AN EASY GUIDE TO

OUTPATIENT
BURN REHABILITATION

Presented by:

Rocky Mountain Model System for Burn Injury

Rehabilitation, In the Department of Rehabilitation
Medicine at the University of Colorado Health Sciences
Center; Denver, Colorado

Supported by:

National Institute of Disability and Rehabilitation Research

United States Department of Education,
Award Number: H133A30015.

The Rocky Mountain Model System for Burn Injury

Rehabilitation was a four year grant (1993-1997) funded
by the National Institute on Disability and Rehabilitation
Research in the United States Department of Education.
The grant incorporated five major areas:
Development of a Model System of burn Injury
Rehabilitation that is patient centered and
coordinated from the onset of the burn injury until
the burn survivor is once again integrated into the
community.
Education of burn patients and their families, rural
burn support teams, and other professionals.
New areas of burn research including
deconditioning of a burn patient, outcome
measurements, and burn related immunologic
studies.
Surveillance of burns and development of
programs to prevent burn injury.
Development of a national database in coordination
with the other Model Burn Systems in the United
States.

Information about this Burn Model System may be

obtained by calling (303)315-0320.

TABLE OF CONTENTS

TOPIC

PAGE

Introduction
1.

Scar Control

A.

Hypertrophic Scarring

B.

Scar Massage

C.

Custom Pressure Garments

2.

Therapeutic Exercise

3.

Manually Resisted Exercise

10

4.

Work Hardening

18

5.

Modalities

26

6.

Activities of Daily Living

29

7.

Splints

30

8.

Outcomes and Interviews

37

9.

References

38

INTRODUCTION

INTRODUCTION
As the designated adult burn rehabilitation center in the State of
Colorado, our facility relies on rural health care providers to continue
the essential outpatient rehabilitation phase. This video,
accompanied by a written informational booklet, provides visual
assistance to those professionals who may not be familiar with
treating a burn survivor.
More and more, our burn survivors are being discharged and treated
as outpatients earlier. This outpatient care requires complex nursing
and Physical and Occupational Therapy services closer to the
patients home. Communication between the burn center and the
outpatient team is essential. The video and educational booklet were
designed to provide assistance on common outpatient issues.
Through the use of brief segments, the outpatient health care
provider can view only those areas needed. By the conclusion of the
video, the viewer will be able to:
1. Identify hypertrophic scarring.
2. Differentiate between an active and a mature scar.
3. Prioritize a burn survivors exercise needs.
4. Describe the proper fit and care of custom pressure
garments and splints.
5. Adapt self care items for independent ADLs.
6. Understand several patients views of rehabilitation.
It should be noted, there is not just one correct way to approach burn
rehabilitation. The information in this video is based on approaches
and techniques used at the University of Colorado Hospital. By using
these few precautions and ideas, a safe and comprehensive program
can be established to help the burn survivor return to living as a
productive member of the community.
1

SCAR CONTROL

SCAR CONTROL
The formation of a scar is an ongoing process for the burn survivor.
Scars are dynamic and continue to grow and change throughout the
maturation process. It is the responsibility of both the patient and the
health care provider to manage scars and decrease the potential for
contractures.
Hypertrophic scarring: Hypertrophic scarring develops due to
tissue tension, persistent inflammation, and the exaggerated
response of the fibroblasts to healing. Fibroblasts deposit excessive
amounts of disorganized collagen which then become adhesed to
other structures. The scar is characterized by the three Rs:
It is Red because it is hypervascular.
It is Raised because there is four times as much collagen
in a burn wound than in any other wound.
It is Rigid because the collagen is disorganized and does
not allow for pliability.
The scars are metabolically active for approximately eighteen
months. After that time the scar is mature, as shown in the video with
Harry. Hypertrophic scarring is more pronounced in African
Americans, Native Americans, Asians, and Hispanics secondary to
increased pigmentation.
Scar Massage: Scar massage has several important functions:
It promotes collagen remodeling by applying pressure to scars:
It helps to decrease itching:
It provides moisture and pliability to the burned region and
donor sites.
The video demonstrates the appropriate technique, as well as the
handout on scar massage in page 4 of the booklet.
2

Custom Pressure Garments: Pressure applied to a scar decreases

the excessive collagen formation and helps to realign the present
collagen. The custom pressure garments are made to conform to a
patients normal body contour, thus limiting abnormal scar formation
and deformity. It is important that the garments fit properly to assure
maximal benefit of wearing them and avoid complications such as
swelling, increased scarring, or abraded areas. Some clues for
proper fit:
It is TOO small if:
1. It binds or digs into the skin.
2. The fingers or toes become swollen, blue or numb.
3. The garment rides up or down with motion.
It is TOO big if:
1. There is any bagging or sagging noted.
2. The garment can easily be pinched away from the skin.
3. The scar appears larger in one area.
The goal is to wear the custom pressure garments twenty-three hours
a day, removing them only for scar massage and bathing. Many
times, when a garment covers a concave area, (i.e., between the
breasts, shoulder blades, or fingers) adequate pressure is not
applies. Foam padding and inserts made from silicone gel or
elastomer can be used to fill in the concave areas and apply
appropriate pressure to scars in those areas.
Garments that have rips or holes no longer apply consistent pressure
and should be replaced. It is also important to note that the garments
should not be cut or altered in any way except by the vendor who has
provided the garment.
Refer to Pages 5 and 6 for instructions on care and wear of custom
pressure garments.

UNIVERSITY HOSPITAL
We practice what we teach

Information for Patients and Family

BURN CARE
SCAR MASSAGE INSTRUCTIONS
1. Apply lotion to all burned or grafted skin and donor sites, once they are healed.
2. Massage the lotion in, applying enough pressure to make the area blanch (turn white).
3. Massage in all three directions as shown below.
Horizontal
Circles
Vertical

4. Do this 3 to 4 times each day.

Lotions
You may use any lotion that will help make your skin soft.
You should avoid perfumed lotions.
There is no need to use lotions containing aloe vera or vitamin E.
If you have any questions or problems, please call your primary therapist.

This information sheet was developed and funded by:

Rocky Mountain Model System for Burn Injury Rehabilitation
Sponsored by the National Institute on Disability Rehabilitation and Research
US Department of Education Grant #HI33A30015
June 1995

University of Colorado Health Sciences Center * Ninth Avenue at Colorado Boulevard * Denver, Colorado
Committed to equal employment opportunity and affirmative action.

UNIVERSITY HOSPITAL
We practice what we teach

Information for Patients and Family

BURN CARE

CARE AND USE OF YOUR

CUSTOM PRESSURE GARMENTS
You have just received your custom pressure garments. These garments were made especially for
you to fit your normal body contours. Their job is to apply pressure to your burned areas to help
your scars lie flat. (That is why they are so tight.)
Care of Your Garment
Your garments should be washed daily in warm water either by hand or in the washing machine.
Do not use harsh detergents or bleach to clean your garments. They should be air dried flat. Do
not put them in the dryer, or in direct sunlight.
When to Wear Your Garment
Your garments should be worn 23 hours a day. You can take them off to have a bath or shower
and to perform your scar massage. You can do all your regular activities in your garments,
including work and sports! (and therapies!)
Problems with Your Garment
If you have problems with your garments, such as swelling, numbness m your hands or feet, or if
your skin is breaking down, call or see your primary therapist immediately. If your therapist is
not available (after hours or on the weekend) take the garment off until you can reach your
therapist. Do not try to cut or alter the garment by yourself. If you do, it may no longer be
effective. Your therapist, __________________, may be reached at ___________.

This information sheet was developed and funded by:

Rocky Mountain Model System for Burn Injury Rehabilitation
Sponsored by the National Institute on Disability Rehabilitation and Research
US Department of Education Grant #HI33A3001594

University of Colorado Health Sciences Center * Ninth Avenue at Colorado Boulevard * Denver, Colorado
Committed to equal employment opportunity and affirmative action.

UNIVERSITY HOSPITAL
We practice what we teach

Information for Patients and Family

BURN CARE

APPLYING CUSTOM PRESSURE GARMENTS

Apply your garments after you have done your scar massage.
To put on your footies:
Turn the footies 1/2 way inside out with the toe portion remaining right-side out.
Put the footies on so your toes are all the way to the end of the garment.
Pull the garment over your heel then up over the front of your ankle.
To put on your pants:
Make sure all the zippers are open.
Slowly inch them up each leg. (Women -- this will be like putting on tight panty hose.)
Place telfa pads over any open areas as you come to them.
Pull the garment up over your waist.
Make sure the pants are on correctly. The zippers should be on the inside portion of
your calf and the seam should run up the center of the back of your leg.
To put on your gloves:
Make sure all the zippers are open.
Both gloves are put on the same way. Put on one glove and then the other.
Turn the gloves inside out just up to where the finger holes begin.
Place each finger in its hole and pull the garment down so your fingers go all the
way to the end of the garment.
Put your thumb in its hole and pull the rest of the garment up and over your hand.
Make sure the gloves are on correctly. There should not be any space between the
glove and where your fingers join the palm of your hand. There also should not be
any space at the end of your finger tips. The zipper is centered over the top part of
your hand (opposite side from your palm).
(OVER)
University of Colorado Health Sciences Center 0 Ninth Avenue at Colorado Boulevard 0 Denver, Colorado * 303-329-3066
Committed to equal employment opportunity and affirmative action.

To put on your vest/bodysuit:

Make sure the zippers are open.
Step both legs into the suit. Pull it up over your waist.
Put one arm into the sleeve, only up to the forearm.
Place telfa pads over any open areas as you come to them.
Put the other arm into the sleeve only up to the elbow.
Pull the garment up both arms, taking turns on each arm. Then pull the garment
up over your shoulders.
Zip up the front of the garment all the way. Zip the sleeves. For the bodysuit, close
the Velcro crotch flap.
Make sure the garment is on correctly. The zippers on the sleeves should be on the
outside of each arm and the garment should not bunch or dig into the armpits.

To put on your face mask:

Anchor the mask over your chin and pull up and over your head.
Make sure your mask is on correctly before you close the Velcro in the back. The
eye and mouth openings should be centered. Your vision should not be limited.
The seam should run over the middle part of your scalp.

This information sheet was developed and funded by:

Rocky Mountain Model System for Burn Injury Rehabilitation
Sponsored by the National Institute on Disability Rehabilitation and Research
US Department of Education Grant #HI33A3001594
June,1995

THERAPEUTIC EXERCISE

THERAPEUTIC EXERCISE
Exercise should begin on the day of the patient's burn injury and should continue
until all wounds are closed and the scars are no longer metabolically active (See
segment on scarring). Fibroblasts, which are responsible for wound contracture,
enter a burn wound in the first twenty-four hours and remain active for up to two
years after the patient's injury. Exercising several times throughout the day
helps to counter the decreased strength and decreased joint range of motion that
may occur from scar contracture.
By the time a burn survivor returns to his/her community, he/she will be ready for
an aggressive outpatient rehabilitation program designed to:
1. increase strength;
2. increase endurance;
3. increase range of motion in the involved regions;
4. promote functional independence; and
5. promote return to work.
A comprehensive circuit training type program has proven very effective at our
facility. Continuing the following components in a gym setting helps promote
patient independence and responsibility for his/her own outcome by allowing
him/her to work as independent as possible on most segments, receiving
guidance and assistance only in those areas needed.
STRETCHING - Stretch is most effective when performed slowly and until the scar
blanches. A prolonged stretch with a light load of two to three pounds placed at the
end of a lever helps to elongate shortened soft tissue. It is important to remember, that
if a burn covers more than one joint, the scar should be elongated at both ends to
promote a maximal stretch. Use blanching as your guide for how far to push (See
Hypertrophic scarring video segment).
STRENGTHENING - Active and resistive range of motion can and should be
used frequently, using resistance whenever possible and as early as tolerated.
A progressive program using pulleys, therabandtm, free weights, eccentric
exercises and weight bearing exercises are started early in the rehabilitation
process, even when burn wounds are still open. Be aware that many burn
survivors have weakness in the proximal muscles of the shoulders and hips as a
result of decreased activity and immobilization. Extra attention should be paid to
those areas.

ENDURANCE - Many burn survivors have decreased muscle bulk and

low endurance as a result of a prolonged hospital stay, possible ventilator
dependency, and periods of immobilization after skin grafting. Training on the bike,
upper body ergometer, or something as simple as repetitions of ascending and
descending stairs, help build endurance. Twenty minutes of aerobic activity,
performed at 60% of maximal heart rate three times a week, can help to retrain the
cardiovascular system.

NOTE: Many burn survivors complain of feeling fatigued throughout the day
and of being unable to stay active all day. This is not uncommon. It may take
months for a burn survivor to feel that their energy will return to normal.
Performing endurance training and helping the burn survivor return to a normal
sleep cycle (i.e., decreasing naps in the day, increase longer periods of sleep
at night) will assist with returning the patient to a ''normal'' level of activity.
COORDINATION - Again, long periods of immobilization and burn scarring can
lead to decreased torso rotation and the ability to perform reciprocal activities.
Proprioceptive Neuromuscular Facilitation and the therapeutic ball are great
activities to promote these motor skills.
FINE MOTOR SKILLS - Many times, burn survivors suffer from decreased
dexterity even when the hands are not burned. Patients with grafting to the
upper arm require immobilization, which limits use of that hand and facilitates
small muscle atrophy. Including pinch, grip and fine motor activities in your
exercise program will facilitate good fine motor control and assist with
independence in activities of daily living.
HOME EXERCISE PROGRAMS - Even the most aggressive outpatient
program needs to be supplemented by a home exercise routine. Scars contract
every minute of every day. Exercising one hour three to five times a week will
not be enough to prevent contractures and deformities. Patients are instructed
in written home exercise programs prior to discharge from the hospital and are
expected to perform these exercises and stretches prior to coming to the
outpatient appointments. That way, outpatient therapies can focus on problem
areas and exercises that patients are unable to perform at home because of
equipment needs.

MANUALLY RESISTED EXERCISE

MANUALLY RESISTED EXERCISE

Proprioceptive Neuromuscular Facilitation (PNF) is the method of promoting or

hastening a desired response through stimulation of the proprioceptors. As
taught by Knott and Voss, PNF uses stimulation through tactile, auditory, visual
and verbal cues to elicit movements in normal patterns. The patient learns to
move in a coordinated, skilled way as facilitated by the therapist. The goals of
PNF treatment with a burn survivor are to decrease muscular guarding, facilitate
normal movement patterns, encourage reciprocal and rotational movement of the
head, neck, torso, upper and lower extremities, and to strengthen proximal
musculature, thereby facilitating distal coordination.
The video briefly shows some PNF techniques that are effective in treating the
burn survivor. They are as follows:
1.

Contract-Relax: a repeated effort is used without sustained effort from the

patient to stimulate a response in the lengthen range of motion. ContractRelax can be used to increase passive range of motion.

2.

Rhythmic Initiation: repeated movement without sustained effort from the

patient in order to stimulate muscle contractions and purposeful
movement. This technique is used to teach the patient how to move and
increase strength.

3.

Diagonal 1 (D1) and Diagonal (D2) Movement Patterns: for both the upper
and lower extremities, with a flexion component and extension component.
Facilitation of rotation is key to a coordinated movement. Diagonal
Patterns work well for home exercise programs and increasing active
range of motion.

4.

Developmental Postures - Manual Resistance: facilitating your patient

through the developmental postures is a great way to gain proximal
stability, strength of all extremities, and range of motion in all joints.

The following pages demonstrate a home exercise program in the PNF upper
extremity diagonal patterns. If you would like to learn more about Proprioceptive
Neuromuscular Facilitation, please refer to the reference list provided.

10

UNIVERSITY HOSPITAL
We practice what we teach

Information for Patients and Family

PNF HOME EXERCISE PROGRAM FOR
____________________________
PERFORM EACH EXERCISE
_______________ TIMES FOR
_______________ REPITITIONS
STOP THE EXERCISE IF YOU FEEL PAIN
OR DISCOMFORT
REST IN BETWEEN EACH EXERCISE TO
PREVENT OVER-FATIGUE
REMEMBER TO MOVE THROUGH THE FULL
RANGE OF MOTION THAT YOU HAVE
CONTACT YOUR
THERAPIST ______________________
AT ______________________
WITH ANY QUESTIONS OR CONCERNS

11

EXERCISE #1
USE RIGHT / LEFT / BOTH HAND(S)
PERFORM EXERCISE IN SITTING /
STANDING / LYING DOWN

BEGIN THE EXERCISE

AS IN THE PICTURE A.

CLOSE YOUR HAND

TURN YOUR ARM
AND PULL UP AND ACROSS

YOUR ARM SHOULD BE

IN THE SAME POSITION
AS IN PICTURE B.

OPEN YOUR HAND

TURN YOUR ARM
AND PUSH DOWN AND OUT
YOUR ARM WILL BE IN
THE SAME POSITION AS
IN THE PICTURE A.

REPEAT
12

EXERCISE #2
USE RIGHT / LEFT / BOTH HAND(S)
PERFORM EXERCISE IN SITTING /
STANDING / LYING DOWN
BEGIN THE EXERCISE
AS IN THE PICTURE A.

OPEN YOUR HAND

TURN YOUR ARM
AND PUSH UP AND OUT

YOUR ARM SHOULD BE

IN THE SAME POSITION
AS IN THE PICTURE B.

CLOSE YOUR HAND

TURN YOUR ARM
AND PULL DOWN AND ACROSS
YOUR ARM WILL BE IN THE
SAME POSITION AS IN THE
PICTURE A.

REPEAT
13

EXERCISE: THE LIFT

PERFORM EXERCISE IN SITTING/
LYING DOWN
BEGIN THE EXERCISE AS IN
THE PICTURE A. HOLD
YOUR _______WRIST WITH
YOUR _______HAND.

OPEN YOUR _______ HAND

TURN YOUR ARM
AND PUSH UP AND OUT
HOLD ______ SECONDS

YOUR ARMS SHOULD BE

IN THE SAME POSITION
AS IN THE PICTURE B.

CLOSE YOUR _______ HAND

TURN YOUR ARM
AND PULL DOWN AND ACROSS
YOUR ARMS WILL BE IN THE
SAME POSITION AS IN THE
PICTURE A.

REPEAT

14

EXERCISE: THE CHOP

PERFORM EXERCISE IN SITTING/
LYING DOWN
BEGIN THE EXERCISE AS IN
THE PICTURE A. HOLD
YOUR _______WRIST WITH
YOUR _______HAND.

CLOSE YOUR _______ HAND

TURN YOUR ARM
AND PULL UP AND ACROSS
HOLD ______ SECONDS

YOUR ARMS SHOULD BE

IN THE SAME POSITION
AS IN THE PICTURE B.

OPEN YOUR _______ HAND

TURN YOUR ARM
AND PUSH DOWN AND OUT
YOUR ARMS WILL BE IN THE
SAME POSITION AS IN THE
PICTURE A.

REPEAT

15

EXERCISE: #1
USE BOTH ARMS
PERFORM EXERCISE IN SITTING/
STANDING / LYING DOWN
BEGIN THE EXERCISE
AS IN THE PICTURE A.

CLOSE YOUR HANDS

TURN YOUR ARMS
AND PULL UP AND ACROSS

YOUR ARMS SHOULD BE

IN THE SAME POSITION
AS IN THE PICTURE B.

OPEN YOUR HANDS

TURN YOUR ARMS
AND PUSH DOWN AND OUT
YOUR ARMS WILL BE IN
THE SAME POSITION AS IN
THE PICTURE A.

REPEAT

16

EXERCISE: #2
USE BOTH ARMS
PERFORM EXERCISE IN SITTING/
STANDING / LYING DOWN
BEGIN THE EXERCISE
AS IN THE PICTURE A.

OPEN YOUR HANDS

TURN YOUR ARMS
AND PUSH UP AND OUT

YOUR ARMS SHOULD BE IN

THE SAME POSITION AS IN
THE PICTURE B.

CLOSE YOUR HANDS

TURN YOUR ARMS
AND PULL DOWN AND ACROSS
YOUR ARMS WILL BE IN
THE SAME POSITION AS IN
THE PICTURE A.

REPEAT
17

WORK HARDENING

WORK HARDENING

In today's society, feelings of self worth and personal identity are tied to the role
he or she plays as a wage earner. When a person has sustained a burn injury,
there are several legal, financial, and psychosocial factors that can facilitate or
prevent a person's return to work. Work Hardening and Work Conditioning
programs can help to identify a patient's abilities and potential problems with
re-entering the work force.
APPROPRIATE REFERRAL:
1.

All wounds closed

2.

Patient wearing custom pressure garments

3.

Most surgeries completed

4.

Patient understands precautions

5.,

Patient off all pain medications

6.

Patient independent with orthotics/prosthetics

7.

PT/OT goals met

INTERDISCIPLINARY TEAM APPROACH:

VOCATIONAL COUNSELOR:
A professional vocational counselor can be employed through the State
Department of Vocational Rehabilitation or through a private agency. They can
assist the burn survivor in identifying if they are able to return to the same job.
They can also provide retraining for other employment as well as counseling on
career changes. Vocational counselors can be accessed through the attached
list of regional phone numbers.

18

December, 1994
DIVISION OF VOCATIONAL REHABILITATION, DEPARTMENT OF HUMAN SERVICES

ADMINISTRATION
DIRECTOR'S OFFICE - DENVER
Field Services
Support Services
REHABILITATION OFFICES
ACADEMY PARK
ALAMOSA
AURORA
BOULDER
BUENA VISTA
COLORADO SPRINGS
COLORADO SPRINGS
DENVER CCB
DENVER CYP
DENVER EAST
DENVER B/D
DENVER WEST
DURANGO
FORT COLLINS
FORT MORGAN
GLENWOOD SPRINGS
GOLDEN
GRAND JUNCTION
GREELEY
LAMAR
LONGMONT
MONTROSE
PUEBLO CYP/BD
PUEBLO
ROCKY FORD
STERLING
TRINIDAD

TELEPHONE
303-620-4153
303-620-4158
303-620-4187
303-986-1299
719-589-5158
303-145-8112
719-395-2434
719-574-2200
719-574-2200
303-894-2380
303-894-2410
303-894-2515
303-894-2650
303-937-0561
970-247-3161
910-223-9823
970-867-3068
970-945-9174
303-271-4888
970-248-7103
970-352-5180
719-336-7712
303-449-7966
970-249-4468
303-452-5875
719-544-1406
719-544-1406
719-254-3358
970-522-3737
719-846-4431

V/TDD
303-866-4153
303-620-4158
303-620-4153
V/TDD
303-988-1299
719-589-5150-TTD only
303-745-8112
719-395-2434
719-574-3606-TTD only
719-574-3606-TTD only
303-894-2380
303-894-2515
303-937-0561
970-247-3161
970-223-9823
970-867-3068
970-945-9174
303-271-4888
970-248-7103
970-353-5750-TTD only
719-336-7712
303-772-2612
970-249-4468
303-452-5875
719-544-1406
719-544-1406
719-254-3358
970-522-3737
719-846-4431

FAX
303-620-4189
303-620-4189
303-620-4189
FAX
719-589-4474
303-750-0098
303-444-9140
719-395-2435
719-574-2530
719-574-2530
303-894-2656
303-894-2656
303-894-2656
303-894-2656
303-934-6854
970-247-8324
970-223-0718
970-867-3069
970-945-9175
303-271-4887
970-248-7118
303-353-5752
719-336-7713
303-772-6849
970-249-2602
303-452-6191
719-544-1634
719-544-1634
719-254-3350
970-522-3738
719-846-4432

REHABILITATION CENTER - 303-937-1226 - v/TDD-303-937-1226 - FAX -303-934-6854

BUSINESS ENTERPRISE PROGRAM - 303-922-3658
REHABILITATION TEACHING AND ELDERLY BLIND - 303-937-1226 - V/TDD - 303-937-1226
DISABILITY DETERMINATION SERVICES - 368-4100 - TDD only 752-5650 - (800)332-8087

19

PSYCHOLOGISTS:
41% of work related burn injuries and 30% of non-work related injuries report
having emotional difficulty with returning to work. Common concerns are a
preoccupation with safety issues, self esteem, and adjustment to a different level
of functioning. Psychologists can assist burn survivors in the return to work
process by working on coping and relaxation strategies as well as addressing
self esteem issues. A referral to your local psychologist can facilitate a burn
survivors adjustment to returning to the community.
SOCIAL WORK:
Social workers are an excellent resource to assist the burn survivor in both legal
and financial recovery. A social worker can make referrals to the appropriate
agencies to provide the patient with such services as temporary housing or
clothing vouchers, which can be available through the local Red Cross in the
event of a house fire. Social workers can also assist the burn survivor in
applying for appropriate government funding for covering medical bills.
PHYSICAL/OCCUPATIONAL THERAPISTS:
Therapists are the trouble-shooters in assisting the burn survivor in returning to
work. They can help to promote maximal physical functioning for return to work.
By obtaining a job description, a therapist can simulate worker roles in the clinic.
By having a patient perform repetitive, simulated motions for four to eight hours
per day, a therapist can identify problem areas and provide treatment to address
those areas. Many times these problems can be missed in the outpatient clinic if
the tasks are not performed for an appropriate amount of time. For instance,
many patients will not have a problem with friction or shearing against their
garments during short periods of activities, but performing the same activities for
longer periods of time can cause skin breakdown.

20

COMMON INTERVENTIONS:
TEMPERATURE EXTREMES:
Many burn survivors will have difficulty regulating their body temperature in
weather extremes. Those persons working in a persistently cold environment
should wear many layers of clothing for insulation. By layering their clothing,
they can easily remove what is no longer necessary once their body warms up.
Many patients will complain of increased stiffness in the burned regions in cold
temperatures. It would be recommended these patients perform additional
stretching exercises immediately prior to beginning work.
Those burn survivors who work in a particularly hot environment need to take
several precautions to prevent heat exhaustion or heat stroke. These patients
should drink plenty of non-alcoholic, non-caffeinated beverages throughout their
work shift. Additional suggestions for keeping cool would include the use of a
fan in their work space and dampening their garments with a water bottle
throughout their shift. Placing a cold pack on the head or the wrist can help to
cool the entire body.
SKIN PROTECTION:
Burn survivors need to take extra precautions to protect their skin whether they
are working or playing. The use of a sunscreen with SPF of 15 or higher is
recommended on all burned regions, as they tend to burn more readily. When
working with detergents and/or chemicals, rubber gloves and/or a protective suit
should be worn over the person's custom pressure garments.
SKIN INTEGRITY:
Hypertrophic scars tend to have problems with friction and shearing. The areas
most commonly affected are the elbows, metacarpal phalangeal joints, knees
and heels. To help prevent shearing, a patient can wear panty hose under their
garments. While this can get a bit warm, it decreases shearing and makes the
application of the garments easier. Patients can also use silicone gel pads or
Telfa pads on high friction areas. See the splinting catalogs listed in the
SPLINTS section for availability of gel pads.

21

FACTS ABOUT
THE AMERICANS WITH DISABILITIES ACT
Title I of the Americans with Disabilities Act of 1990, which takes effect July 26, 1992,
prohibits private employers, state and local governments, employment agencies and labor
unions from discriminating against qualified individuals with disabilities in job application
procedures, hiring, firing, advancement, compensation, job training, and other terms,
conditions and privileges of employment. An individual with a disability is a person who:
Has a physical or mental impairment that substantially limits one or more
major life activities
Has a record of such an impairment; or
Is regarded as having such impairment.
A qualified employee or applicant with a disability is an individual who, with or
without reasonable accommodation, can perform the essential functions of the job in
question.
Reasonable accommodation may include, but is not limited to:
Making existing facilities used by employees readily accessible to and
usable by person with disabilities
Job restructuring, modifying work schedules, reassignment to a vacant
position;
Acquiring or modifying equipment or devices, adjusting or modifying
examinations, training materials, or policies, and providing qualified
readers or interpreters.
An employer is not required to lower quality or production standards to make an
accommodation, nor is an employer obligated to provide personal use items such as glasses or
hearing aids.
PRE-EMPLOYMENT INQUIRES AND MEDICAL EXAMINATIONS
Employers may not ask job applicants about the existence, nature or severity of a disability.
Applicants may be asked about their ability to perform specific job functions. A job offer may be
conditional on the results of a medical examination, but only if the examination is required for all
entering employees in similar jobs. Medical examinations of employees must be job related and
consistent with the employer's business needs.
DRUG AND ALCOHOL ABUSE
Employees and applicants currently engaging in the illegal use of drugs are not
covered by the ADA, when an employer acts on the basis of such use. Test for illegal drugs
are not subject to the ADA's restrictions on medical examinations. Employers may hold
illegal drug users and alcoholics to the same performance standards as other employees.

22

EEOC ENFORCEMENT OF THE ADA

The U.S. Equal Employment Opportunity Commission will issue regulations to
enforce the provisions of Title I of the ADA on or before July 26, 1991. The provisions take
effect on July 26, 1992, and will cover employers with 25 or more employees. On July 26,
1994, employers with 15 or more employees will be covered.
FILING A CHARGE
Charges of employment discrimination on the basis of disability, based on actions
occurring on or after July 26, 1992, may be filed at any field office of the U.S. Equal
Employment Opportunity Commission. Field offices are located in 50 cities throughout the
United states and are listed in most telephone directories under U.S. Government.
Information on all EEOC-enforced laws may be obtained by calling toll, free on 800-USAEEOC. EEOC tool free TDD number is 800-800-3302. For TDD calls from the Washington,
D.C. Metropolitan Area, dial (202) 989-4399 (TDD).

December 1990

EEOC-FS/E-5

23

Rights Division
Coordination and Review Section

AMERICANS WITH DISABILITIES ACT REQUIREMENTS

FACT SHEET
EMPLOYMENT
Employers may not discriminate against an individual with a disability in hiring or promotion if
the person is otherwise qualified for the job.
Employers can ask about one's ability to perform a job, but cannot inquire if someone has a
disability or subject a person to tests that tend to screen out people with disabilities.
Employers will need to provide ''reasonable accommodation" to individual with disabilities.
This includes steps such as job restructuring and modification of equipment.
Employers do not need to provide accommodations that impose an ''undue hardship'' on
business operations.
Who needs to comply?
All employers with 25 or more employees must comply, effective July 26, 1992.
All employers with 15-24 employees must comply, effective July 26, 1994.
TRANSPORTATION
New public transit buses ordered after August 26, 1990, must be accessible to individuals
with disabilities.
Transit authorities must provide comparable paratransit or other special transportation services to
individuals with disabilities who cannot use fixed route bus services, unless an undue burden would
result.
Existing rail systems must have one accessible care per train by July 26,1995.
New rail cars ordered after August 26, 1990, must be accessible.
New bus and train stations must be accessible.
Key stations in rapid, light, and commuter rail systems must be made accessible by July 26, 1993,
with extension up to 20 years for commuter rails (30 years for rapid and light rail).
All existing Amtrak stations must be accessible by July 26, 2010.

24

PUBLIC ACCOMMODATIONS
Private entities such as restaurants, hotels, and retail stores may not discriminate against
individuals with disabilities, effective January 26, 1992.
Auxiliary aids and services must be provided to individuals with vision or hearing
impairments or other individuals with disabilities, unless an undue burden would result.
Physical barriers in existing facilities must be removed, if removal is readily achievable. If not,
alternative methods of providing the services must be offered, if they are readily achievable.
All new construction and alterations of facilities must be accessible.

STATE AND LOCAL GOVERNMENTS

State and local governments may not discriminate against qualified individuals with disabilities.
All government facilities, services, and communications must be accessible consistent with the
requirement of Section 504 of the Rehabilitation Act of 1973.
TELECOMMUNICATIONS
Companies offering telephone service to the general public must offer telephone relay services to
individuals who use telecommunication devices for the deaf (TDDs) or similar devices.
This document is available in the following accessible formats:
Braille

Large print

Audio tape Electronic file on computer disk

and electronic bulletin board (202)-514-6193

For more information about the ADA contact:

U.S. Department of Justice
Civil Rights Division
Coordination and Review Section
P. 0. Box 66118
Washington, D.C. 20035-6118
(202) 514-0301 (voice)
(202) 514-0381 (TDD)
(202) 514-0383 (TDD)

25

MODALITIES

MODALITIES

As with any other patient, modalities are an excellent way to assist in preparing
a region for treatment. However, burn survivors require a note of caution when
using certain modalities.

COLD MODALITIES:
It has been our experience, that few burn survivors can tolerate the use of cold
modalities, such as cold packs, ice massage, etc. The initial vasoconstriction
that accompanies a cold modality reportedly makes the burned region feel stiffer.
It is more comfortable for the patient to use cold modalities on other concurrent
injuries. As always, be sure to check skin tolerance where sensation may be
impaired.
HEAT MODALITIES:
An area that has hypertrophic scarring also has impaired sensation and an
altered vascular system. It is important to be cautious when using heat
modalities over these areas as the scarred region will have difficulty dissipating
heat and can more readily sustain an additional burn injury. As shown on the
video, use extra toweling with hot packs. Use a lower intensity with other heat
modalities, such as ultrasound. Check the skin frequently for blistering.
ELECTRICAL STIMULATION:
TENS can be used for pain control with burn survivors. Be aware that newly
healed skin may be more sensitive than other areas. Also, burned areas contain
many unmyelinated nerve endings which can be hypersensitive and can cause
great discomfort when using electrical current. Be sure to test the TENS on a
small area on the patient's intact skin before using it on burned areas. It has
been our experience that using TENS on nerve roots for more diffuse pain
control works very well. F.E.S. can be used for muscle re-education using the
same precautions.

26

PARAFFIN:
The use of paraffin has several benefits when used properly. It works well to
heat the collagen fibers of the scar in preparation for stretching. It reportedly
relieves superficial stiffness and aches. Also, it contains mineral oil which
moisturizes the scar. As with the other heat modalities, use a lower temperature
and check the skin frequently for signs of burning. Paraffin works especially well
when used in conjunction with a prolonged, low load stretch.
IONTOPHORESIS:
There has been little research in the use of iontophoresis with hypertrophic burn
scars. Dexamethasone has traditionally been injected into persistent
hypertrophic scars. This process is painful. Our facility has had some success
with iontophoresis using dexamethasone over scarring to decrease the local
inflammation. Also, acetic acid in a 2% solution (distilled vinegar) has been
used with the same results. A low intensity should be used to protect the
patient's skin from burns.
FLUIDOTHERAPY:
Fluidotherapy can be used with the same precautions as other heat
modalities once the wounds are completely closed. Even superficial open
areas are a contraindication to fluidotherapy.

27

UNIVERSITY HOSPITAL
We Practice What We Teach

Information for Patients

HOME PARAFFIN TREATMENT
MATERIALS NEEDED
1.
2.
3.
4.
5.

Crock Pot
Paraffin Wax
Candy Thermometer - Essential
Saran Wrap
Towels

DIRECTIONS FOR APPLICATION

1.

Heat paraffin wax in crock pot to approximately 120 Fo. Use a candy thermometer
to measure temperature.

2.

Turn off crock pot. Let paraffin cool approximately 1-2 minutes.

3.

Place affected area on stretch position.

4.

Using your hand (unburned) or a paintbrush paint wax on to a 1/4" thick coat.

5.

Wrap coated area with Saran wrap and two layers of towels.

6.

Leave wrapped area on-stretch for twenty minutes.

7.

You can do this safely 1x/day. Exercise immediately after paraffin treatment.

8.

Paraffin wax is reusable, but only for one patient. No sharing with family or friends.

Any questions or concerns, please call your therapist ________________ at _____________.

University of Colorado Health Sciences Center - Ninth Avenue at Colorado Boulevard - Denver. Colorado 303-329-3066

28

ACTIVITIES OF DAILY LIVING

ACTIVITIES OF DAILY LIVING

Activities of Daily Living, or ADL's, are the foundation to a burn survivor's
successful outcome. The ability to perform ADL's provides us with increased selfesteem, self worth, and a sense of independence. When performing activities
such as feeding, grooming, or dressing, it is important to realize the burn survivor
is working on all of his/her therapeutic goals such as: increase range of motion,
increase strength, increase fine motor coordination, increase balance, etc. As a
care provider, we must encourage him/her to reach the highest level of
independence in all ADL's. This may require adaptive equipment, change in a
routine and modification of the task, as well as lots of encouragement due to
frustration and pain.
The video demonstrates a small portion of activities, modifications and equipment.
ADL's include:
Eating
Dressing
Grooming
Bathing
Toileting

Toilet/tub mobility
Driving
Homemaking skills
Vocational skills

Modifications: This may include lowering frequently used items from a high shelf,
moving a bathroom mirror for better visibility, or moving furniture for increased
safety in mobility. Modifying a person's environment involves creativity and
common sense. The patient may be your best resource to adaptations that they
have thought of in their home.
Equipment: As therapists, we try to anticipate the burn survivor's equipment
needs. However, we can not always know what they may need when actually at
home or their functional status may change as mobility and range of motion
increase. The following catalogs on page 30 are helpful in determining and
choosing a patients equipment needs.

29

REFERENCES FOR ADAPTIVE EQUIPMENT

Catalogs
1.

Sammons/Preston

1-800-323-5547

2.

Smith, Nephew and Roylan

1-800-558-8633

3.

North Coast Medical

1-800-821-9319

4.

Byrd and Cronin

1-800-328-1095

30

SPLINTS

SPLINTS
Splinting of a joint or multiple joints is used to:
1. Prevent contractures;
2. Prevent deformities;
3. Apply pressure/stretch to the burn areas for scar control.
Remember, the position of comfort is also the position of contracture for the
burn survivor. Therefore, he/she may not like to wear the splint provided. It is
important to encourage and insist on splint wear as it will place the joint in a
therapeutic and functional position. Education is the key to compliance with
splint wear.
The splints shown in the video are the most commonly used on an outpatient
basis.
Positional hand splint: a prefabricated splint to put the hand and wrist in a
position of function. Keep in mind the splint has full contact with the palm
and web space of the hand.
Neck conformer: custom-made for the burn survivor, this places the neck in
slight extension to decrease the potential for a neck flexion contracture and
webbing of the neck. Again, the splint must be in full contact with the neck in
order to be effective.
Axillary conformer: A custom-made splint to prevent contractures of the
shoulder. Although not very comfortable, this splint is of utmost importance
to stretching the region. Non-compliance with this splint often results in
surgery to release axilla contractures.
See the chart on proper positioning page 32 for additional positioning ideas.*****
A product and materials list is also provided for additional products and splints
your facility may want to use to assist with proper positioning.
Splinting and Positioning are to be performed continuously until the burn
survivor can easily perform range of motion of the joint within a normal limit.
At that time splinting and positioning can be decreased or discontinued.

31

UNIVERSITY HOSPITAL
POSITION OF COMFORT = POSITION OF CONTRACTURE
JOINT

POSITION OF
COMFORT

THERAPEUTIC POSITION

Neck

Flexed

Extended: towel roll, conformer

Shoulder

Flexed, adducted

Abduct 90o : wedge

Int. Rotated

conformer, lat. arm support

Flexed

Extended -5o pillow, splint

Supinated

Pronated

Wrist

Flexed

Extended 30 60o splint, washcloth

Hand

Clawed: MCP ext

MCP Flexed 70o - splint

PIP + DIP Flex

PIP, DIP extended splint

Thumb adducted
Flexed, IR

Thumb opposed; splint, washcloth

Extended, Neutral Rotation and

Adducted

Abduct; Towel roll

Knee

Flexed

Full Extension

Ankle

Plantar flexed

Dorsiflexed 0o

Inverted

Neutral Ever/Invers foot pillow,

Elbow

Hip

Splint

32

UNIVERSITY HOSPITAL
We practice what we teach

Information for Patients and Family

BURN CARE

CARING FOR YOUR SPLINT

Your splint was custom made for you. Please read the following instructions to learn about the
care of your injured area and your splint. Your splint serves the purposes of assuring proper
body position and preventing contractures. If you have a doubt as to how it fits, please contact
your primary therapist, _________________, at ______________________.
Precautions
Contact your therapist if your splint causes any of the following:
Excessive swelling
Severe pain
Pressure area or sore
Excessive stiffness
Change in skin color
Adjustments
Please notify your therapist if you feel an adjustment is necessary.
Care of Your Splint
Keep it away from open flames. It will melt.
Keep it away from extreme heat. It will lose its shape in temperatures over 139o F.
Do not leave it in direct sunlight, such as in the window or on a dashboard of the car.
Cleaning Your Splint
Your splint may be cleaned with lukewarm water and soap. Do not submerge your
splint in hot water over 139o F.
For ink or hard-to-remove spots, use a cleanser with chlorine
If your splint is lined with foam, it may be cleaned easily by putting it in lukewarm
water and gently rubbing the surface with a bar of soap.
Your splint also may be cleaned with alcohol swabs.
University of Colorado Health Sciences Center 0 Ninth Avenue at Colorado Boulevard 0 Denver, Colorado * 303-329-3066
Committed to equal employment Opportunity and affirmative action,

33

Wearing Your Splint

Your Splint should be worn:
_____Full-time, day and night.
_____Full-time, except for brief periods of exercises, as instructed by therapist and physician
_____At night only.
_____Other schedule:

This information sheet was developed and funded by:

Sponsored by the National Institute on Disability Rehabilitation and Research
US Department of Education Grant #HI33A3001594

June,1995

34

PRODUCT/MATERIALS LIST
SPLINTS AND POSITIONING
DEVICES

PRODUCTS/MATERIALS LIST
SPLINTS AND POSITIONING DEVICES

Soft foam Neck Collar

Can use T-Form
Available in 1/2'', I'', 2'', 3" thickness
and x-soft, soft, medium densities
AliMed, Inc.
297 High Street
Dedham, MN 02026
(800) 225-2610

Interdigital Web Spacers

Dental Cotton Rolls #2 Medium, 1 1/2Length, 3/8'' Diameter
Tidi Products, Inc.
P. O. Box 2020
Troy, MI 38083
(800) 837-1701

Microstomia Prevention Appliance

MPA, Inc.
6526 Meadowbrook Drive
Dallas, TX 75240
(214) 458-0757

Rolyan Finger Rehab System

Smith and Nephew Roylan, Inc.
One Quality Drive P.O. Box 53022
Germantown, WI 53022
(800) 558-8633
FAX (800) 545-7758

Mouth Stretch/Maintainer
Therabite, Inc.
Suite 302
3415 Westchester Pike
Newtown Square, PA 19073
(800) 322-2650
(610) 356-9500 in PA
FAX (610) 356-4292

Hip Abduction Pillows

Disposable or reusable
Bird and Cronin Medical Products, Inc.
Attn: Marcy Revere, Representative
1200 Trapp Road
Eagan, MN 55121
(800) 328-1095
FAX (612) 688-9855

Spandex I'm Lip and Cheek Retractor

Worldwide Dental, Inc.
Suite A
12890 Automobile Blvd.
Clearwater, FL 34622
(800) 328-2335

Knee Immobilizers
Several models abailable
Bird and Cronin Medical Products, Inc..
See address above
Molded Plastic Hip
Abduction Splint
Camp International, Inc.
P.O. Box 89Jackson, MI
49204
(800) 492-1088

35

CPM Companies

Danninger Medical
Technology, Inc.
4140 Fisher Road
Columbus, OH 43228-1067
(800) 225-1814
(614) 276-8267 in OH
Smith and. Nephew Richards Inc.
1450 Brooks Road
Memphis, TN 38116
(800) 238-7538
(901) 396-2121 in Memphis
Thera-Kinetics, Inc.
(J.A.C.E. Products)
1300 Route 73
Mount Laurel, MN 08054
(800) 234-0900
(609) 778-1166 in NJ
Toronto Medical Suite 124
1390 S. Potomac St.
Autota, CO 80012
(800) 289-5139
FAX: (303) 750-2944

36

OUTCOMES AND INTERVIEWS

OUTCOMES AND INTERVIEWS

The first two patient outcomes are examples of two patients who had similar injuries.
Both patients were burned over 50% total body surface area primarily to the upper body
and requiring multiple skin grafts to close their wounds. It is important to note that
Rob required skin grafts to his face while Harry's face healed spontaneously. Also,
Rob's hands were more severely involved. Both were treated by the same therapist,
however Rob refused therapy intervention for the majority of this burn rehabilitation.
The last two interviews are designed to give various examples of other patients views
of burn rehabilitation. These segments assist the care providers and the burn survivor
in understanding the comments and perspectives on surviving a burn injury and the
rehabilitation process.

37

REFERENCES
AND
FURTHER INFORMATION

REFERENCES AND FURTHER INFORMATION

The team at University of Colorado Hospital Burn Unit appreciates your help in
assisting the burn survivor in returning to the community and work. If you have any
questions or problems, feel free to contact us at the following locations.

Burn Unit
University of Colorado Hospital
4200 East Ninth Ave.
Denver, CO 80262
(303) 372-0001

38

Selected References:
Bowden, M.L., Thompson, P.D., & Prasad, J.K. (1989). Factors influencing return to
Employment after burn injury. Archives of Physical Medicine and Rehabilitation,
(70), 772-774.
Burgess, M. C. (1991). Initial management of a patient with extensive burn injury.
Critical Care Nursing Clinics of North America, 3 (2), 165-179
Calistro, A.M. (1993). Burn basics and beyond. RN, March: 26-32
Chapman, R. (1991). The Americans with Disability Act: Civil rights for persons with
disabilities. The Colorado Lawyer, 2234-2236.
Cheng, S., & Rogers, J. (1989). Changes in occupational role performance after a
severe burn: A retrospective study. American Journal of Occupational Therapy,
43 (1). 17-23.
Choiniere, M., Melzak, R., Rondequ, J., Girard, N., & Paquin, M.J. (1989). The pain of
burns: Characteristics and correlates. The Journal of Trauma, 29 (11), 15311539.
Dobkin de Rios, M., & Achauer, B. M. (1991). Pain relief for the Hispanic burn patient
using cultural metaphors. Plastic and Reconstructive Surgery, 88 (1), 161-164.
Duncan, D.J., & Driscoll, D.M. (1991). Burn wound management. Critical Care Nursing
Clinics of North America, 3 (2), 199-220.
Fisher, S., & Heim, P. (1984). Comprehensive Rehabilitation in Burns. Baltimore:
Williams and Wilkens.
Helm, P.A., & Walker, S. (1992). Return to work after burn injury. Journal of Burn Care
and Rehabilitation, 13 (1), 53-57.
Jacobs, K, et. al. (1992). Statement: Occupational therapy services in work place.
American Journal of Occupational Therapy, 47 1086-1088.
Johnson, C. L. (1984). Physical therapists as scar modifiers. American Physical
Therapy Association Journal, 64 (8), 1381-1387.
Key, G. (1991). Working hardening or work conditioning: Semantics or reality? Physical
Therapy Today, 14 (2), 12-16.
Malick, M., & Carr, J. (1 982). Manual on Management of the Burn Patient. Pittsburgh:
Harmarville Rehabilitation Center.

39

Malick, M., Maude H. (1980). Flexible elastomere molds in burn scar control. American
Journal of Occupational Therapy, 24, 603-608.
Munster, A.M. (1993). Severe burns. Baltimore: The Johns Hopkins University Press.
Patterson, D.R. (1992). Practical applications of psychological techniques in controlling
burn pain. Journal of Burn Care and Rehabilitation, 13 (1), 13-18.
Simmons, D. (1983). Family adjustment when the breadwinner is burned. Occupational
Health Nursing, 38-40.
Smith, P. (1990). Work Hardening. In: L. Williams-Pedretti & B. Zoltan. Occupational
Therapy: Practice Skills for Physical Dysfunction. St. Louis: The C.V. Mosby Co.,
272-281.
Velozo, C.A. (1993). Work evaluations: Critique of the state of the art functional
assessment of work. The American Journal of Occupational Therapy, 47, 203209.
Voss, D.E., lonta M.K., Myers, B.J. Proprioceptive Neuromuscular Facilitation: Patterns
and Techniques, Third Edition, Philadelphia, Harper and Row Inc., 1985
Wachtel, T.L., Kahn, V., & Frank, H.A (1983). Current Topics in Burn Care. Rockville,
Md: Aspen Systems Corp.
Watkins, P.N., Cook, E.L., May S.R., & Ehleben, C.M. (1989). Psychological stages in
adaptation following burn injury: A method for facilitating psychological recovery
of burn victims. Burn Care Commentary - A Forum for Burn Care Issues, 5 (1),
1-23.
Wright, P.C. (1984). Fundamentals of acute burn care and physical therapy
management. American Physical Therapy Association Journal, 64 (8), 12171231.
Zeller, J., Sturm, G., & Cruse, C.W. (1993). Patients with burns are successful in work
hardening programs. Journal of Burn Care and Rehabilitation, 14 (2), 189-196.

40