Close
Chapter 94
Burn Rehabilitation
There are approximately 1.25 million burn injuries in the
United States yearly, accounting for 51,000 acute hospital
admissions and 5500 deaths (1). The cause and the risks of
burn injury and death are influenced by age, economic cir-
cumstances, and occupation, with the greatest risk being
economically disadvantaged. Seventy-five percent of all
burn-related deaths are due to house fires, with young chil-
dren and the elderly being most vulnerable. Flame burn is
the predominant type of injury seen in patients admitted
to burn centers, followed by scalding with hot liquids (2).
The majority of burns can be treated on an outpa-
tient basis. However, the extent of the burn, or a compli-
cating factor such as an associated injury or extreme age or
youth, may warrant hospital admission. Inhalation injury,
concomitant trauma, and significant preexisting medical
conditions mandate burn center care for patients with
burns of lesser extent (2).
Major burns are best cared for in a burn treatment
center where the specialized skills of a multidisciplinary
staff and burn-specific equipment ensure optimal survival.
Major burns are classified as follows:
1. Greater than 10% of total body surface area
(TBSA) at an age younger than 10 years or older
than 50 years
2. Greater than 20% of TBSA in patients at an inter-
vening age
3. Significant burns of the face, hands, feet, genitalia,
perineum, or major joints
Lucretia Fitzpatrick
Patrick Murphy
Jill Androwick
Deborah Goldblum
Patricia Wardius
John Wijtyk
4. Full-thickness burns greater than 5% of TBSA
5. Significant electrical injury
6. Significant chemical injury
Burns are coagulative lesions involving surface layers
of the body. They are usually caused by thermal agents
but can also result from chemical agents, radiation, and
electrical injury when electrical energy is transferred to
thermal energy.
The skin is the largest organ of the human body and
consists primarily of two layers, the epidermis and the
dermis. The superficial cells of the epidermis are cells that
arise from deeper germinal layers of keratinocytes. The
underlying dermis consists of fibrous connective tissue,
blood vessels, ataneous nerves, and the epithelial
appendages (sweat glands and hair follicles). The epithelial
cells that line these appendages can serve to repopulate lost
epithelium when the entire epithelial layer is involved in a
burn injury (3).
Clinically, burns are classified based on depth and
extent of tissue damage (4). Burn depth classifications
include superficial, partial thickness, and full thickness
(Table 94-1). Superficial (or first-degree) burns, such as a
sunburn, are painful. This type of burn is limited to the
epidermis and heals spontaneously without scarring.
Partial-thickness burns include the entire epidermis and
variable portions of the dermis. They can be superficial or
deep. Superficial partial-thickness burns are usually more
painful but can heal spontaneously from the epidermal
1761
 Table 94-1: Type of Burn Wounds
DEGREE TYPE LAYER OF INVOLVEMENT APPEARANCE HEALING
First Superficial Epidermis Red Spontaneous <>1 wk
Blanches with pressure
Sensitive to air, light, touch
Second Partial-thickness Epidermis and upper layer Red or pink skin color Spontaneous 5–21 days
superficial of dermis Blistered or mottled
Blanches well
Sensitive to touch
Second Deep Destroys epidermis and Soft elastic texture Occurs from dermal
deeper dermal structures Eschar appendages
Wavy white to red color May require grafting:
Sensitive to pressure, not if wounds are not
to pinprick healed within 21 days
Large thick blisters —potental for scarring
Third Full thickness Epidermis and entire dermis White, tan, black charred Slowly from wound edges
Subcutaneous tissue No blanching <>10–35 days
Dry texture Requires grafting
Leathery, thrombosed
blood vessels visible
Wound is anesthetic—nerve
endings destroyed
Fourth Bone All epidermis Black Requires grafting or
All dermis Necrotic amputation
Subcutaneous fat May need a muscle flap
Bone for coverage

Figure 94-1. Full-thickness burns sustained

from a flame injury. Eschar is
white/brown and leather-like
in appearance.

appendages anchored deep in the dermis. With deep
partial-thickness injury, spontaneous healing is slow, as
fewer epidermal cells remain and more scarring may
occur. A full-thickness burn destroys both the epidermis
and dermis; therefore, healing can only occur from the
wound edges (Fig. 94-1). Skin grafting is needed to close
the wound (3). Surgical intervention may be required for
either a deep partial-thickness wound or full-thickness
wound.
An inhalation injury is a chemical burn to the
airways and can result in mucosal irritation, airway inflam-
mation, interstitial edema, or in most severe injuries,
mucosal necrosis and sloughing. Increased secretions can
lead to distal airway obstruction, atelectasis, and broncho-
pneumonia. Ciliary function is impaired and risk for infec-
tion, such as tracheobronchitis, is high. Bronchospasms
and bronchial edema can lead to hypoventilation. Cough-
ing, pulmonary toilet, secretion management, bronchodila-

1762 Part V Medical Rehabilitation for Diagnostic Groups

tor therapy, ventilator assistance, and infection surveillance
are crucial during the initial postinjury phase. Risk for
infection can last for several weeks (5).
WOUND CARE
Wounds can be treated with an “open” or “closed” tech-
nique. An open technique is sometimes used for a small
superficial burn, where serum dries to form a scab and
serves as an adherent protective dressing. This treatment
can be uncomfortable and unsightly (5).
Closed methods for wound care consist primarily of
using 1) topical antimicrobial agents and dressings, 2) bio-
logic dressings, and 3) synthetic dressings (Tables 94-2 and
94-3). Topical antimicrobial agents include silver nitrate,
silver sulfadiazine, mafenide acetate (Sulfamylon),
mupiricin (Bactroban), bacitracin, gentamicin sulfate
(Garamycin) ointment, and Neosporin. One of the most
common agents utilized is silver sulfadiazine (Silvadene),
which provides broad antimicrobial coverage and assists in
bringing eschar to the surface where it can be débrided.
Once the eschar is débrided, the wound can then be
covered with Xeroform, which assists in drying the tissue
and promotes healing. The involved area can be wrapped
in Kerlix or gauze dressing as needed. Fungal infections,
which can occur, may respond to an equal-part mixture of
nystatin, hydrocortisone, and mupiricin. With each dressing
change, the old topical agent must be removed and the
wound cleansed before reapplication. This method affords
the opportunity for close surveillance of the wounds. The
antimicrobial action lasts from 8 to 12 hours and the fre-
quency of dressing changes will vary among institutions.
Biologic dressings consist of viable or frozen skin
allografts and xenograft (pigskin). These can be used as a
Table 94-2: Antimicrobial Agents
DRESSING ADVANTAGES
Silver nitrate (solution) Excellent antibacterial spectrum
No allergic reactions, no pain
Sliver sulfadiazine Broad antibacterial spectrum
cream (Silvadene Minimal sensitivity, allergic reaction
SSD) Eschar will dry after discontinuation
Gram negative
Mafenide Penetrates eschar well
acetate (Sulfamylon) Excellent gram-negative coverage
Good antimicrobial action
Nitrofurazone Dries wound well
Good antibacterial spectrum
Mupiricin (Bactroban) Effective against gram-positive organisms,
especially streptococcus and
staphylococcus
Chapter 94 Burn Rehabilitation
temporary skin covering until use of autografts is indi-
cated. They are effective in promoting wound healing in
all partial-thickness wounds. Biologic dressings may be
used to test the readiness of a wound for autografting. Fur-
thermore, these dressings reduce fluid and electrolyte
losses, promote healing under grafted areas, minimize
pain, and maintain sterile conditions (6).
Synthetic dressings include Opsite (semipermeable
polyurethane film), Duoderm, Comfeel (hydrocolloid dress-
ing), Elasto-gel (hydrogel dressing), and Biobrane (7,8). Bio-
brane is composed of knitted elastic nylon bonded to a
Silastic semipermeable membrane coated with collagen
polypeptides (Fig. 94-2). It will adhere to a viable wound
surface, reduce fluid loss, and provide a wound vapor
barrier. This minimizes fluid accumulation under the dress-
ing while preventing the passage of bacteria from the envi-
ronment to the wound surface. In selected wounds, this
treatment may have some advantage over traditional
antimicrobial dressings. Biobrane is usually placed on a
wound under sterile conditions while using an anesthetic.
Wound infections can impede healing, delay wound
closure, and cause skin graft loss. Pseudomonas species,
Staphylococcus aureus, Escherichia species, Proteus mirabilis, and
Streptococcus faecalis are the most common agents causing
wound infections. Bacterial contamination leads to an
increased inflammatory response and local release of
cytokines and proteases, and can lead to local tissue
damage. Local infection alters systemic metabolic activity
and nutritional intake and can alter healing (7). Both local
and systemic defenses against infection are impaired after a
major burn. Sepsis is a leading cause of morbidity and
mortality during the postburn period, owing to the loss of
the skin barrier to microbial invasion, the decreased
immunosuppressive state, and the presence of invasive
DISADVANTAGES
Ineffective treating established infections
Causes staining or bleaching of chloride ions
Messy, poor penetration
Delays spontaneous separation of eschar, thus
delaying wound closing
Reported transient leukopenia
Ineffective against establishment of wound sepsis
Does not penetrate eschar well
May cause pain (stinging) 10% allergic rate
Inhibits carbonic anhydrase results in metabolic
acidosis
May cause rash
No effect on gram-negative bacteria
1763
 Table 94-3: Topical Dressings
AGENT ADVANTAGES
BioBrane Transparent
Inexpensive
Available in variety of
sizes
Adheres to wound
Barrier to pathogenic
organisms
OP-SITE Inexpensive
Transparent
Cadaver (graft) Lower infection rates
Temporary dressing
Xenograft Lower infection rates
Closely resembles human
skin
Temporary dressing
Duoderm Barrier to pathogenic
bacteria
Higher absorption rate
Infrequent dressing changes
Xeroform Direct application to
wound surface
Sterile prepackaged
Dries wound
Adaptic Can be combined with
topical agents
Will not stick to wound
Sterile prepackaged
Scarlet red Applied directly to wound
Sterile prepackaged
Helps promote epithelial
cell growth
N-TERFACE Can be combined with
Conformant 2 topical agent
Will not stick to wound
Allows wound to be observed
Vaseline gauze Applied directly to wound
Will not stick to wound
catheters. The most common sites of infection are the
lungs, the burn wound, and vascular catheters (5). Cell-
mediated immunity is impaired, as is macrocyte and
phagocyte function. Complement, required for chemotaxis
and phagocytosis, is depleted after a large burn. Central
lines, endotracheal tubes, and urinary catheters all serve as
sites for colonization and possible infection (5).
Systemic antibiotics should be used as indicated.
Blood cultures should be obtained on admission and then
as needed. Side effects as well as overall clinical response
need to be monitored closely. It is not unusual for multiple
antimicrobial agents to be used together for broad-
spectrum coverage.
1764 Part V Medical Rehabilitation for Diagnostic Groups
DISADVANTAGES PROPERTIES
Wound must be débrided and Semipermeable
cleaned in sterile environment Silcone membrane
Performed in operating room Bonded to nylon
Fabric coated with collagen
Not permeable Semipermeable polyurethane
Depends on location film
Needs good 1-inch border
Availability Human skin
Rejection
Expensive
Fragile
Surgical procedure
Rejection of tissue Pig skin
Fragile
Not readily available
Lower success with larger burns Hydroactive occlusive
dressing
Unable to view progress of Water resistant
wound Skin contact, adhesive inner
layer
Minimal antibacterial effect Fine-mesh absorbent gauze
when used alone impregnated with 3%
bismuth tribromophenate
in nonmedicinal
petrolatum blend
No antibacterial effects when Meshed open-knitted fabric
used alone made of cellular-acetate-
rayon, petroleum based
Messy, stains Fine-mesh absorbent gauze
Patient sensitive to azo dyes impregnated with 5%
scarlet red in nonmedicinal
No antibacterial effects blend of lanolin, olive oil,
and petrolatum
No antibacterial effects when Perforated high-density
used alone polyethylene sheeting
Nonadherent
No antibacterial effect Petroleum based
NUTRITION
Nutritional support can affect the outcome of a burn-
injured patient. Providing the nutritional requirements of
these patients is often difficult. The metabolic response to
thermal injury can be greater than that seen with serious
sepsis (9). Nutritional support is ideally managed by the
enteral route. Parenteral or central nutrition may be neces-
sary in the patient with a burn exceeding 50% of TBSA.
Increased metabolic activity usually peaks between the
seventh and tenth postburn days, and caloric requirements
should be completely met by this time. The magnitude of
increase is directly related to burn size and depth.

However, young patients appear to generate a higher post-
burn metabolic rate than elderly patients (3). Continuous
monitoring is needed to promote wound healing through
the acute and rehabilitative phase.
GRAFTING
The goal of burn wound care is to permanently close the
wound. For full-thickness burns, autografts provide ulti-
mate wound closure. Allografts, xenografts, and artificial
skin substitutes are temporary dressings used until they can
be replaced by autografts. Mechanical dermatomes are
used to harvest skin from the donor site and skin meshers
are used to expand the size of the autograft and allow for
coverage of wider areas (10). The skin at a donor site has a
Chapter 94 Burn Rehabilitation
Figure 94-2. Biobrane utilized for pain
control in a Stevens-Johnson
syndrome patient.
Figure 94-3. An example of cultured
epithelial autografting. The
epithelial cells are placed on
a petroleum jelly gauze that
resembles a “patch”-like
configuration.
definite thickness, and is thinner in the very young and
elderly. Each time a graft is harvested from a donor site,
the skin becomes thinner or is replaced by scar tissue (11).
With large burns, donor sites are limited; therefore, cul-
tured epithelial autografting (CEA) may be employed (Fig.
94-3). With this technique, a skin fragment no larger than
a postage stamp can be grown to a square meter in the
course of a few weeks. This in vitro process is commer-
cially available but costly, and time is needed to grow the
grafts. Because only epithelial cells are utilized, CEA is
fragile and nonadherence may occur (12). Periods of
immobilization and bed rest may be significantly longer as
compared to split-thickness grafting, leading to longer
periods of rehabilitation. Despite its disadvantages, survival
rates have increased and cosmetic outcomes are improved.
A new development in wound management has been the
1765
creation of Integra artificial skin, which received Food and
Drug Administration (FDA) approval in March 1996.
Integra is a biologic, bilayer skin replacement system. The
dermal layer is composed of fibers of bovine tendon colla-
gen and glycosaminoglycan and serves as a template for
fibroblasts and capillaries from the uninvolved dermis. As
healing occurs, a neodermis is formed as new collagen
replaces the bovine collagen. The temporary epidermal
layer is composed of silicone and functions to control
moisture loss from the wound. After 14 to 21 days, ade-
quate vascularization of the dermal layer has occurred.
The silicone layer is removed and a thin, meshed layer of
epidermal autograft is placed over the neodermis. The
advantage is immediate physiologic wound closure until
donor skin is available, thus decreasing pain and the risk of
infection. The epidermal autografts used also allow for
thinner, quicker-healing donor sites and improved cosmetic
and functional outcome (13).
ROLE OF REHABILITATION IN BURN CARE
Rehabilitation of a burned patient is a process that begins
on arrival to the burn treatment center, continues through-
out the hospital course, and often continues for years fol-
lowing injury. A team approach ensures a comprehensive
and holistic perspective for each individual who is faced
with this significant impairment. Team members can
include general and plastic surgeons, pulmonary and criti-
cal care specialists, physiatrists, psychologists, nurses, social
workers, occupational therapists, physical therapists, speech
therapists, dietitians, orthotists, dysphagia services, voca-
tional counselors, and aesthetic therapists. Rehabilitation
professionals are an integral part of the acute phase in
burn care and serve to complement other members of the
team who provide critical care and surgical intervention.
Survival among burn patients has improved dramatically,
but equally important is for rehabilitation efforts to trans-
late into returning survivors to the highest functional level
and quality of life.
Rehabilitation should be viewed on a continuum
with short- and long-term goals being established (Table
94-4). The ultimate goal is to heal the wound while main-
taining and restoring maximal function. Acutely, life-threat-
ening problems may hamper rehabilitation at times. In the
setting of medical instability, restorative intervention may
be passive in nature, with the patient becoming more
active in the rehabilitative program as the condition
permits.
Occupational and physical therapists may be
involved in all stages of patient care and rehabilitation.
Therapists begin their assessment of a patient during the
acute phase of injury in conjunction with medical manage-
ment. Patient evaluation begins with observation of the
extent and location of the wound as well as its effects on
joint range of motion (ROM), mobility, and activities of
daily living (ADLs). In the case of electrical injury, muscle
1766 Part V Medical Rehabilitation for Diagnostic Groups
Table 94-4: Common Short- and
Long-Term Goals
Short-term goals
Control pain
Prevent contractures, deformity
Preserve joint mobility
Preserve strength, coordination, endurance
Promote ADL participation
Promote wound healing
Minimize edema
Patient and family education
Long-term goals
Minimize burn scar formation
Increase strength, coordination, endurance
Increase independence with ADLs
Compensate for physical impairment
Adjustment to disability
Reintegration into society
Education regarding skin care and scar management
ADL = activity of daily living.
strength and sensation are assessed. A treatment plan is
developed based on a comprehensive evaluation with
ongoing assessment and modification.
Therapeutic exercise is a vital part of the burn
patient’s care because contractures and resultant loss of
function can occur rapidly. Burn wound depth and loca-
tion are determinants of the type and intensity of exercise.
Deep partial- and full-thickness wounds have a higher inci-
dence of decreased joint motion and scar contracture (Fig.
94-4). Therefore, the therapist must prioritize specific areas
to exercise.
During the acute phase, ROM exercises are initiated
with the goal of minimizing edema to ensure functional
ROM. ROM may be passive, active-assisted, or active,
depending on a patient’s medical status (pain medications,
affect, associated trauma) or wound status (thick eschar,
tendon exposure). Although exercise will vary with patient
status, there are circumstances that must be given special
consideration. The clinical guidelines for starting ROM
after excision and grafting vary among institutions (Table
94-5). Other conditions that may modify treatment include
tendon, bone, or joint exposure; preexisting joint disease;
periarticular calcification; deep venous thrombosis; and
associated trauma.
Passive ROM (PROM) exercises are performed when
the patient is unable to actively participate in the program.
Guidelines to performing PROM exercises depend on a
patient’s physiologic status, placement of intravenous lines,
eschar tightening or tearing, associated orthopedic or neu-
rologic trauma, or preexisting joint conditions. Active
ROM exercises are encouraged to ensure patient participa-
tion and assisted ROM exercises are especially effective in
a multijoint stretch where the goal is to elongate the scar
tissue over adjacent joints.
 Figure 94-4. Circumferential full-thickness
burns of both lower
extremities, with the potential
for decreased range of motion
due to the location of the
burns, crossing both knee
joints.

promote independence. Functional exercises and ADLs

Table 94-5: Clinical Guidelines for should begin in the early phase of recovery as the patient’s
Starting Range of medical and surgical status allows. Treatment may include
Motion (ROM) self-care activities such as feeding and personal hygiene. If
Exercise possible, therapists should avoid the use of adaptive equip-
ment for ADLs. It is better to increase the patient’s joint
PROCEDURES CLINICAL GUIDELINES motion through functional activities and prevent reliance
Autografting Postop day 4—active ROM. on such devices.
Postop day 5—active-assisted Therapeutic intervention involves a balance between
ROM. mobility and exercise versus positioning and splinting.
Postop day 6—passive ROM. Splints are used for a variety of purposes, including pre-
Use of biobrane Initiate ROM 24–48 hr after
application.
vention of joint contracture and dysfunctional posturing,
Aggressiveness depends on protection of an anatomic instability, postoperative immo-
appearance. bilization, and scar control. If splints are used as position-
Allografting Same as for autografting. ing devices to prevent or minimize contractures, it is
Cultured epithelial Initiate active ROM after take important that the splints be taken off multiple times per
autografting down, which is 7–10 days
after grafting.
day for ROM exercises.
Aggressiveness depends on In the rehabilitative phase, the goals of therapy focus
appearance. on preventing or minimizing joint contractures, controlling
scars, and promoting return to functional independence.
ROM exercises continue, especially for those areas predis-
ROM exercises can be implemented during a dress- posed to joint contractures. The use of reciprocal pulleys
ing change, giving the therapist the opportunity to continu- for upper-extremity stretching and prolonged positioning
ally assess the wound and make appropriate modifications stretches over wedges and bolsters for the trunk and neck
to the program. Additional exercise sessions can occur at have been advocated. Therapeutic balls, foam bolsters, and
the bedside or in the clinic. A continuous passive motion wedges are useful in encouraging active motion. Given the
(CPM) machine is often used to complement ROM exer- physiology of scars and the development of additional soft-
cises. Conditioning, coordination, and strengthening activi- tissue tightness, therapeutic exercise in any form should be
ties are also included in the rehabilitation program. Joint performed daily to four times a day.
mobilization may also be part of a rehabilitation program, Therapeutic exercises and functional activities are
especially in the patient with prolonged immobility and initiated during the acute phase and continued into the
soft-tissue contractures. rehabilitative phase, which may extend for months after
While ROM exercises are vital to maintaining joint discharge from a burn or rehabilitation center. Outpatient
motion, functional exercises should be emphasized to treatment continues to focus on scar management, stretch-
decrease progressive dependency, increase self-esteem, and ing, conditioning, and strengthening. Therapeutic exercise

Chapter 94 Burn Rehabilitation 1767

following surgical scar release is also essential and in most
patients extends years after the burn occurred.
HAND BURNS
One of the most commonly involved and structurally vul-
nerable parts of the body in a burn injury is the hand (Fig.
94-5). Because of the natural human tendency to protect
the face, dorsal hand burns are more common than
palmar burns. In particular, the dorsum of the hand is at
risk, owing to the superficial location of the extensor
tendons and the minimal layers of subcutaneous fascia.
Without early intervention, permanent damage to the
hand can occur. Traumatic shedding of the extensor hood,
ischemic changes secondary to edema, and increased
tension at the proximal interphalangeal (PIP) joints are all
too frequently present. In particular, with a burn trauma to
the hands, the central slip and the lateral bands are jeopar-
dized. In normal function, the lateral bands lie volar to the
axis of flexion at the metaphalangeal (MP) joint and dorsal
to the axis of flexion at the PIP joint. When injury occurs,
the central slip is often disrupted, allowing the lateral
bands to slip volarly, becoming flexors at the PIP joint and
forcing the distal interphalangeal (DIP) joint into hyperex-
tension. This is known as a boutonnière deformity. This and
other deformities can be prevented by splinting, ROM,
exercises and stretching, and proper positioning (14).
As with splinting in general, the hand should be
splinted in a position opposite the expected deformity. The
burn resting hand splint is one of the most common tools
used to protect the hands. This splint varies slightly from
other resting splints as it places the wrist in approximately
30 degrees of extension, the MP joints at approximately 70
degrees of flexion, the interphalangeal (IP) joints in full
extension, and the thumb in opposition and maintains a
Figure 94-5. Partial degloving of the left
hand to reveal a full-thickness
burn injury.
1768 Part V Medical Rehabilitation for Diagnostic Groups
good palmar arch (15). Straps are contraindicated for the
acute stage of injury, for they may interfere with circula-
tion and cause an increase in edema or edema “pocketing”
(14). Instead, Ace wraps are used to secure most splints,
wrapping in a distal to proximal manner. If the burn
requires a skin graft, a modified hand splint is used during
the operative procedure to position and immobilize the
hand, allowing for optimum stretch and graft take (Fig. 94-
6). These modifications include slits between the fingers,
holes at the distal tip of each finger, notches around the
side, and a “roll bar” attached to the thenar area of the
splint. The digits are sutured, by a surgeon, into the holes
at the top of the splint, while the slits allow for adequate
drainage and the roll bar provides extra protection against
damage to the graft. Other splints that are frequently indi-
cated for the burned hand include, but are not limited to
the following:
1. The gutter splint, which maintains or increases
extension of one particular digit
2. The saddle splint, which prevents contracture of the
thumb-index web space
3. The wrist cock-up splint to provide wrist extension,
which aids in hand function
Splint requirements will change as the patient’s
medical status and functional needs change. Therefore, it is
important to monitor a patient’s splint on a daily basis to
assess fit, reassess splinting needs, and check for pressure
areas.
ROM exercises, another important aspect of burn
therapy, are necessary not only to prevent skin contrac-
tures, but also to prevent joint stiffness and tendon adhe-
sions. Active ROM exercises are always preferable, as they
maintain muscle mass and strength. However, since this is
not always feasible, PROM exercises may be performed.
ROM exercises with burned joints need to be frequent and

aggressive but special attention must be paid to the delicate
structures of the hand. With a full-thickness burn to the
dorsum of the hand, a multijoint stretch is contraindicated.
To maintain mobility while preserving tendon integrity, a
modified flexion technique is performed. This involves
achieving MP flexion with IP extension and then IP flexion
with the MP joints extended. Patients should make a full
fist only if the therapist is positive of the tendon status or if
the wound has healed or been grafted. PROM is best com-
pleted while the patient’s dressings are off. If possible, it is
important to have the patient participate in active exercises
and functional activities. This can be done in a gym or at
the patient’s bedside. Without daily exercise, muscle
atrophy, tendon adherence, capsular shortening, and
edema can be ongoing problems.
Proper positioning of the burned hand is essential
for minimizing edema. When the body is subjected to
thermal trauma, there is an immediate and rapid increase
in capillary permeability. As a result, massive fluid accumu-
lates in the area of trauma. This fluid can be very destruc-
tive to the fragile structures of the hand. One of the most
common problems seen in the hand secondary to edema is
the claw hand deformity. The result is that the MP joints
are pulled into hyperextension; the IP joints, into flexion;
and the thumb, into adduction (14). Elevation of the
burned extremity and splinting will assist with the decrease
of edema.
It must also be remembered that the hand functions
as part of the upper extremity. Full hand motion is almost
useless if significant contractures of the elbow or axilla
prevent the patient from positioning the hand so that this
motion can be utilized (16).
PAIN
Pain in burn patients must be managed carefully but
aggressively. The patient’s level of pain should not be
Chapter 94 Burn Rehabilitation
Figure 94-6. An example of a sheet graft
placed on the dorsal aspect of
a left hand. The fingertips are
sutured and secured to the
splint. The splint helps to
maintain a functional posi-
tion and keeps the hand
immobilized to facilitate graft
take.
underestimated. There is great variability in individual
pain thresholds. Patients with “minor” surface area burns
may report significant pain, while conversely a patient with
a “major” surface area burn may have only minimal
complaints.
Pain can occur with activity or at rest. Various
approaches are used to measure pain. The most applicable
to the burn patient appears to be the horizontal Visual
Analog Scale (VAS) or the Verbal Descriptive Scale (VDS).
In the pediatric population, the VAS and Pain Thermome-
ters or the Procedural Behavior Checklist are useful.
However, more research is indicated in this area.
Pain medications include opioids (morphine, meperi-
dine, fentanyl, sufentanil), anti-inflammatories (ibuprofen,
etc), local or general anesthetics (midazolam, nitrous oxide,
lidocaine), and benzodiazepines (lorazepam). Each of these
medications must be administered cautiously and the
patient closely monitored for desired outcome and side
effects. The response to opioids in particular can be signifi-
cantly altered for months after burn injury. Administration
of other medications, prior medical conditions, fluid
volume status, and parenteral nutrition can affect the phar-
macokinetics of drugs.
The route of medication delivery may include intra-
venous injections, patient-controlled epidural perfusion
(PCA), oral route, or less preferable, intramuscular injec-
tions. Some patients will require opioids as well as behav-
ioral modification, psychological supportive counseling,
relaxation therapies, and in extreme cases, hypnosis.
Particularly with the pediatric population, the magni-
tude of pain must not be underestimated. Opiates, seda-
tives, behavioral modification, and even PCA have been
used successfully with this population.
Aggressive pain management can lead to improved
participation in burn rehabilitation as well as improved
overall patient care. The most effective plan of care is tai-
lored to the individual patient’s needs.
1769
COMPLICATIONS
Burn injuries can lead to significant compromise of the
neurovascular system (Fig. 94-7). There are a number of
neurologic complications seen after a burn injury. One
such complication, burn encephalopathy, is a poorly
defined clinical entity that may occur more frequently in
children. Seen in about 30% of patients, it may be trig-
gered by systemic factors, including fever. Peripheral neu-
ropathies are seen more with burns of increased severity.
They are commonly due to direct thermal, chemical, or
electrical injury or secondary to treatment regimens (i.e.,
neurotoxic drugs, tight bandages, faulty positioning, or
improper splinting). Mononeuritis multiplex is seen most
frequently. Axonopathy of the critically ill is not uncom-
mon. Burn injuries can be overwhelming and a prolonged
recovery period can lead to generalized neural collapse.
These patients may require mechanical ventilation, posi-
tioning, splinting, and a medical regimen.
Compartment syndrome can quickly develop
as edema increases and compartment pressures rise. Eschar
can contribute to the development of compartment syn-
drome because it lacks the compliance needed to
accommodate a massive fluid shift. Compartment pressures
may be monitored and decompressive surgery such as
an escharotomy or fasciotomy of the involved area can be
employed to reduce pressure and salvage tissue (Fig. 94-8).

Figure 94-7. An exit site of a high-voltage

electrical injury. An
amputation was indicated
secondary to neurovascular
compromise.

Figure 94-8. A fasciotomy allows deep

tissues to expand, to prevent
increased compartment
pressures.

1770 Part V Medical Rehabilitation for Diagnostic Groups

 Heterotopic ossification is commonly found in burn
patients who sustained deep burn wounds and have been
immobile, particularly following grafting procedures over a
joint. Diligent ROM exercises within surgical guidelines
are optimal to reduce the risk of heterotopic ossification.
Even with proper treatment, heterotopic ossification may
still occur. Treatment for heterotopic ossification fluctuates
from institution to institution.
HYPERTROPHIC SCARRING
The scarring process can limit ROM, cause contractures,
and severely limit function. Most ongoing rehabilitation
difficulties are secondary to the strong contractile proper-
ties of immature scars (17). Full scar maturation may take
up to 12 to 18 months (18), with the most active scarring
period being 4 to 6 months after injury (17). Early and
aggressive treatment of the scars, via use of pressure,
stretching, splinting, and positioning, is essential for good
functional outcomes.
A healed wound is characterized by increased vascu-
larity and an increased number of fibroblasts. Fibroblasts
then synthesize excessive collagen, which redevelops in
irregular shapes and whorl-like masses at four times the
rate of normal skin (19). Early scar is readily influenced by
external forces because cross-linking collagen bonds are
weak and fewer in number in the early stages. Therefore,
these bonds are likely to align themselves in a more orga-
nized parallel format. Pressure may also control collagen
synthesis by producing ischemia in the scar (17) and
decreasing wound vascularity.
The severity of scarring is affected by wound depth
and the time needed for wound closure. If a wound
requires skin grafting or takes longer than 14 days to heal,
pressure therapy will be indicated (Fig. 94-9). Other factors
Chapter 94 Burn Rehabilitation
influencing the severity of scarring include age, race,
genetic disposition, anatomic location of the burn, and the
type of grafting performed. Pediatric patients and patients
with very fair or dark skin tend to be at higher risk for
increased scarring. Burns of the hand, head, and axilla
also tend to be more vulnerable to increased scar forma-
tion. Grafts placed on granulation tissue also tend to scar
more than tangentially excised wounds (17).
Early pressure can be provided via Ace wrapping,
tubular support bandages, interim garments, and prefabri-
cated pressure gloves. These can be tolerated as early as 7
to 10 days after grafting or when open areas are no larger
than the size of a dime (19). These methods of pressure
are used while body weight and edema stabilize prior to
having the patient measured for custom-fit pressure gar-
ments. Custom garments are made of a Dacron/spandex
elastic fabric and provide capillary level pressures of at
least 25 mm Hg (17). The wearing time may need to be
increased gradually to 23 out of 24 hours per day, and the
garments may need to be worn until full scar maturation
has occurred. Proper fit is essential so the fit must be peri-
odically examined and alterations or entire new garments
may be needed.
The sustained use of capillary level pressure on the
growing bones and tissues of small children has been con-
troversial. However, it is now believed that if the fit is
monitored closely to allow for growth, garment use is
acceptable, with the exception of the head.
To maintain uniform pressure in concave areas of
the body, inserts such as elastomer putty, Silastic elastomer
with prosthetic foam, Plastizote, or thermoplastic conform-
ers may be used. Silicone gel sheeting is another option for
the treatment of hypertrophic or keloid scars. Although
effective, the mechanism is not fully understood. The gel
may promote hydration and the degree of occlusion may
Figure 94-9. Scarring occurs along the
margins of a meshed graft
and between interstitial sites.
This graft is ready for the
initiation of pressure
garments to help improve the
cosmetic outcome.
1771
Figure 94-10. Exit site from a high-voltage
electrical injury requiring
bilateral transmetatarsal
amputations.
also play a role (20). Silicone gel sheets may only be used
on completely healed skin surfaces, as internal absorption
remains controversial.
Proper pressure therapy can lead to favorable func-
tional and cosmetic gains. Patient compliance is essential;
otherwise, surgical intervention may be needed (Fig. 94-10).
COSMESIS
Following scar maturation, changes in the texture and
color of the skin may still be present. The visible scarring
may alter a patient’s self-esteem. To minimize discoloration
and disfigurement, cosmetics that camouflage these areas
were developed. Paramedical camouflage is a process by
which the appearance of scar or skin pigment alterations is
normalized. This is achieved through the application of
proper shades and placement of cosmetics. The makeup is
specific for each individual. The patient is instructed in the
proper use of these cosmetics so the desired effect can be
achieved. Creams utilized usually contain a sunscreen and
are waterproof.
DISABILITY
The evaluation of disability is an appraisal of the patient’s
present and future ability to engage in gainful activity as it
is affected by factors such as age, sex, education, econom-
ics, and social relationships. These diverse and subjective
factors are difficult to measure (7). For this reason, perma-
nent impairment is the major criterion used in arriving at
a permanent disability determination. Unlike disability,
permanent impairment can be measured with a reasonable
degree of accuracy and uniformity (21).
The American Medical Association’s Guides to the
Evaluation of Permanent Impairment is a widely accepted aid
1772 Part V Medical Rehabilitation for Diagnostic Groups
and provides a standard framework and method of analy-
sis through which physicians can evaluate, report on, and
communicate information about the impairments of any
human organ system. Many state workers’ compensation
agencies mandate or recommend use of the Guides. Even
though rating or estimating impairment cannot be totally
objective, use of the Guides increases objectivity and
enables physicians to report impairment in a standardized
manner, so that reports from different observers are more
likely to be comparable in content and completeness (22).
The effects of a burn injury on the skin and its
appendages are combined with the estimated impairment
percentages of other body systems, including the muscu-
loskeletal system, the nervous system, the respiratory
system, the ears, the nose, the throat, and related struc-
tures. Additionally mental and behavioral disorders are dis-
cussed in the Guides.
PSYCHOLOGICAL ISSUES
Although the costs of burn treatment are tremendous in
terms of health care dollars, time, effort, pain, suffering,
and mental anguish to patients and families, it is rewarding
if the patient emerges from this ordeal as a functioning
member of society with self-respect and dignity intact.
Certainly, some patients do emerge intact, and some
resume their lives in a more productive and gratifying
manner than before the injury. However, many patients,
despite the best burn treatment, develop psychological
complications that hinder their recovery. Healing on the
outside may not always reflect healing on the inside.
Anxiety, denial, depression, grief, and mourning may
be experienced. Depression may be transient and show
improvement with the healing process or may intensify
with time as the patient realizes what has been lost.
 Many burn injuries are due to premorbid psychologi-
cal problems. This includes a possible history of alcohol or
drug abuse, violence, or fire starting. Depression, alcohol or
drug abuse, and organic brain syndrome can be accompa-
nied by poor concentration, impaired judgment, and slow
motor response, all of which contribute to a high risk of
burn trauma.
Symptoms of posttraumatic stress are expected in
the postburn period. However, if they exacerbate, reinte-
gration into society may be hindered.
Patients need to recover physically and psychologi-
cally after burn injury. All members of the team need to
be aware of how these problems can impact on the
patient’s ultimate functional outcome. Emotional support is
necessary, and patients may require additional assistance
from mental health professionals.
FUTURE TRENDS
The changing health care milieu will affect burn care of
the future. When feasible, outpatient management of burn
injuries will replace more expensive inpatient services.
Future trends also include new wound care technologies
such as developments in artificial skin. A deeper under-
standing of new technology is required to keep pace with
the frequent changes in burn care delivery.

REFERENCES
1. Brigham P, McLaughlin E. Burn azine. Ann Emerg Med 1990;19: Advanced Magazine for Occupa-
incidence and medical care use in 121–124. tional Therapists May 22, 1995.
the U.S.: estimates, trends and
data sources. J Burn Care Rehabil 9. Lown D. Use and efficacy of nutri- 16. Robson MC, Smith DJ Jr, Van-
1996;17:95–105. tional protocol for patients with derZee AJ, Roberts L. Making the
burns in intensive care. J Burn burned hand functional. Clin Plast
2. Sabistan D, ed. Textbook of Care Rehabil 1991;12: Surg 1992;19:663–671.
surgery. Philadelphia: WB 3371–3376.
Saunders, 1991:178. 17. Ward RS. Pressure therapy for the
10. Constable JD. The state of burn control of hypertrophic scar forma-
3. Greenfield LJ. Surgery—scientific care past, present and future. tion after burn injury: a history
principles and practice. Philadel- Burns 1994;20:316–324. and review. J Burn Care Rehabil
phia: JB Lippincott-Raven, 1997. 1991;12:257–262.
11. Heimbach DM. A non-user’s ques-
4. Clark JA. Color atlas of burn tions about cultured epidermal 18. Trombly CA, ed. OT for physical
injuries. New York: Chapman & autograft. J Burn Care Rehabil dysfunction. 2nd ed. Baltimore:
Hall Medical, 1992. 1992;13:127–129. Williams & Wilkins, 1983.

5. Demling R, LaLonde C. Burn
trauma. New York: Thieme
Medical, 1989.
6. Fitzpatrick T, et al. Dermatology in
general medicine. Vol. I. New York:
McGraw-Hill, 1993.
7. Richard R, Staley M. Burn care &
rehabilitation—Principles and
practice. Philadelphia: FA Davis,
1994.
8. Gerding RL, Emerman CL, Effron
D, et al. Outpatient management
of partial-thickness burns: Bio-
brane versus 1% silver sulfadi-
12. Cultured autologous keratinocytes
suspended in fibrin glue to cover
burn wounds. In: Plastic surgery
nerve repair burns. Stark, et al.
New York: 1995:143.
13. Medical economics of Integra arti-
ficial skin. Plainsboro, NJ: Integra
Life Sciences, 1996.
14. Malick and Carr. Manual on man-
agement of the burn patient Pitts-
burgh: Harmarville Rehab Center,
1982.
15. Androwick, Goldblum, et al. “OT
intervention for people with burns.
19. Willard & Spackman’s OT. 5th ed.
Philadelphia: JB Lippincott,
1978.
20. Cica Care pamphlet. Smith &
Nephew Rolyan, 1994.
21. Fisher S, Helm P. Comprehensive
rehabilitation of burns. Baltimore:
Williams & Wilkins, 1984.
22. Doege TC, ed. Guides to the
evaluation of permanent
impairment. 4th ed. Chicago:
American Medical Association,
1993.

Chapter 94 Burn Rehabilitation 1773