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OUTPATIENT
BURN REHABILITATION
Presented by:
Supported by:
TABLE OF CONTENTS
TOPIC
PAGE
Introduction
1.
Scar Control
A.
Hypertrophic Scarring
B.
Scar Massage
C.
2.
Therapeutic Exercise
3.
10
4.
Work Hardening
18
5.
Modalities
26
6.
29
7.
Splints
30
8.
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
UNIVERSITY HOSPITAL
We practice what we teach
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
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
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.
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.
2.
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.
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
11
EXERCISE #1
USE RIGHT / LEFT / BOTH HAND(S)
PERFORM EXERCISE IN SITTING /
STANDING / LYING DOWN
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.
REPEAT
13
REPEAT
14
REPEAT
15
EXERCISE: #1
USE BOTH ARMS
PERFORM EXERCISE IN SITTING/
STANDING / LYING DOWN
BEGIN THE EXERCISE
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.
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.
2.
3.
4.
5.,
6.
7.
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
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
December 1990
EEOC-FS/E-5
23
Rights Division
Coordination and Review Section
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.
Large print
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
Crock Pot
Paraffin Wax
Candy Thermometer - Essential
Saran Wrap
Towels
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.
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.
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.
University of Colorado Health Sciences Center - Ninth Avenue at Colorado Boulevard - Denver. Colorado 303-329-3066
28
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
Catalogs
1.
Sammons/Preston
1-800-323-5547
2.
1-800-558-8633
3.
1-800-821-9319
4.
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
Shoulder
Flexed, adducted
Int. Rotated
Flexed
Supinated
Pronated
Wrist
Flexed
Hand
Thumb adducted
Flexed, IR
Adducted
Knee
Flexed
Full Extension
Ankle
Plantar flexed
Dorsiflexed 0o
Inverted
Elbow
Hip
Splint
32
UNIVERSITY HOSPITAL
We practice what we teach
33
June,1995
34
PRODUCT/MATERIALS LIST
SPLINTS AND POSITIONING
DEVICES
PRODUCTS/MATERIALS LIST
SPLINTS AND POSITIONING DEVICES
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
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
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
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.
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