For patients with burns, rehabilitation can be challenging — and often entails significant use of physical therapist services.
By Chris Hayhurst, APTA Magazine
As a student in the doctor of physical therapy program at the University of Minnesota in the early 2000s, David Lorello, PT, DPT, suddenly found himself in a pinch. The final clinical internship he’d signed on to do “basically fell through last-minute,” he recalls. As he remembers it, he was one of the only people in his class who really liked wound care. The clinical education director knew that, he says, and after “some scrambling around for options that might work,” the director came back with an offer from a hospital burn unit in Detroit.
“I wasn’t sure what to expect,” Lorello says, “but it sounded like it would be an interesting experience. I told her I’d definitely take it, and that was where everything started.” Today, Lorello is a certified burn therapist through the American Burn Association and a member of the burn rehabilitation team at the Arizona Burn Center at Valleywise Health in Phoenix. He came to the facility immediately after graduation and hasn’t looked back since.
“This is my job,” he says, “but it’s also my passion. I think working in a burn center is probably unlike anything else you can do in physical therapy.” When Lorello started 17 years ago, fresh out of school with just months of clinical experience, he did so with the understanding that the learning curve ahead was going to be steep. “I had no idea what I was in for,” he recalls, “but as a new grad, I had all this energy, so I picked up extra shifts and put in extra hours and just pored myself into it.”
The burn center is part of a teaching hospital, so he spent countless hours at its medical library pulling up articles on burn management. Before long, he was asked to present at an annual symposium the facility hosted for a wide range of health care professionals. “That was really high pressure,” he says. “It was important to me that I actually knew what I was talking about.”
Patients with serious burns, Lorello explains, typically require highly specialized care. “A lot of people think, ‘Oh, a burn, that’s a skin issue,’ but the reality is, it’s a devastating injury because it affects so many bodily systems.” That includes the integumentary system, of course, but it also includes the musculoskeletal and cardiovascular systems, for example. “This patient is rapidly losing strength, rapidly losing endurance, and on top of that, they’re dealing with this massive integumentary issue that’s causing them to lose range of motion and function,” he says. As a physical therapist working with such patients, “your job is this constant battle to keep them moving as much as possible.” An Underappreciated Specialty If Lorello’s chance introduction to burn management sounds familiar to others in this specialty, it’s probably because the pathway to this area of practice doesn’t see very much traffic. In Arizona, in fact, the only other physical therapist to be burn therapist-certified by the ABA works in the same facility as Lorello. Nationwide, only a dozen PTs currently hold the ABA burn therapist certification credential.
Physical therapists who focus on burn management don’t have to pursue ABA certification or even be members of the association, but the low numbers are a telling reflection of burn management’s place in physical therapy overall. “I think if you talk to anyone working in a burn center, they’re going to tell you there are not enough therapists,” says ABA President Ingrid Parry, PT, MS, who, along with all of the PTs interviewed in this story, is an ABA-certified burn therapist. That goes for both PTs and occupational therapists, she adds, explaining that most specialized facilities see the two professions as equal and complementary beneath the burn therapist umbrella. Parry was named president of ABA in 2022, the first non-surgeon to hold the role. Her nomination was based on the strength of her years of experience working with burn patients at Shriners Children’s Northern California and leadership within ABA.
Today, in addition to her work with that association, she conducts research on burn rehabilitation at Shriners and the University of California, Davis. Like Lorello, she came to the specialty largely by accident as a PT student doing clinical work. “I was a little intimidated by it at first,” she says, “but I gave it a try and I fell in love with it.” Driving that passion, according to Parry, are the many patients she’s seen over the course of her career. Early on, for example, two girls came to Shriners after surviving a car fire in Mexico. Both had suffered significant burns, and one in particular had deep burns to her hands and face and had lost all of her fingers.
Parry didn’t necessarily think about it at the time, but she says the work that she did then illustrates the “interesting blend of science and the arts” required of therapists in burn rehabilitation. “It’s understanding wound healing and scars,” she explains, “but then there’s also the psychosocial side where you’re helping your patient deal with deformity and the impact of pain and trauma.” Both patients recovered over time, and the girl with the hand injuries went on to learn how to play the piano and do archery. Eventually, as an adult, Parry’s former patient found work helping other burn survivors in Arizona. “She went through a lot of challenges in life, but with her family support and through the therapy she received, she adjusted and was able to be functional,” Parry says. “For me as a physical therapist, there’s nothing better than seeing that evolution from injury to reintegration. That’s why I chose to do what I do.”
Part of an Interdisciplinary Team
Like Parry, Lorello also says it’s the impact he’s had on people’s lives that keeps him coming back for more. One memorable patient, he recalls, was a 6-year-old boy who’d suffered scald injuries to his lower extremities. “He was a skinny little kid with really long legs, and not a lot of skin available for grafting,” he says. Like Parry’s patients from Mexico, the child was from outside of the country. “His family had been on vacation when the accident happened, so compounding the stress associated with everything involved, there was also the fact that they were far from home and English wasn’t their primary language.” In addition to his work at the Arizona Burn Center, Lorello is now an associate professor in the DPT program at Franklin Pierce University in Goodyear, Arizona. He teaches a class on the integumentary system, and part of his course is devoted to understanding burn injuries. He’s also responsible for multisystems courses students take before they start their internships. In that capacity, he often includes hypothetical clinical scenarios involving patients with complex burns. “Maybe, for example, we’ll pretend that they’re in an inpatient rehab facility. In between the patient you’re seeing with a spinal cord injury and this other patient who’s had a stroke, what are you going to do with this person who has burns over 80% of their body?”
For the child he saw with the scald injuries, he had the advantage of working in a hospital where he typically meets patients on day one. “The moment they roll in, we’re already involved,” he says. He’ll go into the operating room before the case starts, “so once the patient is placed under general anesthesia, I can assess their range of motion and look at their wounds and have a conversation with the surgeon about the plan.” He also may end up speaking with the anesthesiologist to see if they can keep the patient under anesthesia long enough for him to place splints on affected limbs after skin grafts are completed. And finally, later, he may talk with the nursing staff to ensure he’s with the patient during dressing changes. “Sometimes I’ll want to see them when their wounds are exposed just to better understand how they’re healing,” he explains. Either way, he almost always schedules his visits to take advantage of the patient’s pain medications. “It’s like, ‘OK, your dressing change is over, now we need to act quickly. Let’s get up, let’s get you to the gym. It’s time to move and start working on function.’"
Ultimately, Lorello says, his patient with the scald injury went through months of rehabilitation before he was finally discharged. “He nearly returned to full function, and today he’s an adult and I still talk with his family.” In class with his DPT students, he knows the vast majority won’t wind up working in a specialized burn center. On the other hand, he says, he encourages students to think about what patients like his inevitably go through on their way to recovery. He also suggests they try to remember that specialists are available to talk to if they see patients with burns in their own clinics. “I always tell them, and practicing therapists as well, ‘Please call us if you have any questions,’” Lorello says. “Us” could mean him and his colleagues in Phoenix, or it could mean the PTs and OTs working in the hospital where their patient was originally seen. “Talk to those therapists right away, because they obviously will have a lot of knowledge.”
Helping Patients Get Back to Their Lives
Lara Fong, PT, DPT, affiliate faculty member with the Department of Physical Therapy at the University of Florida in Gainesville, agrees with Lorello on all accounts. With her own students, she’ll often relay the lessons she’s learned as a clinician working with patients with burns, she says. Ingrid Parry, PT, MS, conducts research with a burn survivor playing interactive video games. 19JULY 2023Most recently — and at the start of her career — she was at the Burn Center at Cooperman Barnabas Medical Center in Livingston, New Jersey, but she also practiced in Florida for two years at the Warden Burn Center at Orlando Regional Medical Center.
“I like to say working with patients with burns really encompasses just about everything you’ve learned in PT school,” she notes. That’s because anyone can get burned, “whether it’s a child or a teenager or an adult, someone who had a stroke and fell in hot water, or someone with cardiac issues or cerebral palsy who was burned trying to cook something on the stove.”
A PT working in a burn center, Fong says, would see patients soon after they’re admitted and have to consider concurrent conditions such as limb amputations or spinal cord injuries. PTs in other settings might see them months or years later, either for issues related to their burns or for an unrelated issue, and, either way, the earlier burn experience may influence how the PT determines the plan of care for that patient. “Sometimes, when people are burned, they have underlying things going on, too,” Fong says. One of the challenges for therapists can be differentiating what they’re seeing. “If you have the patient flex their shoulder, for example, is the pain that they’re feeling because of the burn, or is it because they have a rotator cuff injury?”
Fong says she’s worked with patients of all ages and at all stages of rehabilitation. At Cooperman Barnabas, for example, she’d often first meet her patients on their day of admission and then work with them for months as they progressed from their inpatient stay to outpatient therapy. One patient was 17 years old when he suffered both electrical and flame burns to about 70% of his body. He also fell from a height in the accident and broke multiple bones. The patient underwent several surgeries, including skin grafting and a below-the-knee amputation. When Fong first saw him, he still had chest tubes, and he had a sugar tong splint an occupational therapist had created to protect a fractured elbow. “As a PT, it was the kind of case where you’re thinking, how can I pull all of this together? You start working on something, and there’s always something else.” One of the patient’s primary goals was to be able to walk on crutches by the time he left the hospital. Fong, for her part, wasn’t sure he’d be able to do it, but she wasn’t about to tell him not to try. With such patients, Fong says, the pain they’re in almost always becomes one of the biggest hurdles they have to clear. “You have to push and push to help them through it, because early mobility and movement is so imperative to prevent contracture.” In her experience, many patients develop tolerance as small successes start adding up. “They know it’s going to hurt when they first step out of bed, but then as they go through their exercises, they’re going to feel a little looser and a little better. They get that glimpse of getting back to their life again, and that’s empowering for them.”
Her teenage patient, Fong recalls, required “all the PT skills I had.” He was also on crutches by the time he left her facility, able to walk about 100 feet with contact guard assist. “It was truly incredible, considering his stay in the ICU and the sedation he’d been under, as well as the fractures and amputation,” she says. “It was a reminder for me to always recognize my patients’ potential.”
A Discipline and a Passion
Fong says she’s seen many other patients who successfully found their way back to daily life. One was a young mother who was another PT’s patient but who Fong was able to work with once. The patient knew she’d have to carry her baby when she returned home, so part of their work together involved carrying a 15-pound ball up and down the hospital’s stairs. Approaching burn management with functional goals in mind is a strategy that Dominique Kuzma, PT, DPT, says she uses with her patients, as well. Acute care supervisor with the Centers for Rehab Services at UPMC Mercy in Pittsburgh and a certified burn therapist, Kuzma sees a range of serious injuries in her work, but her primary caseload consists of patients admitted to the hospital’s ABA-verified burn center.
Like Fong, Kuzma often finds herself coaching her patients through their pain. “The biggest thing I try to do in the beginning is build a rapport with them,” she says. “They often don’t want to work with you because they know it’s going to hurt. So you have to kind of read the room a little bit.” Once a patient is comfortable and ready to start physical therapy, Kuzma says she’ll usually ease into the work of stretching and mobilization. “There’s a lot of negotiating involved, explaining why we need to do something and what it’s going to benefit. It’s important to help them see the light at the end of the tunnel when you’re asking them to move so early on.”
For burn survivors, even one or two days of inactivity can limit their function down the road. This means that physical therapists often spend significant time with their patients. That, combined with the tough love therapists must give, means “it’s almost impossible not to bond with them as a result,” Kuzma says. She worked with one memorable patient in the ICU for more than three months, she recalls. “Twice a day, every day, I saw him go through all the phases from being really down and questioning the point [of the exercises] to actually being thankful for what we were doing.” The man had been in an explosion at work and was convinced he’d be in pain for the rest of his life. “When he finally left, he was walking with a cane. Now he comes back to visit, and he loves to tell us about the time he gets to spend with his grandkids.” R. Scott Ward, PT, PhD, FAPTA, interim dean and professor at the University of Utah’s College of Health in Salt Lake City, knows exactly what Kuzma means when she talks about the bonds that develop in burn centers. Although today the former APTA president enjoys research on burn injury and rehabilitation, he’s spent much of his 40-plus-year career teaching students and others about burn care and working in the clinic with patients with burns.
“What I love most about this setting is how every day and every patient is a different challenge and opportunity,” he says. “Working in burn care is never boring because no two burn cases are alike.” Ward says he thinks there are “a lot of misperceptions” about burn care in the physical therapy profession. One of the biggest, in his opinion, is that most PTs simply aren’t cut out for this kind of work. “The reality is, the competencies that are required in burn care are the same required in any practice, plus a few very specific things,” he says. Like any orthopedic or neurologic specialist, for example, PTs in burn care are fluent in the intricacies of patient evaluation and evidence-informed decision making, and they know that movement early and often is key to successful rehabilitation. In addition, burn specialists also master the competencies of splinting and scar assessment and management, among others. Yes, the injuries that burn care professionals see can be incredibly complex, and the psychosocial aspects of burn management can be difficult for some to navigate, but PTs who choose this line of work rarely regret doing so. “You develop a passion around it because of the relationship you develop with patients,” Ward says. “It’s a unique population to serve, but it’s a population that deserves unique care.”
Chris Hayhurst is a freelance writer and frequent contributor to APTA Magazine. To read this full edition of APTA Magazine, visit https://www.apta.org/apta-magazine/2023/07/01/apta-magazine-july-2023.