Pain in the Burn Rehabilitation Patient

Fig. 13.1

Optimal positioning to prevent burn contractures

Heterotopic Ossification : Treatment of HO begins with conservative measures. NSAIDs, bisphosphonates, and radiation therapy have proven efficacy for HO prophylaxis in patients with major hip surgery [48–50] and spinal cord injury [51, 52] but have not been commonly reported for burn patients [53]. Provision of perioperative radiation therapy, however, has been recommended to decrease HO recurrence in burn patients [54].

Infection : Early eschar excision, wound debridement, and wound closure can decrease the incidence of invasive wound infections [55]. Performing bedside sterile wound care and implementing preemptive barrier precautions prevent nosocomial microbial transmission [56]. For preventing infection, using topical antibiotics (mupirocin, neomycin, bacitracin, mafenide acetate) on a rotating basis substantially reduces microbial load and antibiotic resistance. Topical silver sulfadiazine, the most widely used silver-based agent for burns, has broad-spectrum antibacterial coverage (including Pseudomonas aeruginosa ), while silver ion eluting dressings may provide additional coverage of methicillin-resistant Staphylococcus aureus [44] and require less frequent dressing changes, which improves comfort [21, 57]. Topical application of honey, a natural antimicrobial, may accelerate wound healing [44]. Proper nutrition along with anabolic agent supplementation (e.g., oxandrolone, insulin, insulin-like growth factor 1) for a hypermetabolic state assist with wound healing and immune competence [58]. Infectious Disease consultation should be requested and appropriate antibiotic therapy started for known infection.

Compartment Syndrome : Prevention and early detection by monitoring compartment pressures can avoid CS. Monitoring intra-abdominal pressure has been recommended for patients with greater than 30% TBSA burn who require significant volume resuscitation [26]. Preventative measures include relieving external pressure, elevating the injured extremity to heart level, and providing appropriately calculated fluid resuscitation, including use of hypertonic or colloid solutions to limit volume [59].

Rehabilitation

Nociceptive Pain : Given the strong psychological influences of the pain experience, with pharmacologic approaches alone being unable to completely manage procedural pain and anxiety in up to 75% of burn patients [60], incorporating nonpharmacologic and psychological adjunctive therapies is recommended for optimal pain and anxiety control.

Cognitive interventions include distraction, guided imagery, and reappraisal techniques [61]. Music therapy can be applied according to specific protocols [62, 63], including listening to, singing, or creating music; responding to musical cues; vibroacoustic therapy; imagery [60]; or entraining vital rhythms [64] to manage pain and anxiety of mild intensity [65] and strengthen coping skills [66]. Sensory focusing, which directs attention away from emotional unpleasantness, can provide greater analgesia compared to music therapy and reduce remembered pain [67]. Virtual reality distraction can reduce procedural pain [68, 69], be effective for greater pain intensities [70], and remain effective with repeated use [71].

Behavioral interventions are based on respondent (e.g., relaxation training) and operant conditioning (e.g., rewarding patients after completing PT). Having patients apply relaxation techniques, including jaw relaxation [72], relaxation breathing [73], biofeedback [74], progressive muscle relaxation [75], and stress inoculation [76], or simply having them participate in wound care can reduce perceived pain and anxiety and empower patients with a sense of control over their pain experience [77].

Hypnosis and rapid induction anesthesia [78] are considered effective adjunctive interventions to reduce anxiety and opioid and anxiolytic requirements; however, trained staff, time, and patient cognitive effort are required, and results may vary by patient [79–82].

Complementary therapies, including massage therapy, thought to increase vagal and serotonergic activity [83]; transcutaneous electrical nerve stimulation (TENS), which stimulates nerve fibers [84]; auricular acupuncture, thought to release endogenous opiates [85, 86]; and therapeutic touch, which balances body energy through non-contact manual manipulation [87], have been shown to decrease procedural pain and anxiety [88].

Neuropathic Pain : A cornerstone of pruritus management are emollients, which include simple moisturizers, aloe vera, lanolin, liquid paraffin, coconut oil, and various vegetable oils to improve skin quality. Scar massage, as well as the therapeutic effect of emollient application, decreases pain and itching [89]. Compression garments and extremity elevation appear to be effective for neuropathic pain [10]. Somatosensory rehabilitation may also be effective for neuropathic burn pain [90]. Topical adjuncts like cold compresses, colloidal oatmeal, pulsed dye laser, silicone gel, and TENS also have positive effects [43].

Scars and Contractures : Rehabilitative measures include functional orthoses, splinting, bracing, and serial casting [91] for anti-deformity positioning; avoidance of direct sunlight; scar massage [92]; and supervised ROM exercises [93]. Burns across joints and exposed tendons should receive empirical splinting, such as dorsal hand splinting or surgical high-top shoes with a metatarsal bar to prevent metacarpophalangeal and metatarsophalangeal joint hyperextension subluxation, respectively [6]. ROM exercises may begin within 1 week of skin grafting. PT and aerobic and resistance training lead to improvement in contractures and fewer release surgeries [94]. Intralesional steroid injections [95] and light- and laser-based therapies have also been used with some clinical improvement [96].

Heterotopic Ossification : During the acute inflammatory phase, the involved joint should be rested in a functional position and receive periodic, gentle, passive ROM to avoid both aggravation of inflammation and prolonged immobilization, both thought to contribute to HO development. After inflammation subsides, positioning and gentle PT that includes pain-free passive, active-assisted, and active ROM exercises that do not exceed the point of resistance should be applied to prevent worsening of joint motion [97].

Neuropathies: Proper positioning to avoid excessive stretch of nerves (e.g., lying supine with shoulder in 90° of abduction and 30° of horizontal adduction to avoid excessive stretch of the brachial plexus, or limiting the frog-leg position to avoid peroneal nerve injury) [28], avoiding prolonged immobilization, using splints, monitoring wound care, preventing contractures, and properly applying casts and bulky dressings to avoid compression of superficial peripheral nerves can mitigate neurologic complications. Effective splints avoid pressure over bony prominences and are compatible with grafts.

Behavioral Management

Pain is significantly influenced by psychological factors [98]. Burn patients often have complicated psychiatric needs, spanning preexisting psychosocial risks, such as substance abuse, psychiatric disorders, and domestic abuse; to anxiety, depression, and post-traumatic stress disorder from the burn trauma; to sleep disturbance, delirium, and distress caused by pain and medications. These can worsen the pain experience, adversely affect long-term outcomes, and increase the risk of suicide. Almost all burn patients require Psychology or Psychiatry evaluation to diagnose, prevent, and treat psychological sequelae and psychosocial inciting risk factors (“yellow flags”) that influence pain [84].

Interventions/Surgery

Scars and Contractures : Acute management of deep burns includes resurfacing with skin grafts or substitutes to hasten wound healing and prevent contractures [99]. Secondary procedures are delayed until scars have matured, which may take approximately 1 year. Release of formed contractures through scar excision, soft tissue rearrangement, and skin grafting seeks to improve joint ROM. Various reconstructive techniques, including grafts, flaps based on random vascularization, tissue expansion, and newer techniques involving flaps based on defined vascularization, and dermal substitutes that avoid the need for donor grafts have been reported to improve ROM, scar quality, and cosmesis [100]. Risks include lack of graft take, necrosis, and flap loss.

Osteophytes: Osteophyte excision is indicated when there is severely limited ROM or nerve entrapment. Removing bony growth from the olecranon and coronoid process along with breaking down adhesions can restore ROM. Surgery should be postponed until there is no granulating surface or active scar tissue and should be followed by postoperative PT [17].

Heterotopic Ossification: Excision of elbow HO significantly improves functional ROM, independent of TBSA burned [101]. Surgery is traditionally reserved, except in cases of nerve compromise, until after radiographic evidence of HO maturation, which is usually 12–18 months [97]; however, studies also show good results from early HO excision [102]. Ulnar nerve release and transposition can be performed along with HO excision [54]. Surgical complications include infection, nerve injury, HO recurrence, vascular injury, wound problems like synovial cutaneous fistulas, and delayed healing [101].

Infection: Excision of the wound and infected tissue, or incision and drainage may be needed for invasive infections.

Compartment Syndrome: Early decompressive escharotomy of deep circumferential limb burns along with fasciotomy for CS can prevent amputation [103]. Decompression, nerve release [104], and debridement of myonecrotic tissue for limb CS associated with electrical or crush injuries have provided good return of function [105]. Split-thickness skin grafts, regional composite grafts, or skin-stretching devices to facilitate primary re-approximation of wound edges are used for closure [106]. Decompressive escharotomy of the anterior trunk, percutaneous peritoneal drainage, and even laparotomy may be needed to relieve abdominal pressures greater than 25 mmHg in established abdominal CS [107].

Neuropathies : Nerve compression from edema or eschar requires immediate decompressive fasciotomy or escharotomy, while surgical intervention for compression from hypertrophic scarring is often delayed [108]. Surgical decompression and nerve release are commonly performed for peripheral neuropathies [108], such as HO resection and ulnar nerve transposition for ulnar neuropathy [54]; median, ulnar, radial, posterior tibial, and peroneal nerve release in electrical burns [104, 109]; and anterior interosseous nerve neurolysis and repair for burn scar compression [110], with improvements in pain and function. Nerve release always carries the risk of rapid nerve injury or transection, wound dehiscence, and infection [111].

Potential Treatment Complications

Sedation is the most common adverse effect of opioids, opioid-like pain medications, and antihistamines and can limit participation in PT. For other adverse effects of medications, refer to the Medication Management chapter 28 on Adjuvant Medications for Pain.

Regional nerve blocks are associated with risks of muscular weakness, overdose, and infection via the catheter. Systemic absorption of lidocaine carries the risk of cardiac arrhythmias and seizures.

Silicone gel sheets for hypertrophic scarring may result in skin maceration or contact dermatitis.

Poorly applied splints and casts for contractures may cause loss of skin grafts, skin abrasions, pressure sores, and compression neuropathies, commonly seen in the peroneal nerve.

There is a small but potential carcinogenic risk of radiotherapy for preventing HO recurrence [112].

Current Developments

Fat grafting, or lipotransfer, is currently being investigated for treating neuropathic burn scar pain, hypothesized to provide benefit through regenerative characteristics to improve scar quality and reduce inflammation [113]. CO₂ fractional photothermolysis may be efficacious to reduce neuropathic pain, scar tightness, and pruritus [114]. Nabilone, a synthetic cannabinoid receptor 1 agonist, has also been studied for controlling neuropathic pain [115]. Use of intravenous lidocaine for procedural pain is under investigation [116], as is botulinum toxin injection for pruritus [117].

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