Jeffrey Saffle, MD, Paradigm Medical Director, Paradigm Catastrophic Care Management
My colleagues and I who specialize in caring for people with burn injuries are often asked, “Why does burn rehabilitation take so long?” The answer is that burn injury and recovery are uniquely difficult for patients, their families, employers, and care providers.
Burn injuries require intense, prolonged, and expert care. This includes ongoing wound care, physical and occupational therapy, reconstructive surgery, community reintegration, and psychological support, which may extend even after other outcomes are achieved.
It’s not uncommon for a patient with a major burn (60-90% body surface area) to require four years of care after hospital discharge. Patients with moderate burns of 30-50% body surface area routinely require 24 months of rehab.
And yet, most patients do recover from these wounds and return to their families and communities. Let’s consider three aspects of burn injury and recovery that make overcoming these injuries so challenging:
- Wound healing
- Metabolic stress and recovery
- Psychological trauma and support
Wounds take months to heal
No matter how the patient looks when they are discharged from the hospital, it is likely that they will look worse six months later. Typically, scar tissue proliferates and wounds gets redder and thicker for six to eight months after the injury. Throughout this time, the skin is dry and fragile, requiring moisturizers and sun protection.
Burn wounds are considered closed once they are covered with intact new skin. For partial-thickness burns, this may take as little as 14-21 days. Deeper and larger burns may need months for skin grafting and closure. Even then, burn wound healing continues for at least 12 months after injury.
During this time, the skin remodels through inflammation (which is why healing burns appear red) and collagen replenishment. Scar tissue routinely gets thicker and harder for at least six months, and only then begins to flatten and soften. The new skin lacks oil glands, so moisturizing is often required permanently, and itching can be relentless. As scar tissue heals by pulling together, progressive and severe contractures form around joints.
Although there are many ways to manipulate and cover burn wounds, so far there is no way to make the wound heal more quickly. Scars contract every night, and must be re-mobilized each day. This means patients sometimes endure 12-18 months of daily topical care and painful, consistent stretching and therapy. This can be stressful and discouraging for patients, who see little progress from day-to-day. But remember that new burn scars are pliable and can be improved by stretching, in contrast to mature scars, which are rigid. Only surgery can correct them.
Several techniques help wounds heal. Compression garments flatten the scars. These tight-fitting garments are uncomfortable and hot, though patients often grow to like the support they provide. They must be worn continuously (23 and a half hours a day) until wound redness fades, indicating that scars are mature and healing is complete. Only then — months to years after injury — is reconstructive surgery most successful. Sometimes such surgery is required earlier to correct significant functional deficits. In these cases, surgery may be repeated when healing is complete.
Importantly, advances in laser therapy for burn wounds have shown tremendous promise. Laser therapy can reduce the development of severe scars, and lessen and relax scars and contractures. Lasers are effective on scarring within a few weeks of injury and just as effective on mature scars, even years later. Laser treatment often can replace surgery to relieve contractures and improve motion.
Usually a course of laser treatment is four to six outpatient sessions at four- to six-week intervals. Small wounds can be treated under topical anesthesia. Larger areas may require general anesthetic. Recovery is quick; patients require some local wound care with antibiotic ointment for a few days, but they can usually be back to work or school within three to five days.
Metabolic changes: Restoring strength requires extensive therapy
The metabolic stress of a major burn injury is greater than any other form of trauma, with loss of up to a half-pound of lean body mass per day. Burn injuries induce the most serious destructive metabolism – catabolism — of any known injury, leaving patients weak and deconditioned. In addition, the muscle loss associated with hospitalization is severe: Spending two weeks in bed induces as much muscle loss as aging 10 years in a normal person.
So, patients must build themselves back up. Good nutrition is obviously important and emphasized during acute care, often with feeding tubes. But in order to rebuild muscle, exercise is essential. To minimize loss, burn professionals know that rehabilitation begins at the time of injury. Exercises, stretching, and endurance are key elements of care even in the ICU.
After discharge, patients need continuing exercise and stretching, as well as normal activities. Initially, formal sessions with physical and occupational therapists are essential, though patients must work at home as well. As they improve, patients often move to more self-directed therapy with therapist check-ups. A gym membership, perhaps with a trainer, is a great next step in restoring strength and mobility. Remember that the increased metabolism of the burn injury will persist for months after the injury, which is one reason patients often take so long to regain function.
PTSD takes a long time to work out
Psychological stress, including depression and Post-Traumatic Stress Disorder, are probably more common in burn patients — and often more severe — than with other injuries. In fact, psychological stress is expected in patients with large burns. Just like the therapists and the dietician, the psychologist/psychiatrist is an important member of the acute burn team. Psychological assessment and support begins in the hospital.
In addition to the horrific memory of the injury itself, the debility and alteration of body image are tremendously stressful to patients, who often compare themselves to terrifying characters from popular culture. Villains like Freddy Krueger and Darth Vader come to mind, and patients often fear the worst, especially when they begin to venture outside the security of the burn center. This combines with patient’s very real loss of function, income, and future plans.
These psychological injuries can be the greatest impediment to return to a normal life, including work. Being around fire, or visiting the scene of the accident — often the workplace — can induce severe flashbacks. Nightmares and intrusive thoughts can be incapacitating. Not all psychologists and psychiatrists are competent or willing to take on these patients, and finding the best specialists may be difficult.
In recent years we’ve seen an increasing number of injured workers with a pre-existing psychiatric diagnosis and/or substance abuse problem. Pain control for acute burns almost always requires narcotics, which may lead to dependency. Chronic pain problems can persist after other recoveries are achieved, and a pain specialist may be required.
For all these reasons, psychological, psychiatric, and social work support is necessary for complete rehabilitation of the injured worker. It’s easy to see that coordinating all these specialists — plus physicians and therapists — can be difficult. That’s where a dedicated case manager can make all the difference to a recovering patient.
Groups like the Phoenix Society and local SOAR (Survivors Offering Assistance in Recovery) are additional resource. These programs offer burn survivors peer-to-peer support, which helps patients appreciate that they are not alone or unique in their injuries. Many burn centers have camps or other support groups as well.
Plan for a lifetime
Even after months or years of intensive rehabilitation, some effects persist forever. Grafted skin remains dry and susceptible to damage from the sun, and patients will need to avoid sun exposure and use moisturizers permanently. Grafted skin doesn’t sweat, so patients will suffer from extremes of temperature — both heat and cold –often for life. And the psychological scars persist.
What’s the good news?
Despite the obvious challenges of a major burn injury, the vast majority of patients do recover from their wounds. As indicated here, this requires intensive support that can tax the patience and the resources of patients, their families, employers, and care providers. With compassion and perseverance, patients regain lost function and self-esteem, return to work or school, and enjoy family and community life. They become, in every sense of the word, burn survivors.
About Dr. Jeffrey Saffle
Jeffrey Saffle, MD, is a Paradigm Medical Director specializing in burn surgery and rehabilitation. He was director of the Department of Telemedicine for the University of Utah Health Center. Dr. Saffle has published more than 140 articles in peer-reviewed journals, as well as a number of book chapters and numerous abstracts. He was the recipient of the University of Utah Distinguished Teaching Award in 2000, as well as the American Burn Association Harvey Stuart Allen Award in 2012.
For almost 30 years, Paradigm has been the industry leader in solving complex health care challenges and improving lives. With the most connected and experienced team in health care, we define and deliver outcomes that exceed financial and health expectations for our clients, as well as for individuals and their families.
Paradigm delivers its solutions through three divisions: Catastrophic Care Management, Complex Care Solutions and Specialty Networks. The Paradigm divisions are built on expertise from five best-in-class businesses: Paradigm Outcomes, The ALARIS Group, Encore Unlimited, ForeSight Medical, Restore Rehabilitation, and Adva-Net. Founded in 1991, Paradigm is headquartered in Walnut Creek, California with offices across the U.S. For more information, please visit https://www.paradigmcorp.com/.