Burn rehab

--burns are number one case of accidental death in children < 2 yrs, majority of which are due to abuse
--number 2 in children under 4

--systemic response to burns: loss of fluid, hyperventilation, inhalation injury, increase followed by increase in cardiac output, multi-organ system failure
--electrical burns cause more severe injury to deeper tissue (muscle and bone)

--newer burn categorization:
• Superficial partial thickness: epidermis and upper part of dermis injured
• Deep partial thickness: epidermis and large upper portion of dermis
• Full thickness: all layers destroyed

--Rule of 9’s (% body surface area burned):
• Head: 9%
• Each UE: 9%
• Each LE: 18%
• Anterior trunk: 18%
• Posterior trunk: 18%
• Perineum: 1%

--Worse prognosis associated with age (very young or very old), great BSA burned, depth of burn, and associated injuries

--Contractures: occur in first 1.5 years
*need 25 mm of pressure to counteract contraction of scars
--Position patient in extension and abduction
--Splinting can be used with ROM
--Compression garments are used to decrease hypertrophic scarring, worn 23 hours per day
--Silastic gel can reduce hypertrophic scarring in the absence of pressure
--Local steroids may reduce hypotrophic scarring

--Body is in highly catabolic state and may need 2000-2200 cal/day and 15gm nitrogen per sq meter of BSA

--Peripheral neuropathy present in 15-20% of burn patients with BSA of 20% or greater
--Osteophytes may occur near elbow and olecranon or coracoid process
--HO common --> most common at elbow
--Subluxation can be seen in MCP and MTP joints, prevent with splinting

Cancer rehab

--most common rehab problems in cancer: general weakness, ADL deficits, pain, difficulty with ambulation
*also have problems with speech, swallowing, respiratory, neuro impairment, skin problems, nutritional deficits, lymphedema, skeletal disease, psych
--keep high index of suspicion for swallowing problems, which are assoc with cognitive impairment, CNS involvement, radiation, and gen deconditioning
--keep high index of suspicion for metastatic involvement of spine and extremities

--Most prevalent cancer in children: 1) leukemia, 2) brain tumors
--most common posterior fossa tumor in childhood: 1) cerebellar astrocytoma (best prognosis), 2) medulloblastoma (most common in kids < 7 yrs)
--25% of patients with cancer have brain mets:
• Most common symptom: HA
• Most common focal sign: weakness
• Common first presenting sign: seixures
• Best diagnostic test: contrast CT or MRI

--Radiation effects on spinal cord:
• Induced transient myelopathy: most common, develops after 1-30 months, peak onset 4-6 months, with transient demyelination of sensory neurons in posterior column and lateral spinothalamic tract --> symmetric paresthesias. Resolves in 1-9 months
• Delayed radiation myelopathy: irreversible, begins 9-18 months after radiation, most within 30 mo. Lower extremity paresthesias followed by bowel dysfunction and weakness
--Radiation can cause peripheral nerve damage due to effects on nerve itself or by involvement of surrounding tissue
--Radiation plexopathy is uncommon, usually presenting with numbness, paresthesias, and involvement of the upper trunk, myokymia on EMG
*differentiation from Pancoast’s syndrome, caused by tumor extension into superior pulmonary sulcus, producing pain in C8-T2 nerves and Horner’s syndrome
--cognitive effects of radiation likely dose related, presents slowly, and is higher risk in children

--Chemotherapy can cause a distal, symmetrical neuropathy
*often associated with vincristine (distal axonal degeneration)
*vincristine and cisplatin can also cause autonomic neuropathies

--carcinomatous myopathy: seen in metastatic disease, c/w muscle necrosis, symptoms are prox muscle weakness
--carcinomatous neuropathy: affects peripheral nerves and muscle, often occurring with lung cancer, type II muscle atrophy

--lymphedema: damage or blockage of lymphatic system, in which accumulation of protein occurs in interstitium, drawing fluid into the interstitial space
*3 grades: pitting (reversible), nonpitting, elephantiasis
--sequential pumps help resorb water into the capillaries, but proteins remain in interstitium so must be used daily, should not be used when there are multiple edematous areas
--following mastectomy, immed post-op therapy: hand pumping, hand and elbow ROM, positioning techniques, postural exercises, and shoulder ROM exercises to 40 degrees flexion and abduction

--most common mets to bone: breast, lung, prostate
--most consistent symptom of bony mets: pain, most severe at night or with weightbearing
--skeletal mets are rarely solitary
--70% spinal mets in T-spine, 95% extradural and involve vertebral body anterior to spinal cord
--bone scans pick up met disease early, but are nonspecific
--more than 90% of UE mets involve the humerus
--most LE mets involve the hip and femur
--indications for surgical treatment of met bone disease: intractable pain, impending fx, fx
--lytic lesions (occurring w/ breast, lung, kidney, thyroid, GI, lymphoma, melanoma) are thought to be more prone to fracture than blastic lesions
--blastic lesions more likely in prostate ca

--most common primary malignant tumor of the bone in children: osteosarcoma
*occurs in adolescence, commonly involving knee and prox humerus
--multiple myeloma: punched out lytic lesions, presents with pain, usually leads to renal failure

Cancer Pain:
--from tumor invasion, chemo, peripheral neuropathy, plexopathy, postsurgical pain, procedures, other
--3 step analgesic ladder: nonopiate analgesics, tricyclics --> add step 2 opioid analgesic --> increase dose or add step 3 opioid

--serotonin antagonists (Zofran) effective as anti-emetics in cancer pts
*lack of extrapyramidal side effects
*mild HA common