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Physical Therapy Management of the Child with Complex Medical Needs Across Pediatric Settings Integumentary Conditions Sue Migliore PT, DPT, MS, PCS.

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Presentation on theme: "Physical Therapy Management of the Child with Complex Medical Needs Across Pediatric Settings Integumentary Conditions Sue Migliore PT, DPT, MS, PCS."— Presentation transcript:

1 Physical Therapy Management of the Child with Complex Medical Needs Across Pediatric Settings Integumentary Conditions Sue Migliore PT, DPT, MS, PCS

2 Course Objectives Describe the challenges to physical therapists practicing with children with integumentary issues. Develop a repertoire of effective strategies for measurement and quantification of pain in pre-verbal, non-verbal, and verbal children Apply the principles of family- or relationship-based care for children with complex medical conditions Understand the impact of complex integumentary conditions on all body systems (musculoskeletal, neuromuscular, cardiopulmonary) and their relationship to physical therapy management using the ICF Model Utilize the ICF Model to develop appropriate physical therapy plans of care for children with integumentary needs. Utilize the components of the Guide to PT Practice for children with integumentary needs across the life span including identifying critical components of family and client education Apply current evidence and course content to case studies along the continuum of care


4 Health Condition: Congenital Abnormalities Epidermolysis Bullosa (EB) – Genetically based skin fragility disorder – 3 main types: simplex (EBS), junctional (JEB) and dystrophic (DEB) – Affects 1 in every 50,000 births in US (

5 Health Condition: EB EB characteristics: – EBS: autosomal dominant; localized blisters, limited mucosal involvement, normal teeth/hair – JEB: autosomal recessive; widespread blistering, scarring, severe mucosal involvement, alopecia – DEB: both autosomal dominant and recessive; hemorrhagic blisters, scarring, pseudosyndactyly, severe mucosal involvement, significant morbidity/mortality

6 Health Condition: Pressure Ulcers Definition: – “Pressure ulcers are areas of local tissue trauma, usually developing where soft tissues are compressed between bony prominences and any external surface for prolong time periods. “ Agency for Health Care Research and Quality (AHRQ, formerly AHCPR)

7 Health Condition: Pressure Ulcers Pressure ulcers occur from mechanical injury to the skin and underlying tissues Primary forces are friction and shear Compression, especially over bony prominences causes alterations in the vascular network Occlusion of blood and lymphatic circulation lead to deficient nutrition due to ischemia If compression is relieved in time, reactive hyperemia restores tissue nutrition

8 Health Condition: Pressure Ulcers Time and Pressure: – Low pressure, over a long period – High pressure for a short period – Pressures differ by position: lying: buttocks 70 mmHg sitting: 300mmHg over ischial tuberosities - Both of these levels are above capillary closing pressures and are capable of causing tissue ischemia

9 Health Condition: Pressure Ulcers Hyperemia: within 30 minutes. Redness of skin and dissipates within one hour after pressure is relieved Ischemia occurs after 2-6 hours of continuous pressure. Erythema present is deeper in color and may take up to 36 hours to disappear once pressure is relieved

10 Health Condition: Pressure Ulcers Necrosis: occurs after 6 hours of continuous pressure. Skin may be blue or gray, disappears on an individual basis Ulceration: may occur within 2 weeks after necrosis with potential infection.

11 Health Condition: Pressure Ulcers Five classic locations – Sacrum/coccyx – Greater trochanter – Ischial tuberosity – Heel – Lateral malleolus Other problem areas: – scapula – elbow – occiput – shunt sites (head) – anterior ankle crease /dorsum of foot(casting)

12 Health Condition: Thermal Injuries On average in the United States in 2010, someone died in a fire every 169 minutes, and someone was injured every 30 minutes (Karter 2011). 435 children treated in the ED every day About 85% of all U.S. fire deaths in 2009 occurred in homes (Karter 2011). In 2010, fire departments responded to 384,000 home fires in the United States, which claimed the lives of 2,640 people (not including firefighters) and injured another 13,350, not including firefighters (Karter 2011). Most victims of fires die from smoke or toxic gases and not from burns (Hall 2001). Cooking is the primary cause of residential fires (Ahrens 2011).

13 Health Condition: Thermal Injuries Groups at risk: – Children 4 and under (CDC 2010; Flynn 2010); – African Americans and Native Americans (CDC 2010; Flynn 2010); – The poorest Americans (Istre 2001; Flynn 2010); – Persons living in rural areas (Ahrens 2003; Flynn 2010); – Persons living in manufactured homes or substandard housing (Runyan 1992; Parker 1993). –

14 Health Conditions: Thermal Injuries Mechanisms of injury: – Flame – Scald – Immersion – Contact – Chemical – Electricity

15 Examination History – Age at onset – Mechanism of injury/type of congenital abnormality – Medical/surgical interventions to date – Developmental and Social History Pain (CRIES, FLACC, Wong-Baker Faces, Numeric) ****Put common pain slide in here???***

16 Examination Systems review: – Cardiopulmonary (restrictive conditions due to scarring, inhalation injuries) – Musculoskeletal (contractures, pseudosyndactyly) – Neuromuscular (compartment syndrome, peripheral neuropathies)

17 Examination Tests and Measures: – ROM (joints involved) – Strength – Functional mobility/ADL’s – Fine/gross motor skills

18 Examination Tests and Measures – Integumentary Photography Measurements Lund and Browder Chart (burn total body surface area (TBSA) ) Braden Q scale (pressure ulcers) Vancouver Scar Scale Wound healing assessment tools

19 Examination Wound measurements: – Length (12:00- 6:00) (head to toe) – Width (9:00-3:00) (side to side) – Tunneling (in cm and with regards to hands of the clock) – Undermining – Depth (in cm) use if paper tape measure, Q tip, scalpel handle, feeding tube – Tape measure stickers

20 Examination Wound description – Exudate (amount and color) – Odor – Tissue type (red/yellow/black) – Epidermal ridging/rolling – Periwound tissue Hemosiderin staining Maceration Erythema

21 Impairments: EB Skin integrity Blisters Denuded skin Contractures Loss of space between fingers/toes

22 Impairments: Pressure Ulcers Pressure Ulcer Staging: – February 2007, NPUAP published new guidelines and terminology for staging pressure ulcers (first described by Shea in 1975) – 4 original stages with 2 additional stages – Staging/grading of pressure ulcers according to the depth of tissue destruction and only once necrotic tissue has been removed

23 Impairments: Pressure Ulcers Suspected Deep Tissue Injury: – Purple or maroon localized area of discolored, in tact skin or blood-filled blister due to damage of the underlying soft tissue from pressure and/or shear. – Surrounding tissue may be boggy, mushy, painful – May be difficult to detect in individuals with dark skin tones. It may evolve into a thin blister, or may become covered with thin eschar

24 Impairments: Pressure Ulcers Stage I Pressure Ulcer – Intact skin with non-blanchable redness of a localized area usually over a bony prominence. – Area may be painful, soft, warmer or cooler as compared to adjacent tissue. – May be difficult to detect in individuals with dark skin tones

25 Impairments: Pressure Ulcers Stage II: – Partial thickness loss of dermis – Presents as a shallow, open ulcer with a red/pink wound bed without slough – Can also present as an intact or open/ruptured serum-filled blister – Should not be used to describe skin tears, maceration or excoriation

26 Impairments: Pressure Ulcers Stage III: – Full thickness tissue loss – Subcutaneous fat may be visible, but bone, muscle or tendon are not. Slough may be present but does not obscure the depth of the tissue loss – May include undermining and tunneling – Varies by anatomical location – (bridge of nose, occiput do not have subcutaneous fat and can have a shallow stage III) – Areas of high fat tissue content may have very deep stage IIIs

27 Impairments: Pressure Ulcers Stage IV: – Full thickness tissue loss – Exposed bone, tendon or muscle (visible and palpable) – Slough or eschar may be present – Often includes undermining and tunneling – Depth varies by anatomical location

28 Impairments: Pressure Ulcers Unstageable: – Full thickness skin loss – Base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) or by eschar (tan, brown, black) – Until enough slough/eschar is removed to expose the base of the wound, no stage can be determined – Stable, dry, adherent eschar in heels should be left alone

29 Impairments: Thermal Injuries According to body structures involved Old model uses “degrees” Newer model describes according to level of skin involvement

30 Superficial Partial-Thickness Burn

31 Deep Partial-Thickness Burn


33 Surgical Interventions: Thermal Injuries Skin grafting: autografts – Split-thickness skin graft (STSG) – Full-thickness skin graft (FTSG) – Meshed graft – Sheet graft

34 Participation Abilities: depending on where in continuum of recovery/rehabilitation Restrictions: – EB: daily care, bonding, self-calming, gross and fine motor play – Acute injury: restricted from previous activities until skin integrity issues resolve/heal – Chronic Injury: typical developmental activities, play, social, sports

35 Participation Chronic problems – Restrictions from regular day to day activities – Swimming/gym class – Pressure ulcers: restriction from wheelchair, which impacts their means of locomotion

36 Environmental Internal – Age of onset – Adaptability – Self image/disfigurement – Behavior External – Support of family – Stress (resources) – Daily bandaging/wound care/chronic skin care – Acceptance by friends/family/school

37 Evaluation Determination of depth of skin involvement Identification of all impairments identified across all systems Based on stage of healing (inflammatory, proliferative phase, maturation phase)

38 Phases of Wound Healing Inflammatory phase: – Increase in temperature – Swelling (vasodilation) – Pain – Cellular response Neutrophils/macrophages Mast cells (histamine) Fibroblasts (collagen matrix)

39 Phases of Wound Healing Proliferative phase – “Healing phase” – Fibroplasia – Wound Contraction – Grafting vs healing on its own

40 Phases of Wound Healing Maturation phase: – “Scar phase” – Balance of collagen synthesis and lysis – Hypertrophic vs keloid scars – Will last for 18-24 months post injury or new surgical procedure

41 PT Diagnosis Depth of burn Staging of pressure ulcer Extent of skin surface involved in EB ROM/strength/mobility/gross motor deficits

42 Prognosis Considerations: – Healing time for partial thickness burns, or burns s/p grafting – Length of time since burn/last surgical intervention – Healing time for surgical or non-surgical interventions for pressure ulcers – Prognosis for EB depending on subtype

43 Interventions Wound care Positioning Splinting Compression Pressure relief/skin protection Pain management: non-pharmacological

44 Wound Care Wound cleansing Decrease bacterial count Promote healing Increase comfort

45 Positioning Remember your pressure loads and amount of time to cause tissue damage Frequent changes in position (use clock) supine, prone, sidelying, sitting HOB: <30 degrees, or up to 90 degrees to decrease friction at sacrum Watch “slide” transfers to/from bed/ w/c, major cause of shear injuries

46 Splinting Prevent contractures Maintain ROM Protect joints/tendons Improve function

47 Compression Goals of pressure – Decrease edema – Re-align collagen into parallel orientation – Decrease collagen synthesis – Decrease raised appearance of scars

48 Indications for Compression None used for those burns which heal in <10 days Used for any partial thickness burn that doesn’t heal in that timeframe Always used after a full thickness or skin grafted area Children prone to hypertrophic scarring

49 Evidence-Based Studies Harte et. al. 2009 Use of pressure and silicone No statistically significant difference in rate of change via VSS Both groups demonstrated decreased VSS scores Small sample group, need to account for variables such as compliance and nutrition

50 Evidence-Based Studies Momeni et. al. 2008 Study in adults Use of VSS to study silicone sheets vs placebo After 4 months, VSS scores significantly lower in the silicone gel group

51 Pain Management Non-Pharmacological – Music/art therapists – Virtual reality – Interactive video games Parry et al 2012: active range of motion for shoulder flexion/abduction after a burn, looking at Wii™ and PlayStation™

52 Outcomes Wound healing tools Burn wound healing (self or via graft) Scars: Vancouver Scar Scale Quality of Life (Peds QL) Wee-FIM

53 Quality of Life Post Burn Weedon/Potterton 2010 Study of children ages 2-12, mean of 4 Flame, hot water or hot oil burn Mean TBSA 11% Peds QL and Household Economic and Social Status Index (HESSI) were given to patients and caregivers Quality of life improved three months post burn Severity of burn was a predictor of quality of life Highlighted increase risk of burn where poor socio- economic status existed

54 Quality of Life Post Burns Van Baar et. al. 2011 Children 5-15 years old; admitted to burn center Burn Outcomes Questionnaire (BOQ) Higher TBSA (>10%) had less optimal UE function, appearance and satisfaction with current state After 24 months post burn, QOL was comparable to other pediatric injuries

55 Plan of Care Stage of skin/ulcer/burn healing Wound care Fit of braces/splints/orthotics Active vs passive range of motion Pressure relieving surfaces home/school Community based activities/accommodations School re-entry/peer acceptance

56 Plan of Care Interdisciplinary team approach Transition and collaboration from medical model to EI/IU model Psychological support Camps

57 Links (American Burn Association) (Southeastern PA burn centers) (Journal of Burn Care and Rehabilitation) (National Safe Campaign) (national network of OTs/PTs working with burns) (EB website) (National Pressure Ulcer Advisory panel)

58 References Baryza, M.J., Baryza, G.A. The Vancouver Scar Scale: An Administration Tool and Its Inter-rater Reliability. Journal of Burn Care and Rehabilitation 1995:16:535-538. Carrougher, G.J. (Ed.) (1998) Burn Care and Therapy. St. Louis: Mosby. Hansen S.L., Voigt, D.W., Wiebelhaus, P., Paul, C.N. Using Skin Replacement Products to Treat Burn Wounds. Advances in Skin Wound Care 2001:14(1):378-44. Harte, D., Gordon, J., Shaw, M., Stinson, M., Porter-Armstrong, A. The Use of Pressure and Silicone in Hypertrophic Scar Management in Burns Paitents: A Pilot Randomized Controlled Trial. Journal of Burn Care and Research 2009:30 (4), 632- 642 Johnson, R.M., Richard R., Partial Thickness Burns: Identification and Management. Advances in Skin and Wound Care 2003:16(4), 178-187. Lin, J., Nagler W. Use of Surface Scanning for Creation of Transparent Facial Orthoses. A Report of Two Cases. Burns 2003:29(6), 599-602.

59 References Lund, C.C., & Browder, N.C. (1944). The Estimation of Areas of Burns. Surgery, Gynecology, and Obstetrics, 79, 352-358. McCaskey M., Kirk L., Gerdes C. Prenting Skin Breakdown in the Immobile Child in the Home Care Setting. Home Healthcare Nurse. 2011: 29 (4) 248-255. Migliore, S. The Integumentary System. In Effgen S, ed.Meeting the Physical Therapy Needs of Children 358(pp. 329-358). Philadelphia: F.A. Davis, 2005. Momeni, M., Hafezi, F., Rahbar, H., Karimi, H. Effects of Silicone Gel on Burn Scars. Burns 2009:35:70-74. Noonan C., Quigley S., Curley M. Using the Braden Q Scale to Predict Pressure Ulcer Risk in Pediatric Patients. Journal of Pediatric Nursing: 2011 (26) 566-575 Pallija G., Mondozzi M., Webb A., Skin Care of the Pediatric Patient. Journal of Pediatric Nursing 1999 :14 (2)80-87. Parnham A. Pressure Ulcer Risk Assessment and Prevention in Children. Nurinsg Children and Young People 2012:24 (2) 24-29 Parry, I., Bagley, A., Kawada, J., Sen, S., Greenhalgh, D., Palmieri, T. Commercially Available Interactive Video Games in Burn Rehabilitation: therapeutic potential. Burns 2012:38:493-500. Rogers B, Chapman T, Rettele J., Gatica J, Darm T. et. al Computerized Manufacturing of Transparent Face Masks for the Treatment of Facial Scarring. Journal of Burn Care and Rehabilitation 2003:24(2):91-96.

60 References Sankar R., Bansai S., Garg V. Epidermolysis Bullosa: Where do we stand? Indian Journal of Dermatology, Venereology and Leprology. 2011:77 (4) 431-438. Van Baar,M.E., Polinder S., van Loey N.E.E.,. Oen I.M.M.H., Dokter J., Boxma H., van Beeck E.F. Quality of Life After Burns in Childhood (5-15 years): Children experience substantial problems. Burns 2011  37) 930-938. Weedon M., Potterton J. Socio-economic and Clinical Factors Predictive of Paediatric Quality of Life Post Burn. Burns 2010: (37) 572-579. Williams, F., Knap, D., Wallen, M. Comparison of the Characteristics and Features of Pressure Garments Used in the Management of Burn Scars. Burns 2001:27(3):205-214. Wound Care: A Collaborative Practice Manual for Health Professionals. Sussman, C & Bates-Jensen B. Eds. Wolters Kluwer. Philadelphia 2007.

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