Residency · Residency · Physical Medicine Rehabilitation
Burn Rehabilitation
Introduction
Burn injuries present unique and complex rehabilitation challenges that span the continuum from acute care through lifelong community reintegration. Advances in critical care have dramatically improved survival rates for major burns, shifting the focus toward optimizing functional outcomes and quality of life. Rehabilitation must begin on the day of admission and continue for months to years. The physiatrist plays a central role in coordinating the interdisciplinary burn rehabilitation team.
Classification of Burn Injuries
Superficial (first-degree): epidermis only; erythema, pain, no blistering; heals in 3-7 days without scarring. Superficial partial-thickness (second-degree): epidermis and superficial dermis; blisters, moist wound bed, severe pain; heals in 10-14 days with minimal scarring. Deep partial-thickness (second-degree): epidermis and deep dermis; mottled appearance, reduced sensation, prolonged healing (3-6 weeks); significant scarring risk. Full-thickness (third-degree): entire epidermis and dermis destroyed; waxy, leathery, insensate; requires surgical excision and grafting.
Fourth-degree: extends into subcutaneous tissue, muscle, tendon, or bone. Total body surface area (TBSA) estimated using the Rule of Nines or Lund-Browder chart.
| Burn Depth | Tissue Involved | Appearance | Sensation | Healing |
|---|---|---|---|---|
| Superficial (1st degree) | Epidermis | Erythema, no blisters | Painful | 3-7 days, no scarring |
| Superficial partial (2nd) | Epidermis + superficial dermis | Blisters, moist pink base | Very painful | 10-14 days, minimal scar |
| Deep partial (2nd) | Epidermis + deep dermis | Mottled, less moist | Reduced | 3-6 weeks, significant scar |
| Full-thickness (3rd) | Entire dermis | Waxy/leathery | Insensate | Requires grafting |
| 4th degree | Subcutaneous, muscle, bone | Charred/exposed deep tissue | Absent | Requires excision/flap |
Acute Rehabilitation Priorities
Edema Management
Elevation of burned extremities above heart level to reduce dependent edema. Active and passive range of motion initiated within 24-48 hours of admission. Compression wraps and garments as wounds permit. Monitor for compartment syndrome in circumferential burns; escharotomy may be required.
Positioning and Splinting
Anti-deformity positioning is critical to prevent contracture formation in the position of comfort. Neck: extension and neutral (avoid flexion contracture from anterior neck burns). Shoulder: 90 degrees abduction with slight external rotation. Elbow: extension.
Wrist: 20-30 degrees extension with MCP flexion 70 degrees, IP extension (intrinsic plus position). Hip: extension and neutral abduction; avoid flexion and adduction. Knee: extension. Ankle: neutral dorsiflexion (90 degrees). Splints worn during rest periods and at night; removed for therapy sessions.
Range of Motion
Begin active and active-assisted ROM on day of admission when hemodynamically stable. Perform ROM before, during, and after dressing changes when analgesia is optimized. Autografted areas require 5-7 days of immobilization post-surgery to allow graft adherence; then resume ROM gradually. Aggressive, consistent ROM is the single most important intervention to prevent contracture.
Scar Management
Hypertrophic Scarring
Develops in wounds healing beyond 14-21 days or after skin grafting. Characterized by raised, erythematous, pruritic, and contracted tissue. Peak activity at 3-6 months; matures over 12-24 months. Risk factors include darker skin pigmentation, younger age, anatomic location (chest, shoulders), and wound depth.
Interventions
Pressure garments: custom-fitted garments providing 24-35 mmHg pressure; worn 23 hours per day for 12-18 months until scar maturation. Silicone sheeting and gel: applied directly to scars; reduces collagen deposition and scar height. Massage: deep tissue and friction massage to improve scar pliability and reduce adhesions. Serial casting and dynamic splinting: for established contractures resistant to stretching.
Intralesional corticosteroid injection (triamcinolone acetonide): for resistant hypertrophic scars. Laser therapy: pulsed dye laser and fractional CO2 laser for scar remodeling and pruritus.
Pain and Pruritus Management
Pain
Background pain: constant, baseline discomfort; managed with scheduled long-acting analgesics. Procedural pain: intense pain during wound care, dressing changes, and therapy; requires pre-procedural analgesia. Breakthrough pain: episodic; managed with short-acting opioids or adjuvants. Multimodal approach: acetaminophen, NSAIDs, gabapentin/pregabalin, opioids, anxiolytics, non-pharmacological methods (distraction, virtual reality, relaxation techniques). Neuropathic pain is common after deep burns and nerve injury; responds to gabapentinoids and duloxetine.
Pruritus
Affects up to 90% of burn survivors; peaks during scar maturation. First-line: antihistamines (cetirizine, diphenhydramine), moisturizers. Second-line: gabapentin, pregabalin, ondansetron. Massage, pressure garments, and transcutaneous electrical nerve stimulation (TENS) provide adjunctive relief. Cooling sprays and colloidal oatmeal baths for symptomatic relief.
Functional Rehabilitation
Early ambulation: initiate as soon as hemodynamically stable; lower extremity burns may require elastic wraps before dangling and weight-bearing. ADL training: adapted techniques for self-care with burns to hands and upper extremities. Strengthening: progressive resistive exercise program beginning in the acute phase and continuing outpatient. Cardiovascular reconditioning: burn survivors lose significant aerobic capacity; structured exercise programs improve VO2 max by 20-30%. Return to work and school: vocational rehabilitation, workplace modification, and gradual reintegration.
Psychological and Social Rehabilitation
Post-traumatic stress disorder: present in 20-45% of major burn survivors. Depression and anxiety: common, often persisting beyond physical recovery. Body image disturbance: particularly significant with facial burns and visible scarring. Social reintegration programs: community reentry, social skills training, peer support.
Early psychological intervention and ongoing mental health follow-up are standard of care. Address caregiver and family stress; family therapy may be beneficial.
Special Considerations
Electrical Burns
Tissue damage often exceeds surface appearance; deep muscle necrosis, vascular injury, and nerve damage. Compartment syndrome risk; cardiac monitoring for arrhythmias. Long-term complications include cataracts, peripheral neuropathy, and spinal cord injury.
Inhalation Injury
Leading cause of mortality in burn patients. Airway edema, bronchospasm, and pulmonary damage. Aggressive pulmonary hygiene, bronchodilators, and early mobilization.
Pediatric Burns
Growth-related contractures require long-term follow-up and scar releases. Developmental considerations in therapy goals and psychosocial support. Higher risk of hypertrophic scarring.
Key Clinical Pearls
Anti-deformity positioning and early aggressive ROM are the most critical rehabilitation interventions in burn care; the position of comfort is the position of contracture. Autografts require 5-7 days of immobilization post-surgery before ROM is resumed; premature mobilization risks graft failure. Pressure garments must be worn 23 hours per day for 12-18 months and require replacement every 2-3 months as they lose compression. Burn rehabilitation is a years-long process; functional and psychosocial needs evolve well beyond wound closure. Pruritus is one of the most distressing long-term symptoms; gabapentin is an effective second-line treatment when antihistamines are insufficient.
References
- Richard RL, Staley MJ. Burn Care and Rehabilitation: Principles and Practice. F.A. Davis Company; 1994.
- Esselman PC, Thombs BD, Magyar-Russell G, Fauerbach JA. Burn rehabilitation: state of the science. American Journal of Physical Medicine & Rehabilitation. 2006;85(4):383-413.
- Schneider JC, Holavanahalli R, Helm P, et al. Contractures in burn injury: defining the problem. Journal of Burn Care & Research. 2006;27(4):508-514.
- Goverman J, Mathews K, Goldstein R, et al. Adult contractures in burn injury: a burn model system national database study. Journal of Burn Care & Research. 2017;38(1):e328-e336.