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Chapter 21
Burn Rehabilitation
LynneBenavides, BetseyFerreira, OscarE.Suman,
andJeffreyC.Schneider
Introduction
Burn care or burn rehabilitation at any level or phase of
recovery can be very overwhelming to the non-burn specialist. In this chapter, we aim to provide education and
practical approaches to burn rehabilitation for the nonburn specialist. With all of the significant advances in medical care for the patients that have suffered a burn injury
over the past few decades, the survival rates of patients
L. Benavides (*) · B. Ferreira
Rehabilitation Medicine, Rhode Island Hospital,
Providence, RI, USA
e-mail: lbenavides@lifespan.org; BFerreira1@lifespan.org
O. E. Suman
Department of Surgery, School of Medicine, University of Texas
Medical Branch, Galveston, TX, USA
e-mail: oesuman@utmb.edu
J. C. Schneider
Department of Physical Medicine and Rehabilitation, Spaulding
Rehabilitation Hospital, Massachusetts General Hospital, Harvard
Medical School, Boston, MA, USA
e-mail: jcschneider@mgh.harvard.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
J. O. Lee (ed.), Essential Burn Care for Non-Burn Specialists,
https://doi.org/10.1007/978-3-031-28898-2_21
433
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L. Benavides et al.
with large total body surface area (TBSA) burn have
greatly increased. There is evidence to support early
involvement of occupational therapy (OT), physical therapy (PT), and exercise training in helping burn survivors
reach their best possible outcome and continue to lead a
meaningful and productive life. Implementing a rehabilitation program as soon as a patient is medically stable is
imperative. This applies to a patient who has suffered a
large burn and is being treated in a burn unit or to a patient
who has suffered a small burn and is being treated in an
outpatient setting. This chapter focuses on rehabilitation
including OT and PT for the burn patients.
In rehabilitation of the burn patient, the lines between OT
and PT can become blurred. The occupational therapist
(OTs) and physical therapist (PTs) work as burn rehabilitation therapists. Each discipline has their specific roles and
goals, however, burn therapy as a collective has many common threads. For example, goals of rehabilitation include
prevention of contractures, preserving or regaining range of
motion (ROM), strength, and functional abilities as well as
helping patients to return to independent living. Although
this is not a complete and exhaustive list, these are a few of
the common threads for both OTs and PTs.
Role ofOT inCare oftheBurn Patient
OT theory is based on the belief that rehabilitation of
dysfunction can occur through the use of occupations (daily
activities and tasks) that have meaning for a patient. OTs
assist the burn patient in engaging in and recovering the
ability to perform Activities of Daily Living (ADLs)/
Instrumental Activities of Daily Living (IADLs), vocational
and avocational activities, to help them return to their life
roles as soon as possible. In burn care, OTs will screen or
assess for potential for contractures, possible effects of scar,
loss of skill performances, as well as evaluating for loss of
motion, strength, edema, sensory injury or issues, cognition,
Chapter 21. Burn Rehabilitation
and psychological adjustment. One of the major roles for an
OT is determining the need for orthoses, positioning devices,
adaptive or assistive equipment, and pressure garments.
Once the screen or evaluation is complete, the OTs will
establish a treatment plan. The OTs will inform and collaborate with the burn team on their plan of care. Initiation of
OT should begin within 24 h of a patient being admitted
after burn injury. OT will continue through the acute care
phase, as well as during an acute rehabilitation stay, and in
an outpatient setting. OT and /or PT should also be part of
an outpatient burn clinic and care should be initiated as
soon as possible to help achieve the best possible outcomes.
Function, scar, and cosmesis will be the initial goals of treatment at this stage. A key point will be communication
between all identified health care team.
435
Role ofPT inCare oftheBurn Patient
PTs plays a critical role in the multidisciplinary care of a
patient who has sustained burns. Burns cause multisystem
medical problems causing potential for prolonged hospitalizations and lengthy recovery. In the acute phase of care for
hospitalized patients, PT should be initiated as early as the
first 24 h. PTs primary goals are to limit loss of ROM,
reduce edema, prevent predictable contractures through
positioning and splinting, and prepare the patient for discharge by addressing patient function. Care for the patient
will continue through rehabilitation stays and home care.
The primary PT goals remain the same with the addition of
assisting with initial scar management through early compression. The PTs may also assist with helping the patient
adapt to any psychosocial issues related to their burn. Some
key concepts to consider with acute treatment of patients
with burns are maintaining effective communication with
the team, scheduling therapy sessions around pain medication distribution, as well as patient and family education.
As the patient progresses, outpatient services are often
436
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L. Benavides et al.
warranted and should be initiated as soon as possible upon
the patient returning home. The outpatient PTs must continue to address any continued problem areas with ROM
and edema but also progress the patient’s strength and
endurance through resistive exercise and cardiovascular
exercise. The PTs should also address function as it pertains
to return to work and any ADL. Special education should
be provided on pressure garments, and scar management,
and communication with the burn team should be ongoing
to provide input on any skin contractures that may need
reconstructive surgery.
Acute Rehabilitation ofaBurn Injury
After a burn patient has been admitted to a hospital and
has been stabilized medically, referrals for OT and PT
should be placed. OT and PT begin in the acute care stage
of burn patients and continue throughout the entire rehabilitation process. These along with familiar components of
rehabilitation including evaluation, assessment of ROM,
strength, sensation, edema, mobility, and ADLs are paramount to a successful initiation and plan for rehabilitation.
Adaptive equipment or devices may also be used in the
acute phase of treatment, and of significant importance to
the progress and success in this acute stage will be positioning and orthoses. Psychological adjustment is also important to consider when treating a person who has suffered a
burn injury. Even with small burns, it can have an effect
psychologically and socially. These psychosocial effects
should be monitored throughout the rehabilitation process,
discussed, and addressed with the entire team as needed.
During this acute rehabilitation stage, pain can be a limiting
factor in a patient’s participation in activities and exercise.
Along with being aware of medication regimens, patient
education regarding coping techniques should also be initiated early.
Chapter 21. Burn Rehabilitation
437
Positioning andOrthoses
Positioning
Throughout a patient’s recovery, with significant emphasis in
the acute phase of hospitalization, attention to positioning and
prevention of contractures should be near the top of the priority after medical stability. Preventing or correcting contractures is integral in helping a burn patient return to function.
Positioning a patient is all health care team’s responsibility,
however a rehabilitation therapist, OT, and/or PT may lead
the way in determination of positioning for the best possible
effect on functional performance and mitigation of possible
contractures. Communication throughout the team regarding
positioning will need to take place regularly. Pictures placed in
the medical record or in the patient’s room along with in person education for the staff and families are also a good way to
ensure proper positioning. Also, if a patient is able in the acute
stage, reinforcement of proper positioning verbally and with
visual aids with the patient will begin to allow the patient to
engage in their recovery process.
Keys to remember in a positioning program include
reducing edema, reducing risk of contractures, allowing
proper joint alignment, allowing facilitation of wound care,
and reducing risk of possible associated iatrogenic injuries
such as peripheral neuropathy and pressure sores.
There are several ways to achieve a proper antideformity
positioning and neutral postures as well as protection of bony
prominences. Orthoses, serial casting, foam-based troughs,
wedges, pillows, straps and at times surgical intervention with
pins or traction may be utilized to achieve a positioning goal.
Awareness and knowledge of contracture predisposition
are important to understand for positioning and splinting
purposes. Below is a table of some of the most common contracture predispositions and their splinting or orthotic recommendations (Table21.1).
L. Benavides et al.
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438
Towel roll, anterior neck orthses,
torticollis strap
~15° without rotation; no
pillow use
Airplane orthoses, pillows, foam
wedges, bedside tables, arm troughs
90° abduction; 15–20°
horizontal adduction and
15–20° external rotation
elbow flex/ext and pronation/
supination orthoses
Pan splint/orthosis
Wrist extension, minimal
MCP flexion, digits extended
and abducted
Flexion Neutral -> slight extension
Affected area Contracture predisposition Prevention Position(s) Device
Head Midline, elevated 30–45° Head of bed
T . List of recommended positioning
Neck—
Extension Neutral ->slight flexion Pillow behind head
anterior
Neck—
Adduction, protraction if
anterior shoulder, chest
involved
Elbow flexion Elevation, extension Anterior elbow orthoses, dynamic
posterior
Spine Monitor for signs of scoliosis
Shoulder/
Axilla
Elbow
(anterior)/
Forearm
Wrist and digit flexion,
digit adduction, palmar
Wrist/Hand-
anterior/
cupping
palmar
Chapter 21. Burn Rehabilitation
439
Intrinsic+orthosis
Wrist extension, MP flexion,
Abduction pillows; strapping
IP extension, thumb mid-
palmar/radial abduction
Abduction 15–20°; full
extension; 0° rotation
flexion, thumb adduction
external rotation
LE orthoses; knee immobilizer
quad function or mobility/
casting, multi podus boot
ambulation
Dorsiflexion/clawing Neutral Foot plate, multi podus boot
Curling or flexing Neutral Foot plate, multi podus boot
Hand-dorsal MCP hyperextension, IP
Hip Flexion, adduction,
Knee Flexion Full extension until good
Foot/Ankle Plantar flexion Neutral or slight dorsiflexion Orthosis, footboard, traction, serial
Toes (dorsal
burn)
Toes (plantar
burn)
Mouth Microstomia Microstomia orthosis
Nostrils Stenosis of anterior naris Dilation device, gauges
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L. Benavides et al.
Orthoses
The overarching goal of splinting is to assist in reaching the
best functional outcome. The use of orthoses or casting can
help to prevent loss of motion, preserve or improve ROM,
protect vulnerable structures (skin grafts), assist in scar management and correction of contractures, support and/or assist
weakened muscles as well as support, protect, and immobilize
affected joints. Care should be taken so that an orthosis can
allow for a reduction of edema, promotion of wound healing
and maintenance of proper joint alignment. Care should also
be taken that an orthosis does not cause harm in the form of
pain, improper application over pressure points, and shearing
of tissue or new skin grafts. An orthosis should be designed
with forethought of function and ease of application and
removal for dressing changes and/or exercise and function. In
the acute hospital or rehabilitation stay, education for the
health care team, family members and patients will be imperative to achieving the overall outcome for the use of an
orthosis. In person demonstration of application/removal and
proper positioning is vital, and adjunct education in the form
of pictures or even videos in the patient’s EMR, pictures
hanging on the walls of the patient’s room will assist in making sure an orthosis is utilized correctly for maximum
effectiveness.
Early Mobilization
As with any critically ill patient, early mobilization is a key
component of a patient’s full recovery. Prolonged immobilization can lead to multiple issues such as joint immobility,
weakness, deep vein thrombosis, pressure ulcers, and neuropathies. The challenge with mobilizing burn patients early
in their intensive care unit stay is often limited by the need
for frequent surgeries and post-operative restrictions with
splints. When a patient undergoes a skin graft procedure that
crosses a joint, the area is often splinted until the first dress-
Chapter 21. Burn Rehabilitation
ing take down. This may limit the patient’s ability to move
and ambulate. However, ambulation should be started as
soon as possible. The therapist will need a complete understanding of graft placement, ROM restrictions that may
apply, as well as weight bearing precautions prior to initiating
any mobility. A double layer of elastic compression should be
applied starting from the toes and ending proximal to the
grafted skin prior to ambulation. Initial ambulation should be
limited in distance to avoid risk to the skin graft. Assistive
devices should be utilized to aid the patient with stability and
allow for adherence to weight bearing restrictions. In summary, the key points to allow early mobilization of burn
patients are good communication with a multidisciplinary
team, as well as the patient, good understanding of ROM and
weight bearing precautions, application of a double layer of
elastic compression, and sufficient assistance to allow the
patient to have a successful experience.
441
Early Therapeutic Intervention
“Early therapeutic intervention in the burn unit has long
term implications for restoration of function” [1]. Initiating
therapy in the early phase of burn care in the form of stretching and exercise among other therapeutic interventions can
contribute greatly to the prevention of contractures. Therapists
will engage patients in either active ROM, active assisted
ROM, or passive ROM depending on patients’ medical condition. Ideally, active ROM is the goal as it assists in reducing
edema and stretches healing tissue as well as promotes
strength, endurance, and function. If a patient is having difficulty moving through their full ROM due to strength, endurance, tightness, or interference of medical equipment, active
assistive ROM may be performed. For those patients who are
critically ill or sedated, passive ROM is appropriate for a
therapist to perform to help preserve ROM and prevent contractures. Once a patient is actively participating in their
rehabilitation program, strengthening is also introduced into
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L. Benavides et al.
the program. Strengthening exercises can be in the form of
isometric or isotonic exercises depending on the patient’s
condition. Endurance will also be a factor during therapeutic
exercise. Shorter treatment sessions twice (or more) a day vs.
one session per day may be beneficial if a patient is inhibited
by low endurance.
Scar Management, aRehabilitation
Perspective
Scar is a natural part of the healing process and is defined as
fibrous tissue replacing normal tissue that was destroyed by
injury or disease [2]. Hypertrophic scar is characterized as
having excess amounts of collagen which contributes to a
red, raised scar but not to the extent of a keloid. It is also
noted to not extend beyond the boundary of its original
injury. It can promote scar contracture, but it can also
regress with time. A keloid scar can appear as rounded protuberances that can be anywhere from pink to purple in
color and extend beyond the boundaries of the original
wound. Scar contracture is not common with keloids, but
they do not regress over time and can recur after surgical
intervention. The concerns for scarring in a burn injury are
functional deficits as well as the psychosocial impact of scarring and its effect on cosmesis. It is important to provide
education to patients and families regarding scar formation—the what, why, and how of development and treatment as well as to provide resources for psychological
support for a patient and their family.
Burn patients are at risk for hypertrophic scarring. The
time it takes for healing of a burn wound or skin graft
(>2–3 weeks) contributes to hypertrophic scarring. Burn
scars can take up to 2years for full maturation.
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