------------------------------------+
| **Shoulders / **  | Adduction and internal rotation;  | • **Abduction to 90°** and horizontal     |
| **Axillae**       | axillary web space obliteration   |   **adduction to 20°** (airplane splint). |
+-------------------+-----------------------------------+-------------------------------------------+
| **Elbows & **     | Elbow flexion and forearm         | • **Full extension**; forearm in neutral  |
| **Forearms**      | pronation                         |   or slight supination (extension splint).|
+-------------------+-----------------------------------+-------------------------------------------+
| **Wrist & Hand**  | 'Claw hand' / Intrinsic Minus     | • **Intrinsic Plus / 'Safe Position':**   |
|                   | (wrist flexion, MCP hyperextension|   - **Wrist:** 20° – 30° extension        |
|                   |  PIP/DIP flexion, thumb adducted) |   - **MCP Joints:** 70° – 90° flexion     |
|                   |                                   |   - **IP Joints (PIP/DIP):** Full ext (0°)|
|                   |                                   |   - **Thumb:** Radial/palmar abduction    |
+-------------------+-----------------------------------+-------------------------------------------+
| **Hips & Knees**  | Hip flexion/adduction; knee flex  | • Hips neutral extension, 10–15° abduct;  |
|                   | contracture                       | • Knees in **full extension** (post. splint)|
+-------------------+-----------------------------------+-------------------------------------------+
| **Ankles / Feet** | Plantarflexion (foot drop)        | • **Neutral dorsiflexion at 90°** (AFO).  |
+-------------------+-----------------------------------+-------------------------------------------+

Phase 2: Acute Phase (72 Hours to Wound Closure)

• Medical Interventions: Surgical excision of devitalized tissue and coverage with split-thickness skin autografts (STSG) or full-thickness skin grafts (FTSG).
• Critical Post-Skin Grafting Immobilization Protocol:
  • Following skin grafting, the operative body part must be strictly immobilized for 3 to 5 days (in some protocols 5–7 days) to allow capillary vascularization, fibrin adherence, and graft take.
  • NO active or passive range of motion is permitted on the grafted joint during this initial immobilization window.
  • After graft adherence is confirmed by the surgical team (typically post-op day 4–5), gentle active range of motion (AROM) is initiated, followed by active-assisted ROM. Aggressive PROM is avoided early to prevent shearing.

Phase 3: Rehabilitation Phase (Wound Closure to Scar Maturation)

• Pathophysiology of Hypertrophic Scarring: Hypertrophic scars occur when myofibroblasts and disorganized collagen bundles proliferate, producing raised, thick, rigid, erythematous scar tissue confined within original wound borders.
• Compression Therapy Standard:
  • Custom Pressure Garments: Provide constant gradient pressure of 20 to 30 mmHg (or up to 35 mmHg) to compress capillary beds, induce local hypoxia, and force collagen fibers into parallel alignment.
  • Wearing Schedule: Worn 23 hours per day, removed only for 1 hour for bathing and skin care, for 12 to 24 months until the scar matures (becomes soft, flat, pale, and pliable).
• Adjunctive Scar Interventions: Silicone gel sheeting placed under garments over contoured areas, deep friction scar massage with non-perfumed water-based moisturizers, and strict sun protection (SPF 30+) for at least 1 year.

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3. Edema Management & Complex Regional Pain Syndrome (CRPS)

Multi-Modal Edema Reduction Strategies

Post-surgical, post-traumatic, and burn-related edema must be managed proactively to prevent collagen cross-linking and permanent tissue fibrosis.

+---------------------------------------------------------------------------------------------------+
|                                EDEMA MANAGEMENT MODALITIES MATRIX                                 |
+-----------------------+---------------------------------------------------------------------------+
| Intervention Method   | Mechanism & Clinical Guidelines                                           |
+-----------------------+---------------------------------------------------------------------------+
| **Elevation**         | • Elevate affected extremity **above heart level**; maximizes lymphatic   |
|                       |   drainage and venous return via gravity.                                 |
+-----------------------+---------------------------------------------------------------------------+
| **Active Muscle Pump**| • Active ROM (e.g., finger composite flexion/extension, ankle pumps)      |
|                       |   creates skeletal muscle contractions compressing lymphatic channels.    |
+-----------------------+---------------------------------------------------------------------------+
| **Compression Wrap**  | • **Coban wrapping:** Applied **distal to proximal** with spiral tension;|
|                       | • Compression gloves and elastic tubular bandages (Tubigrip).             |
+-----------------------+---------------------------------------------------------------------------+
| **Retrograde Massage**| • Light, gentle stroking performed **distal to proximal** toward axillary |
|                       |   or inguinal lymph nodes; follow with active elevation.                  |
+-----------------------+---------------------------------------------------------------------------+
| **Manual Edema**      | • Gentle, specialized manual lymphatic drainage technique; clears proximal|
| **Mobilization (MEM)**|   lymphatic trunks before mobilizing distal edema fluids.                 |
+-----------------------+---------------------------------------------------------------------------+

[!CAUTION] Edema Contraindications: Retrograde massage, MEM, and aggressive compression are strictly contraindicated in the presence of: (1) Acute untreated Deep Vein Thrombosis (DVT), (2) Active cellulitis or localized soft tissue infection, and (3) Decompensated Congestive Heart Failure (CHF) where fluid return overburdens central circulation.

Complex Regional Pain Syndrome (CRPS)

CRPS (formerly known as Reflex Sympathetic Dystrophy / Causalgia) is an abnormal amplified neuropathic pain condition characterized by autonomic dysfunction and neurogenic inflammation.

+---------------------------------------------------------------------------------------------------+
|                                 CRPS CLASSIFICATION & PRESENTATION                                |
+------------------------------------+--------------------------------------------------------------+
| CRPS Type I (RSD)                  | Develops following trauma, fracture, or surgery **without**  |
|                                    | a confirmed peripheral nerve lesion.                         |
+------------------------------------+--------------------------------------------------------------+
| CRPS Type II (Causalgia)           | Develops following a **confirmed major nerve injury**.       |
+------------------------------------+--------------------------------------------------------------+
| Cardinal Clinical Signs            | • **Allodynia:** Severe pain elicited by non-painful stimuli |
|                                    |   (e.g., light air breeze, clothing touching skin).          |
|                                    | • **Hyperalgesia:** Exaggerated pain to mild painful stimuli.|
|                                    | • **Vasomotor / Sudomotor Changes:** Temperature asymmetry,  |
|                                    |   blotchy skin discoloration, abnormal sweating.             |
|                                    | • **Trophic Changes:** Shiny skin, coarse hair, brittle nails|
+------------------------------------+--------------------------------------------------------------+

Evidence-Based OT Interventions for CRPS

1. Stress Loading Program: The gold-standard mechanical loading regimen consisting of:
   • Scrubbing: Active back-and-forth scrubbing motion with a weighted scrub brush on a flat board or table while bearing weight through the involved upper extremity (initiated at 3 minutes, 3 times/day, progressing to 10–15 minutes).
   • Carrying: Carrying a weighted briefcase or handbag (1 to 5 lbs) during functional walking and standing throughout the day. Provides proprioceptive input that normalizes sympathetic tone.
2. Graded Motor Imagery (GMI): Sequential cortical reorganization protocol:
   • Step 1: Left/Right Discrimination (Implicit Motor Imagery): Identifying left vs. right hand photographs.
   • Step 2: Explicit Motor Imagery: Mentally imagining moving the affected limb without physical movement.
   • Step 3: Mirror Therapy: Observing the reflection of the moving unaffected limb in a mirror while the affected limb is hidden.
3. Desensitization Protocols: Graded tactile stimulation moving from soft textures (silk, cotton) to coarser materials (terrycloth, corduroy, wool).
4. Critical Contraindication: Aggressive passive range of motion (PROM) and rigid immobilization are strictly prohibited because they trigger severe autonomic flare-ups and worsen neuropathic pain.