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Chapter 94
Burn Rehabilitation

Lucretia Fitzpatrick
Patrick Murphy
Jill Androwick
Deborah Goldblum
Patricia Wardius
John Wijtyk

There are approximately 1.25 million burn injuries in the 4. Full-thickness burns greater than 5% of TBSA
United States yearly, accounting for 51,000 acute hospital 5. Significant electrical injury
admissions and 5500 deaths (1). The cause and the risks of 6. Significant chemical injury
burn injury and death are influenced by age, economic cir-
cumstances, and occupation, with the greatest risk being Burns are coagulative lesions involving surface layers
economically disadvantaged. Seventy-five percent of all of the body. They are usually caused by thermal agents
burn-related deaths are due to house fires, with young chil- but can also result from chemical agents, radiation, and
dren and the elderly being most vulnerable. Flame burn is electrical injury when electrical energy is transferred to
the predominant type of injury seen in patients admitted thermal energy.
to burn centers, followed by scalding with hot liquids (2). The skin is the largest organ of the human body and
The majority of burns can be treated on an outpa- consists primarily of two layers, the epidermis and the
tient basis. However, the extent of the burn, or a compli- dermis. The superficial cells of the epidermis are cells that
cating factor such as an associated injury or extreme age or arise from deeper germinal layers of keratinocytes. The
youth, may warrant hospital admission. Inhalation injury, underlying dermis consists of fibrous connective tissue,
concomitant trauma, and significant preexisting medical blood vessels, ataneous nerves, and the epithelial
conditions mandate burn center care for patients with appendages (sweat glands and hair follicles). The epithelial
burns of lesser extent (2). cells that line these appendages can serve to repopulate lost
Major burns are best cared for in a burn treatment epithelium when the entire epithelial layer is involved in a
center where the specialized skills of a multidisciplinary burn injury (3).
staff and burn-specific equipment ensure optimal survival. Clinically, burns are classified based on depth and
Major burns are classified as follows: extent of tissue damage (4). Burn depth classifications
include superficial, partial thickness, and full thickness
1. Greater than 10% of total body surface area
(Table 94-1). Superficial (or first-degree) burns, such as a
(TBSA) at an age younger than 10 years or older
sunburn, are painful. This type of burn is limited to the
than 50 years
epidermis and heals spontaneously without scarring.
2. Greater than 20% of TBSA in patients at an inter- Partial-thickness burns include the entire epidermis and
vening age variable portions of the dermis. They can be superficial or
3. Significant burns of the face, hands, feet, genitalia, deep. Superficial partial-thickness burns are usually more
perineum, or major joints 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 An inhalation injury is a chemical burn to the
partial-thickness injury, spontaneous healing is slow, as airways and can result in mucosal irritation, airway inflam-
fewer epidermal cells remain and more scarring may mation, interstitial edema, or in most severe injuries,
occur. A full-thickness burn destroys both the epidermis mucosal necrosis and sloughing. Increased secretions can
and dermis; therefore, healing can only occur from the lead to distal airway obstruction, atelectasis, and broncho-
wound edges (Fig. 94-1). Skin grafting is needed to close pneumonia. Ciliary function is impaired and risk for infec-
the wound (3). Surgical intervention may be required for tion, such as tracheobronchitis, is high. Bronchospasms
either a deep partial-thickness wound or full-thickness and bronchial edema can lead to hypoventilation. Cough-
wound. ing, pulmonary toilet, secretion management, bronchodila-

1762 Part V Medical Rehabilitation for Diagnostic Groups

tor therapy, ventilator assistance, and infection surveillance temporary skin covering until use of autografts is indi-
are crucial during the initial postinjury phase. Risk for cated. They are effective in promoting wound healing in
infection can last for several weeks (5). 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
WOUND CARE losses, promote healing under grafted areas, minimize
Wounds can be treated with an “open” or “closed” tech- pain, and maintain sterile conditions (6).
nique. An open technique is sometimes used for a small Synthetic dressings include Opsite (semipermeable
superficial burn, where serum dries to form a scab and polyurethane film), Duoderm, Comfeel (hydrocolloid dress-
serves as an adherent protective dressing. This treatment ing), Elasto-gel (hydrogel dressing), and Biobrane (7,8). Bio-
can be uncomfortable and unsightly (5). brane is composed of knitted elastic nylon bonded to a
Closed methods for wound care consist primarily of Silastic semipermeable membrane coated with collagen
using 1) topical antimicrobial agents and dressings, 2) bio- polypeptides (Fig. 94-2). It will adhere to a viable wound
logic dressings, and 3) synthetic dressings (Tables 94-2 and surface, reduce fluid loss, and provide a wound vapor
94-3). Topical antimicrobial agents include silver nitrate, barrier. This minimizes fluid accumulation under the dress-
silver sulfadiazine, mafenide acetate (Sulfamylon), ing while preventing the passage of bacteria from the envi-
mupiricin (Bactroban), bacitracin, gentamicin sulfate ronment to the wound surface. In selected wounds, this
(Garamycin) ointment, and Neosporin. One of the most treatment may have some advantage over traditional
common agents utilized is silver sulfadiazine (Silvadene), antimicrobial dressings. Biobrane is usually placed on a
which provides broad antimicrobial coverage and assists in wound under sterile conditions while using an anesthetic.
bringing eschar to the surface where it can be débrided. Wound infections can impede healing, delay wound
Once the eschar is débrided, the wound can then be closure, and cause skin graft loss. Pseudomonas species,
covered with Xeroform, which assists in drying the tissue Staphylococcus aureus, Escherichia species, Proteus mirabilis, and
and promotes healing. The involved area can be wrapped Streptococcus faecalis are the most common agents causing
in Kerlix or gauze dressing as needed. Fungal infections, wound infections. Bacterial contamination leads to an
which can occur, may respond to an equal-part mixture of increased inflammatory response and local release of
nystatin, hydrocortisone, and mupiricin. With each dressing cytokines and proteases, and can lead to local tissue
change, the old topical agent must be removed and the damage. Local infection alters systemic metabolic activity
wound cleansed before reapplication. This method affords and nutritional intake and can alter healing (7). Both local
the opportunity for close surveillance of the wounds. The and systemic defenses against infection are impaired after a
antimicrobial action lasts from 8 to 12 hours and the fre- major burn. Sepsis is a leading cause of morbidity and
quency of dressing changes will vary among institutions. mortality during the postburn period, owing to the loss of
Biologic dressings consist of viable or frozen skin the skin barrier to microbial invasion, the decreased
allografts and xenograft (pigskin). These can be used as a immunosuppressive state, and the presence of invasive

Table 94-2: Antimicrobial Agents

DRESSING ADVANTAGES DISADVANTAGES
Silver nitrate (solution) Excellent antibacterial spectrum Ineffective treating established infections
No allergic reactions, no pain Causes staining or bleaching of chloride ions
Messy, poor penetration
Sliver sulfadiazine Broad antibacterial spectrum Delays spontaneous separation of eschar, thus
cream (Silvadene Minimal sensitivity, allergic reaction delaying wound closing
SSD) Eschar will dry after discontinuation Reported transient leukopenia
Gram negative Ineffective against establishment of wound sepsis
Does not penetrate eschar well
Mafenide Penetrates eschar well May cause pain (stinging) 10% allergic rate
acetate (Sulfamylon) Excellent gram-negative coverage Inhibits carbonic anhydrase results in metabolic
Good antimicrobial action acidosis
Nitrofurazone Dries wound well May cause rash
Good antibacterial spectrum
Mupiricin (Bactroban) Effective against gram-positive organisms, No effect on gram-negative bacteria
especially streptococcus and
staphylococcus

Chapter 94 Burn Rehabilitation 1763

 Table 94-3: Topical Dressings
AGENT ADVANTAGES DISADVANTAGES PROPERTIES
BioBrane Transparent Wound must be débrided and Semipermeable
Inexpensive cleaned in sterile environment Silcone membrane
Available in variety of Performed in operating room Bonded to nylon
sizes Fabric coated with collagen
Adheres to wound
Barrier to pathogenic
organisms
OP-SITE Inexpensive Not permeable Semipermeable polyurethane
Transparent Depends on location film
Needs good 1-inch border
Cadaver (graft) Lower infection rates Availability Human skin
Temporary dressing Rejection
Expensive
Fragile
Surgical procedure
Xenograft Lower infection rates Rejection of tissue Pig skin
Closely resembles human Fragile
skin Not readily available
Temporary dressing
Duoderm Barrier to pathogenic Lower success with larger burns Hydroactive occlusive
bacteria dressing
Higher absorption rate Unable to view progress of Water resistant
Infrequent dressing changes wound Skin contact, adhesive inner
layer
Xeroform Direct application to Minimal antibacterial effect Fine-mesh absorbent gauze
wound surface when used alone impregnated with 3%
Sterile prepackaged bismuth tribromophenate
Dries wound in nonmedicinal
petrolatum blend
Adaptic Can be combined with No antibacterial effects when Meshed open-knitted fabric
topical agents used alone made of cellular-acetate-
Will not stick to wound rayon, petroleum based
Sterile prepackaged
Scarlet red Applied directly to wound Messy, stains Fine-mesh absorbent gauze
Sterile prepackaged Patient sensitive to azo dyes impregnated with 5%
Helps promote epithelial scarlet red in nonmedicinal
cell growth No antibacterial effects blend of lanolin, olive oil,
and petrolatum
N-TERFACE Can be combined with No antibacterial effects when Perforated high-density
Conformant 2 topical agent used alone polyethylene sheeting
Will not stick to wound Nonadherent
Allows wound to be observed
Vaseline gauze Applied directly to wound No antibacterial effect Petroleum based
Will not stick to wound

catheters. The most common sites of infection are the NUTRITION

lungs, the burn wound, and vascular catheters (5). Cell-
mediated immunity is impaired, as is macrocyte and Nutritional support can affect the outcome of a burn-
phagocyte function. Complement, required for chemotaxis injured patient. Providing the nutritional requirements of
and phagocytosis, is depleted after a large burn. Central these patients is often difficult. The metabolic response to
lines, endotracheal tubes, and urinary catheters all serve as thermal injury can be greater than that seen with serious
sites for colonization and possible infection (5). sepsis (9). Nutritional support is ideally managed by the
Systemic antibiotics should be used as indicated. enteral route. Parenteral or central nutrition may be neces-
Blood cultures should be obtained on admission and then sary in the patient with a burn exceeding 50% of TBSA.
as needed. Side effects as well as overall clinical response Increased metabolic activity usually peaks between the
need to be monitored closely. It is not unusual for multiple seventh and tenth postburn days, and caloric requirements
antimicrobial agents to be used together for broad- should be completely met by this time. The magnitude of
spectrum coverage. increase is directly related to burn size and depth.

1764 Part V Medical Rehabilitation for Diagnostic Groups

 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.

However, young patients appear to generate a higher post- definite thickness, and is thinner in the very young and
burn metabolic rate than elderly patients (3). Continuous elderly. Each time a graft is harvested from a donor site,
monitoring is needed to promote wound healing through the skin becomes thinner or is replaced by scar tissue (11).
the acute and rehabilitative phase. 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
GRAFTING course of a few weeks. This in vitro process is commer-
The goal of burn wound care is to permanently close the cially available but costly, and time is needed to grow the
wound. For full-thickness burns, autografts provide ulti- grafts. Because only epithelial cells are utilized, CEA is
mate wound closure. Allografts, xenografts, and artificial fragile and nonadherence may occur (12). Periods of
skin substitutes are temporary dressings used until they can immobilization and bed rest may be significantly longer as
be replaced by autografts. Mechanical dermatomes are compared to split-thickness grafting, leading to longer
used to harvest skin from the donor site and skin meshers periods of rehabilitation. Despite its disadvantages, survival
are used to expand the size of the autograft and allow for rates have increased and cosmetic outcomes are improved.
coverage of wider areas (10). The skin at a donor site has a A new development in wound management has been the

Chapter 94 Burn Rehabilitation 1765

creation of Integra artificial skin, which received Food and
Drug Administration (FDA) approval in March 1996. Table 94-4: Common Short- and
Integra is a biologic, bilayer skin replacement system. The Long-Term Goals
dermal layer is composed of fibers of bovine tendon colla- Short-term goals
gen and glycosaminoglycan and serves as a template for Control pain
fibroblasts and capillaries from the uninvolved dermis. As Prevent contractures, deformity
healing occurs, a neodermis is formed as new collagen Preserve joint mobility
replaces the bovine collagen. The temporary epidermal Preserve strength, coordination, endurance
Promote ADL participation
layer is composed of silicone and functions to control Promote wound healing
moisture loss from the wound. After 14 to 21 days, ade- Minimize edema
quate vascularization of the dermal layer has occurred. Patient and family education
The silicone layer is removed and a thin, meshed layer of Long-term goals
epidermal autograft is placed over the neodermis. The Minimize burn scar formation
Increase strength, coordination, endurance
advantage is immediate physiologic wound closure until Increase independence with ADLs
donor skin is available, thus decreasing pain and the risk of Compensate for physical impairment
infection. The epidermal autografts used also allow for Adjustment to disability
thinner, quicker-healing donor sites and improved cosmetic Reintegration into society
and functional outcome (13). Education regarding skin care and scar management

ADL = activity of daily living.

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- strength and sensation are assessed. A treatment plan is
out the hospital course, and often continues for years fol- developed based on a comprehensive evaluation with
lowing injury. A team approach ensures a comprehensive ongoing assessment and modification.
and holistic perspective for each individual who is faced Therapeutic exercise is a vital part of the burn
with this significant impairment. Team members can patient’s care because contractures and resultant loss of
include general and plastic surgeons, pulmonary and criti- function can occur rapidly. Burn wound depth and loca-
cal care specialists, physiatrists, psychologists, nurses, social tion are determinants of the type and intensity of exercise.
workers, occupational therapists, physical therapists, speech Deep partial- and full-thickness wounds have a higher inci-
therapists, dietitians, orthotists, dysphagia services, voca- dence of decreased joint motion and scar contracture (Fig.
tional counselors, and aesthetic therapists. Rehabilitation 94-4). Therefore, the therapist must prioritize specific areas
professionals are an integral part of the acute phase in to exercise.
burn care and serve to complement other members of the During the acute phase, ROM exercises are initiated
team who provide critical care and surgical intervention. with the goal of minimizing edema to ensure functional
Survival among burn patients has improved dramatically, ROM. ROM may be passive, active-assisted, or active,
but equally important is for rehabilitation efforts to trans- depending on a patient’s medical status (pain medications,
late into returning survivors to the highest functional level affect, associated trauma) or wound status (thick eschar,
and quality of life. tendon exposure). Although exercise will vary with patient
Rehabilitation should be viewed on a continuum status, there are circumstances that must be given special
with short- and long-term goals being established (Table consideration. The clinical guidelines for starting ROM
94-4). The ultimate goal is to heal the wound while main- after excision and grafting vary among institutions (Table
taining and restoring maximal function. Acutely, life-threat- 94-5). Other conditions that may modify treatment include
ening problems may hamper rehabilitation at times. In the tendon, bone, or joint exposure; preexisting joint disease;
setting of medical instability, restorative intervention may periarticular calcification; deep venous thrombosis; and
be passive in nature, with the patient becoming more associated trauma.
active in the rehabilitative program as the condition Passive ROM (PROM) exercises are performed when
permits. the patient is unable to actively participate in the program.
Occupational and physical therapists may be Guidelines to performing PROM exercises depend on a
involved in all stages of patient care and rehabilitation. patient’s physiologic status, placement of intravenous lines,
Therapists begin their assessment of a patient during the eschar tightening or tearing, associated orthopedic or neu-
acute phase of injury in conjunction with medical manage- rologic trauma, or preexisting joint conditions. Active
ment. Patient evaluation begins with observation of the ROM exercises are encouraged to ensure patient participa-
extent and location of the wound as well as its effects on tion and assisted ROM exercises are especially effective in
joint range of motion (ROM), mobility, and activities of a multijoint stretch where the goal is to elongate the scar
daily living (ADLs). In the case of electrical injury, muscle tissue over adjacent joints.

1766 Part V Medical Rehabilitation for Diagnostic Groups

 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 good palmar arch (15). Straps are contraindicated for the
patients extends years after the burn occurred. 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
HAND BURNS requires a skin graft, a modified hand splint is used during
One of the most commonly involved and structurally vul- the operative procedure to position and immobilize the
nerable parts of the body in a burn injury is the hand (Fig. hand, allowing for optimum stretch and graft take (Fig. 94-
94-5). Because of the natural human tendency to protect 6). These modifications include slits between the fingers,
the face, dorsal hand burns are more common than holes at the distal tip of each finger, notches around the
palmar burns. In particular, the dorsum of the hand is at side, and a “roll bar” attached to the thenar area of the
risk, owing to the superficial location of the extensor splint. The digits are sutured, by a surgeon, into the holes
tendons and the minimal layers of subcutaneous fascia. at the top of the splint, while the slits allow for adequate
Without early intervention, permanent damage to the drainage and the roll bar provides extra protection against
hand can occur. Traumatic shedding of the extensor hood, damage to the graft. Other splints that are frequently indi-
ischemic changes secondary to edema, and increased cated for the burned hand include, but are not limited to
tension at the proximal interphalangeal (PIP) joints are all the following:
too frequently present. In particular, with a burn trauma to 1. The gutter splint, which maintains or increases
the hands, the central slip and the lateral bands are jeopar- extension of one particular digit
dized. In normal function, the lateral bands lie volar to the 2. The saddle splint, which prevents contracture of the
axis of flexion at the metaphalangeal (MP) joint and dorsal thumb-index web space
to the axis of flexion at the PIP joint. When injury occurs,
3. The wrist cock-up splint to provide wrist extension,
the central slip is often disrupted, allowing the lateral
which aids in hand function
bands to slip volarly, becoming flexors at the PIP joint and
forcing the distal interphalangeal (DIP) joint into hyperex- Splint requirements will change as the patient’s
tension. This is known as a boutonnière deformity. This and medical status and functional needs change. Therefore, it is
other deformities can be prevented by splinting, ROM, important to monitor a patient’s splint on a daily basis to
exercises and stretching, and proper positioning (14). assess fit, reassess splinting needs, and check for pressure
As with splinting in general, the hand should be areas.
splinted in a position opposite the expected deformity. The ROM exercises, another important aspect of burn
burn resting hand splint is one of the most common tools therapy, are necessary not only to prevent skin contrac-
used to protect the hands. This splint varies slightly from tures, but also to prevent joint stiffness and tendon adhe-
other resting splints as it places the wrist in approximately sions. Active ROM exercises are always preferable, as they
30 degrees of extension, the MP joints at approximately 70 maintain muscle mass and strength. However, since this is
degrees of flexion, the interphalangeal (IP) joints in full not always feasible, PROM exercises may be performed.
extension, and the thumb in opposition and maintains a ROM exercises with burned joints need to be frequent and

Figure 94-5. Partial degloving of the left

hand to reveal a full-thickness
burn injury.

1768 Part V Medical Rehabilitation for Diagnostic Groups

 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.

aggressive but special attention must be paid to the delicate underestimated. There is great variability in individual
structures of the hand. With a full-thickness burn to the pain thresholds. Patients with “minor” surface area burns
dorsum of the hand, a multijoint stretch is contraindicated. may report significant pain, while conversely a patient with
To maintain mobility while preserving tendon integrity, a a “major” surface area burn may have only minimal
modified flexion technique is performed. This involves complaints.
achieving MP flexion with IP extension and then IP flexion Pain can occur with activity or at rest. Various
with the MP joints extended. Patients should make a full approaches are used to measure pain. The most applicable
fist only if the therapist is positive of the tendon status or if to the burn patient appears to be the horizontal Visual
the wound has healed or been grafted. PROM is best com- Analog Scale (VAS) or the Verbal Descriptive Scale (VDS).
pleted while the patient’s dressings are off. If possible, it is In the pediatric population, the VAS and Pain Thermome-
important to have the patient participate in active exercises ters or the Procedural Behavior Checklist are useful.
and functional activities. This can be done in a gym or at However, more research is indicated in this area.
the patient’s bedside. Without daily exercise, muscle Pain medications include opioids (morphine, meperi-
atrophy, tendon adherence, capsular shortening, and dine, fentanyl, sufentanil), anti-inflammatories (ibuprofen,
edema can be ongoing problems. etc), local or general anesthetics (midazolam, nitrous oxide,
Proper positioning of the burned hand is essential lidocaine), and benzodiazepines (lorazepam). Each of these
for minimizing edema. When the body is subjected to medications must be administered cautiously and the
thermal trauma, there is an immediate and rapid increase patient closely monitored for desired outcome and side
in capillary permeability. As a result, massive fluid accumu- effects. The response to opioids in particular can be signifi-
lates in the area of trauma. This fluid can be very destruc- cantly altered for months after burn injury. Administration
tive to the fragile structures of the hand. One of the most of other medications, prior medical conditions, fluid
common problems seen in the hand secondary to edema is volume status, and parenteral nutrition can affect the phar-
the claw hand deformity. The result is that the MP joints macokinetics of drugs.
are pulled into hyperextension; the IP joints, into flexion; The route of medication delivery may include intra-
and the thumb, into adduction (14). Elevation of the venous injections, patient-controlled epidural perfusion
burned extremity and splinting will assist with the decrease (PCA), oral route, or less preferable, intramuscular injec-
of edema. tions. Some patients will require opioids as well as behav-
It must also be remembered that the hand functions ioral modification, psychological supportive counseling,
as part of the upper extremity. Full hand motion is almost relaxation therapies, and in extreme cases, hypnosis.
useless if significant contractures of the elbow or axilla Particularly with the pediatric population, the magni-
prevent the patient from positioning the hand so that this tude of pain must not be underestimated. Opiates, seda-
motion can be utilized (16). tives, behavioral modification, and even PCA have been
used successfully with this population.
Aggressive pain management can lead to improved
PAIN participation in burn rehabilitation as well as improved
Pain in burn patients must be managed carefully but overall patient care. The most effective plan of care is tai-
aggressively. The patient’s level of pain should not be lored to the individual patient’s needs.

Chapter 94 Burn Rehabilitation 1769

COMPLICATIONS frequently. Axonopathy of the critically ill is not uncom-
mon. Burn injuries can be overwhelming and a prolonged
Burn injuries can lead to significant compromise of the recovery period can lead to generalized neural collapse.
neurovascular system (Fig. 94-7). There are a number of These patients may require mechanical ventilation, posi-
neurologic complications seen after a burn injury. One tioning, splinting, and a medical regimen.
such complication, burn encephalopathy, is a poorly Compartment syndrome can quickly develop
defined clinical entity that may occur more frequently in as edema increases and compartment pressures rise. Eschar
children. Seen in about 30% of patients, it may be trig- can contribute to the development of compartment syn-
gered by systemic factors, including fever. Peripheral neu- drome because it lacks the compliance needed to
ropathies are seen more with burns of increased severity. accommodate a massive fluid shift. Compartment pressures
They are commonly due to direct thermal, chemical, or may be monitored and decompressive surgery such as
electrical injury or secondary to treatment regimens (i.e., an escharotomy or fasciotomy of the involved area can be
neurotoxic drugs, tight bandages, faulty positioning, or employed to reduce pressure and salvage tissue (Fig. 94-8).
improper splinting). Mononeuritis multiplex is seen most

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 influencing the severity of scarring include age, race,
patients who sustained deep burn wounds and have been genetic disposition, anatomic location of the burn, and the
immobile, particularly following grafting procedures over a type of grafting performed. Pediatric patients and patients
joint. Diligent ROM exercises within surgical guidelines with very fair or dark skin tend to be at higher risk for
are optimal to reduce the risk of heterotopic ossification. increased scarring. Burns of the hand, head, and axilla
Even with proper treatment, heterotopic ossification may also tend to be more vulnerable to increased scar forma-
still occur. Treatment for heterotopic ossification fluctuates tion. Grafts placed on granulation tissue also tend to scar
from institution to institution. more than tangentially excised wounds (17).
Early pressure can be provided via Ace wrapping,
tubular support bandages, interim garments, and prefabri-
HYPERTROPHIC SCARRING cated pressure gloves. These can be tolerated as early as 7
The scarring process can limit ROM, cause contractures, to 10 days after grafting or when open areas are no larger
and severely limit function. Most ongoing rehabilitation than the size of a dime (19). These methods of pressure
difficulties are secondary to the strong contractile proper- are used while body weight and edema stabilize prior to
ties of immature scars (17). Full scar maturation may take having the patient measured for custom-fit pressure gar-
up to 12 to 18 months (18), with the most active scarring ments. Custom garments are made of a Dacron/spandex
period being 4 to 6 months after injury (17). Early and elastic fabric and provide capillary level pressures of at
aggressive treatment of the scars, via use of pressure, least 25 mm Hg (17). The wearing time may need to be
stretching, splinting, and positioning, is essential for good increased gradually to 23 out of 24 hours per day, and the
functional outcomes. garments may need to be worn until full scar maturation
A healed wound is characterized by increased vascu- has occurred. Proper fit is essential so the fit must be peri-
larity and an increased number of fibroblasts. Fibroblasts odically examined and alterations or entire new garments
then synthesize excessive collagen, which redevelops in may be needed.
irregular shapes and whorl-like masses at four times the The sustained use of capillary level pressure on the
rate of normal skin (19). Early scar is readily influenced by growing bones and tissues of small children has been con-
external forces because cross-linking collagen bonds are troversial. However, it is now believed that if the fit is
weak and fewer in number in the early stages. Therefore, monitored closely to allow for growth, garment use is
these bonds are likely to align themselves in a more orga- acceptable, with the exception of the head.
nized parallel format. Pressure may also control collagen To maintain uniform pressure in concave areas of
synthesis by producing ischemia in the scar (17) and the body, inserts such as elastomer putty, Silastic elastomer
decreasing wound vascularity. with prosthetic foam, Plastizote, or thermoplastic conform-
The severity of scarring is affected by wound depth ers may be used. Silicone gel sheeting is another option for
and the time needed for wound closure. If a wound the treatment of hypertrophic or keloid scars. Although
requires skin grafting or takes longer than 14 days to heal, effective, the mechanism is not fully understood. The gel
pressure therapy will be indicated (Fig. 94-9). Other factors 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.

Chapter 94 Burn Rehabilitation 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 and provides a standard framework and method of analy-
on completely healed skin surfaces, as internal absorption sis through which physicians can evaluate, report on, and
remains controversial. communicate information about the impairments of any
Proper pressure therapy can lead to favorable func- human organ system. Many state workers’ compensation
tional and cosmetic gains. Patient compliance is essential; agencies mandate or recommend use of the Guides. Even
otherwise, surgical intervention may be needed (Fig. 94-10). though rating or estimating impairment cannot be totally
objective, use of the Guides increases objectivity and
enables physicians to report impairment in a standardized
COSMESIS manner, so that reports from different observers are more
likely to be comparable in content and completeness (22).
Following scar maturation, changes in the texture and
The effects of a burn injury on the skin and its
color of the skin may still be present. The visible scarring
appendages are combined with the estimated impairment
may alter a patient’s self-esteem. To minimize discoloration
percentages of other body systems, including the muscu-
and disfigurement, cosmetics that camouflage these areas
loskeletal system, the nervous system, the respiratory
were developed. Paramedical camouflage is a process by
system, the ears, the nose, the throat, and related struc-
which the appearance of scar or skin pigment alterations is
tures. Additionally mental and behavioral disorders are dis-
normalized. This is achieved through the application of
cussed in the Guides.
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 PSYCHOLOGICAL ISSUES
are waterproof.
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
DISABILITY if the patient emerges from this ordeal as a functioning
The evaluation of disability is an appraisal of the patient’s member of society with self-respect and dignity intact.
present and future ability to engage in gainful activity as it Certainly, some patients do emerge intact, and some
is affected by factors such as age, sex, education, econom- resume their lives in a more productive and gratifying
ics, and social relationships. These diverse and subjective manner than before the injury. However, many patients,
factors are difficult to measure (7). For this reason, perma- despite the best burn treatment, develop psychological
nent impairment is the major criterion used in arriving at complications that hinder their recovery. Healing on the
a permanent disability determination. Unlike disability, outside may not always reflect healing on the inside.
permanent impairment can be measured with a reasonable Anxiety, denial, depression, grief, and mourning may
degree of accuracy and uniformity (21). be experienced. Depression may be transient and show
The American Medical Association’s Guides to the improvement with the healing process or may intensify
Evaluation of Permanent Impairment is a widely accepted aid with time as the patient realizes what has been lost.

1772 Part V Medical Rehabilitation for Diagnostic Groups

 Many burn injuries are due to premorbid psychologi- patient’s ultimate functional outcome. Emotional support is
cal problems. This includes a possible history of alcohol or necessary, and patients may require additional assistance
drug abuse, violence, or fire starting. Depression, alcohol or from mental health professionals.
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
FUTURE TRENDS
burn trauma. The changing health care milieu will affect burn care of
Symptoms of posttraumatic stress are expected in the future. When feasible, outpatient management of burn
the postburn period. However, if they exacerbate, reinte- injuries will replace more expensive inpatient services.
gration into society may be hindered. Future trends also include new wound care technologies
Patients need to recover physically and psychologi- such as developments in artificial skin. A deeper under-
cally after burn injury. All members of the team need to standing of new technology is required to keep pace with
be aware of how these problems can impact on the the frequent changes in burn care delivery.

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Chapter 94 Burn Rehabilitation 1773