Ricky Proelss had been mustering cattle all day on a rural property in Alpha, in outback Queensland, before he decided to do some last-minute mechanical repairs to his ute.

His clothes were splattered with oil from the repairs but, as a man on the land, Ricky was used to the hard and dirty work, and he didn’t give his attire a second thought.

Later that fateful night in 2017, the then 23-year-old station hand fell asleep in an armchair around a campfire with friends.

Ricky was wearing the same clothes he’d been in that day, zipped into a Driza-Bone jacket for warmth. An errant ember from the fire landed on a sleeping Ricky and set him alight.

He remembers waking up and looking down to see his shirt on fire.

Within seconds he was engulfed in flames, and he began frantically trying to put the flames out.

In the unfolding horror, Ricky saw the skin on his arms falling off, all the while desperately trying to raise the alarm.

Having set up the campfire in a remote area away from the property’s homestead, there was limited water for Ricky’s scrambling friends to help treat or douse him.

Ricky was loaded into a 4wd ambulance and driven to the small community hospital at Alpha.

There, Ricky was stabilised, intubated and airlifted the 1200 kilometres to Royal Brisbane and Women’s Hospital.

He had suffered third degree burns to 48 per cent of his body. They were mostly full thickness burns to both his arms, both sides of his trunk, his buttocks and upper left thigh.

‘I woke up in hospital four weeks later, I’d been put in a coma,’ Ricky says.

Ricky had endured debridement of his entire anterior and posterior trunk (fascial debridement), bilateral upper limbs and buttocks, and biobrane was applied before he had three skin graft operations.

He was in a lot of pain—physically and mentally. And it was at this point that he began his burns rehabilitation journey.

‘In the first week I came out of my coma we were into the physiotherapy,’ Ricky says.

‘Those first few physio sessions were pretty painful. I had to have the gas and the drugs, Endone and stuff like that, but I couldn’t really do a whole lot the first few times. I couldn’t walk or bend my elbows or anything.

'We started doing just small stuff, like trying to move my hands and then stretching my arms and my neck; it was hard at the start because I had so many dressings.’

Ricky credits his physiotherapy team, led by Anita Plaza, APAM, with working on both his body and his mind.

At some low points in his recovery, Ricky struggled to cope with the pain and the devastation to his body.

But, with the help of the team, Ricky began to focus on two very specific goals—get back to work on the cattle property, and then to fly helicopters.

‘At the start my head was in some different spaces and I didn’t really know a whole lot because I was so angry at what happened. I didn’t know how I was going to get back to work,’ Ricky says.

‘Anita was pretty quick to encourage me and say “you can do it” and “I’ve had patients that got back to work in however many months”. And I think that really helped me.

‘She’d just always talk to me, and she would get there early in the mornings too, before everyone else was allowed to come in.

'She would talk to me about little things, and even about how I could do the bath,’ Ricky says.

‘I used to hate having a bath because they’d take the staples out and all this stuff, and I just hated it. Didn’t want to do it. Sometimes Anita would come in and sit there with me, just talk me (through the exercises and the dressing process) while they did all the painful stuff.’

The team also got Ricky’s family, from Victoria, involved in his rehabilitation and they also got creative in ways to inspire Ricky to exercise.

In the hospital gym, Ricky was encouraged to use bars on the wall that were similar in height to cattle enclosures.

He worked in the gym in the burns unit, undertook hydrotherapy sessions and performed resistance exercises and had physiotherapy as an outpatient.

In all, Ricky was in hospital for about three months; initially he was told to expect to be in hospital for between 18 months and two years.

Ricky has since returned to the work he loves—and he is now flying helicopters. He no longer requires the daily intensive exercise program that got him back up on his feet and back out into the country he loves.

Working with patients such as Ricky is what Anita chose to do after she started working at the Royal Brisbane and Women’s Hospital (RBWH) and had a rotation through the intensive care unit.

She met burns patients who reminded her of her grandfather, a cane farmer in North Queensland who suffered burns in a cane fire.

As a young girl, Anita recalls seeing the skin grafts on her grandfather’s legs; the experience changed her view of burns and eventually drew her to working in that field.

Anita is now in her 26th year as a physiotherapist, 25 of those spent working within burns patients at RBWH or at the Royal Children’s Hospital (now known as the Queensland Children’s Hospital).

‘Ricky has had a long journey in hospital and after hospital, and he has returned to working on a cattle property and flying helicopters. So it’s quite a good outcome,’ Anita says.

‘I guess the biggest thing I get out of working with patients with burn injuries such as Ricky is that I like to see that progression from day one of the burn injury right through to being back to independence, to doing all their activities, back at work, back into their normal function.

'And knowing that we’ve been able to contribute to that, from a physiotherapy point of view, to make that happen, is very special.

‘It can be challenging too; the patients are usually in a lot of pain and are going through a lot of psychological issues as well.

'How I tend to cope is to make sure the patient is well looked after first. We make sure they have appropriate pain relief and appropriate psychosocial management so that we can actually get in and achieve our physiotherapy goals for that patient.’

As part of a multidisciplinary team approach, treating burns patients begins with pain management and progresses to developing a good rapport with the patient, and educating them about the need to participate in exercise as part of their rehabilitation program, Anita says.

‘We have a great burns team here at Royal Brisbane, and we work very closely with our pain service as well as psychologists and social workers within the team to make sure we are appropriately managing these patients right from the start,’ Anita says.

‘I think that’s probably one of the things that may be different from other areas [of physiotherapy] is that you’re looking at the entire patient not just thinking about what are we doing from a musculoskeletal point of view but thinking about holistic patient management.’

As the team leader, Anita has dual roles of clinician and educator.

She educates junior physiotherapists coming through RBWH in how to manage burns patients, and also educates and provides support and advice in a consultative role to physiotherapists in Queensland and northern New South Wales.

She also provides undergraduate burns information to students at several universities including the University of Queensland, Central Queensland University, the Australian Catholic University and Bond University on the Gold Coast.

Anita is also involved in research and has several research projects in the pipeline, including projects related to physical activity mapping and also the use of telehealth to deliver physiotherapy programs for patients with burn injuries.

Working in this field, Anita has seen many changes and medical advances in burns treatment and rehabilitation.

For one, burns survival rates have improved significantly in the last two decades. Anita says patients with larger burns are surviving readily, right up to those who have 80 or up to 90 per cent burns to their body.

This has resulted in patients experiencing added complications that need to be managed long term.

‘In terms of the exciting developments, there are a number of different skin substitute products developed here in Australia that are being used, which are helping patients with larger precentage burns survive,’ Anita says.

‘So we need to understand about using those in the acute setting. But then the challenge, and a big challenge for us physios, is that now we have patients with many more complications, from a whole gamut of reasons, that we need to think about how to manage long term.

‘Along with most other areas in physio, motivation is often a big problem with these patients. A big challenge is trying to get patients motivated to continue in their programs, because it’s often a long rehabilitation program, particularly for patients with bigger burns.

‘Patients who have burns that are greater than 40, 50 or 60 per cent need ongoing physiotherapy treatment for sometimes two or three years.

'Being able to keep them motivated long term is something I’ve learnt, during my time in the burns unit, is definitely a challenge.’

Anita says ensuring her team members are able to debrief and find support with each other and outside the direct patient care environment is also important when working with this patient cohort.

She says the work can be emotionally challenging as burns patients are often experiencing pain and trauma in life-altering ways.

However, she is quick to point out that physiotherapists who have little experience working with burns patients need not fear doing so.

‘If someone hasn’t had exposure to working in a burns unit or with a patient with burn injuries, you’ll often find that the first reaction is that the physiotherapist might be quite fearful of taking the patient on as they don’t believe they have the experience or skills,’ Anita says.

‘But once you get past that fear and anxiety…and they realise that we are using all of our normal physiotherapy skills, looking particularly at exercise prescription and problem-solving, then they understand that it’s really not that difficult after all.

'I think the perception from the outside looking in is that it’s really hard, and they’ve not had that experience. But, really, every physio has the skill to be able to do it.’

These are views echoed by Associate Professor Dale Edgar, Head of the Burn Injury Research Node at the Institute for Health Research at The University of Notre Dame in Perth.

Having been in the part- time academic role since 2015, Dale has also held the dual role of senior physiotherapist in the State Adult Burns Unit at Fiona Stanley Hospital, and Director of Clinical Research for the Fiona Wood Foundation.

He has been devoted to the provision and improvement of burn survivor and acute trauma rehabilitation for more than two decades.

Dale says that apart from wanting to help patients and advance burns knowledge, he was drawn to work with burns primarily as it allowed for full use of his physiotherapy skills.

He developed a passion for being able to use a multitude of skills, from respiratory to acute management to neuro and musculoskeletal, in the prescription of therapy interventions and exercise for burns patients.

And after moving to Western Australia from Brisbane, where he began his burn care career with Professor Stuart Pegg, Anita and the team at RBWH, he took up the position at Fiona Stanley Hospital.

In Western Australia, Dale was able to develop and use his splinting and hand therapy skills as well.

‘In treating burns you have such a broad range of challeneges and thus, the ability to use a multitude of physiotherapy skills.

'I’ve trained up in lymphoedema management, applying those skills in actue control and reduction of swelling. I’ve trained up in splinting and splinting techniques, hand therapy and all sorts of musculoskeletal applications.

'It offers us as physiotherapists a very, very broad spectrum or scope of practice, and that’s what I love about it.

‘What has continued to allow me to stay passionate about burns care is the research work, and what we’ve discovered is that burns impact on every single system of the body,’ Dale says.

‘The inflammatory insult on the body is by far the greatest of any sort of tissue damage that we see in any other context, even in multi traumas and surgery.

'Burn is further up the scale in terms of the type of inflammatory response, the hypermetabolic response, and the magnitude of the inflammatory response which is evoked because of the burn injury.

'Tissue damage due to burn is far greater than any other sort of injury or tissue damage that we’ve studied.’

Like Anita, Dale says working with this patient cohort can be emotionally challenging for the clinician as well as the patient.

Getting burn patients up and moving as early as possible after their hospital admission is the primary focus, and physiotherapists in these roles need to help their patients understand that movement and mobility will not lead to further tissue damage.

‘I don’t think people appreciate how hard it is to get up day in, day out and know that patients are going to be going through pain to achieve what we need them to achieve, or to achieve what we know is potentially their optimal or best outcome,’ Dale says.

‘I’m very fortunate to have a great team of physios that understand that we have to justify why we would ask patients to crash through pain barriers to get to the other side.’

‘My thinking around pain has changed in the last five years, particularly around de-threatening pain and allowing patients to understand pain and provide them with explanations so that they understand that their physical apparatus, which provides them with noxious information or pain messages at the skin interface, is damaged,’ Dale says.

‘So with a burn, the distal or peripheral nerve field, the nerve sensors, are damaged and so the threshold to providing a pain message is much lower.

'So the patients’ understanding that they’re not doing damage by moving is a key justification for why we ask them to do what we ask them to do.

‘We know that we’re not doing any further tissue damage and yet their body continues to give them that message, and erroneously tell them there remains a threat of damage being done because they’re moving or because you’re breathing in the general direction of your leg or whatever.

'For instance, patients get pain just because of a change of blood volume in their leg when they stand up.

'They get pain because they move their burn area, they get pain around a burn area because their inflammatory processes have fired up in an area of secondary hyperalgesia.

'There’s a whole bunch of reasons—and good physiological reasons—as to why they’re getting a pain message.’

He says much of the work done in the hospital setting with burns patients focuses on activity and positioning associated with managing swelling, particularly acute swelling, in the first 48–72 hours, as a way of trying to improve the speed of healing.

As a key part of the wound management team, physiotherapists are heavily involved in early activities of swelling management and making sure the burn wound has high-quality oxygenation in the tissues, as well as optimising the respiratory system.

Physios get the patient to start moving as soon as they get into the hospital; they get up, they walk, they do functional things and they get into the gym within our burn unit.

‘It’s a standard of care that ensures the patient doesn’t have unbroken bed rest, which can lead to muscle wastage. We get the patient into the gym and they’re exercising and using their muscles against resistance,’ Dale says.

‘We are key advocates of trying to coordinate and ensure that the patient has as much analgesia as they need to complete their therapy, maintain function when we are not there, and not be zonked out and not be able to get out of bed.’

Dale says that during the first 10 years he worked in the burns service, a great deal of collaboration with anaesthetists and acute pain specialists was undertaken to develop multimodal analgesic approaches.

‘It was about the same time that a cultural change was taking place in the burn unit where the whole medical team got on board with the idea that patients ought to be moving while simultaneously being provided the best background pain relief.

‘So if a nurse walks in at 10 am and says to the patient, “I want you to walk into the toilet and have your shower” or “go to the toilet before you start having your dressing changed”, they can do that without having to ask the physio to get the patient up because that is the norm in our environment.

'Often times we still do help get the patient up because there are some patients who struggle.

‘But ultimately the whole team will go in, including the doctors, and they’ll say, “how’d you go overnight, have you been walking? Have you been sitting out for your meals?” They’ll reinforce that normality around mobility and function, and encourage getting up and moving.’

Over in Tasmania, Jenny Ball, AM, APAM, is the senior physiotherapist in Hands, Burns and Plastics at Royal Hobart Hospital, where she has worked for the past 40 years.

Now in a part-time capacity, Jenny also runs her own private practice, Jennifer Ball Hand and Upper Limb Physiotherapy. 

As a junior physiotherapist, 38 years ago, Jenny was rotated into the Hands, Burns, and Plastics rotation at Royal Hobart, and was responsible for managing all burns patients (inpatients and outpatients) who came to the state-wide centre in Tasmania.

She found the experience confronting, challenging—and something that she had to navigate by herself.

‘Fortunately, as a student in Sydney I had done an elective in burns,’ Jenny says.

‘But now I was doing the job as the solo physiotherapist. Without a senior physiotherapist to learn from I really relied on the rest of the staff in the unit, the surgeons and nursing staff, to help me to do my daily work and to know the complexity and extent of my role.

‘A stong, cohesive and caring burns team is the key to co- ordinated treatment, common outcome goals and physical and psychological support for patients, families and staff.’

The focus of this month’s National Burns Awareness Month, an initiative of Australia’s leading community organisation dedicated to child injury prevention, Kidsafe, is burns prevention and first aid.

Jenny says the team at the hospital’s burns unit sees a variety of burns in both adults and children, arising from flame, electrical, chemical and hot liquid accidents through to self-inflicted burns.

‘We have a particular problem here in Tasmania where families use wood burners to heat their houses in winter.

'The glowing flames look very attractive to crawling babies and toddlers, and when not screened effectively children can touch the glass of the wood burner and burn their hands,’ Jenny says.

‘The burns are deep and require grafting, splinting, exercises and long-term rehabiliation and scar management. As the child grows, revision surgery is required to allow for finger and hand growth, and the whole cycle of physiotherapy begins again.

‘I treat children and adults—both ends of the spectrum, but children can be very difficult to treat.

'They are in pain, awake and fearful, and the families can be very distressed. There were times when I would come home from work totally drained, physically and emotionally.

‘And then patients do sometimes die in the unit, and that can be very awful for all of the staff, for everybody. This is when the team pulls together to work through the grieving process.’

Jenny says physiotherapists are ideally suited to treat burns patients.

It attracts very dedicated physios who work in the area for a long time, developing specialised skills.

They are passionate about what they do, but remain on the fringes of the profession, possibly because their overall numbers are so small.

While there is amazing multidisciplinary support and professional development from the Australian and New Zealand Burn Assoication, Jenny says there is limited scope for professional advancement and currently no specialisation offered via the APA Career Pathway.

Jenny hopes to see more recognition of this area of work from within the profession.

‘There are some amazing physios who have, like me, spent their whole career working in burns in hospitals across Australia, doing research, PhDs, teaching their peers and students and really contributing to the knowledge base but not getting much recognition outside of the burns community.

‘As far as a career goes, it encompasses all of the things we learn at university, all of the skills and clinical reasoning that we learn and develop across all of the areas to do with musculoskeletal, cardiorespiratory and rehabilitation physiotherapy, as well as gaining along the way a very unique respect for healing tissues and their propensity to contract.

‘For physiotherapists fortunate enough to work with these patients through their whole journey from acute admission to discharge from rehabiliation and return to home, school and work, the reward is knowing that the foundation skills we all have are actually invaluable,’ Jenny says.