(Procter F. Rehabilitation of the burn patient. Indian J Plast Surg. 2010;43(Suppl):S101‐S113. doi:10.4103/0970-0358.70730)
Rehabilitation for patients with burn injuries; It starts from the day of injury, lasts for several years and requires multidisciplinary effort. A comprehensive rehabilitation program is essential to reduce the patient’s post-traumatic effects and improve functional independence. (1) However, while providing optimal treatment involves a multidisciplinary team approach, when this is not possible or the availability of therapists and support services is limited, all members of the burn team can take responsibility for their role in rehabilitation to maximize benefit to the patient. While different professionals have expertise in their respective fields, there are some simple and effective methods that can be used to help the patient achieve their maximum functional results. It is the dedication and commitment of individuals within the burn team to care for the patient and encourage and participate fully in their rehabilitation, which can make such a difference in their long-term l quality of life.
Efforts are made in this article to share key aspects of burn rehabilitation and provide practical information that can be followed (and taught to best assist patient members) by different professionals working within the burn specialty.
Rehabilitation of burn patients is an active treatment process from admission. There should be no characterization between the “acute phase” and the “rehabilitation phase” , as this idea may increase the disparity of the secondary discrete scar management and/or functional rehabilitation team.  However, to make it easier to follow the patient care pathway, the rehabilitation phases are divided into early and advanced rehabilitation phases; however, it should be understood that there may be significant cross-treatment between these two phases, depending on the individual patient.
Early Rehabilitation Stages
Depending on the size and severity of the injury, the age of the patient, and other pre-illness factors, this stage can last from a few days to several months. The patient may be inpatient or outpatient and is likely to undergo regular dressing changes, which are often painful and can also be a very frightening experience for the patient.
Before all interventions such as regular pain relief, especially dressing and exercise change; it must be given in sufficient time to take effect before processing begins. The aim of analgesic drugs should be to develop good basic pain control to enable functional movement and activities of daily living to occur at any time during the day.  Indequate pain relief in the early stages may cause the patient to be completely reluctant to participate in their rehabilitation, both in the short and long term.
Starting rehabilitation early is key to treatment adherence and maximizing long-term outcomes. When various aspects of rehabilitation are introduced as an integral part of care from day one, whether as an inpatient or an outpatient, it is easier for the patient to accept and monitor than to be an additional element to the patient’s care at a later date when contractures are already developing.
Remember tomorrow may be too late!
Patients may wish to delay their rehabilitation until they feel better; however, each day that passes without burn therapy intervention will make the possible rehabilitation process more difficult and painful and lead to worse outcomes. If windows are missed, they are not easily regained because the inevitable sequelae of ever-increasing joint stiffness and associated soft tissue slippage become increasingly devastating as time passes.  Patients may try to refuse treatment because they are suffering and may not fully understand the impact of not participating in their rehabilitation; therefore they need the encouragement and help of professionals who are involved in burn care and who have the knowledge of how their quality of life can be different.
It is important to initiate physical rehabilitation on day 1 of admission, regardless of whether the patient is walking and well, or is at bed rest and sedentary.
When a patient is admitted with severe burns, it is important to reduce as much as possible the risks of escalation of further complications occurring. Postural treatment of the patient by raising the head and chest helps the chest cavity and reduces swelling of the head, neck and upper airway.
Significant edema may be present in the early stages, especially in the peripheries; poor positioning can lead to unnecessary additional diseases, which can be avoided. Elevation of all affected limbs is necessary to quickly reduce edema; hands should be splinted or positioned and feet should be kept at 90 degrees, care and attention should also be paid to the heel area, which can develop pressure quickly. The legs should be kept in a neutral position and ensure that the patient does not turn outward from the hips [Graph 1].
Passive movements should be completed to maintain the range of motion (ROM) of immobile patients and to prevent the development of stiffness. If this is not possible on a daily basis due to surgical intervention and skin grafting, it can be achieved during the change of dressings.
It is important to remember that burn patients often experience a very frightening event that leads to their burn injury, and for them the hospital experience itself can be frightening. Patients and family members may experience severe feelings of guilt, anger, and hopelessness; they may also experience nightmares and memories of the event they experienced. While professionals can treat many people in a day, the experience for each patient is personal and their experience can affect their mental health and readiness to participate in their treatment. It is important to give comfort and comfort to the patient so that they feel safe. Taking the time to listen to the patient’s concerns, showing genuine empathy and compassion, providing adequate information and answering their questions can often go a long way in alleviating fears, making the treatment process easier for both patient and professional.
INSERTION OF ANTI-CONTRACTURE
Anti-contracture positioning and splinting starts from the first day and can last for months after injury. It applies to all patients, whether or not their skin is grafted. Positioning is important to influence tissue length by limiting or inhibiting loss of ROM secondary to the development of scar tissue.  Patients stand in a comfortable position; this is usually a flexion position as well as a contracture position. Wounds begin the healing process almost as soon as they begin, and an important part of this process is wound contracture as shown in the photo below.
Without continued advice and assistance with positioning, the patient continues to assume the contracture position and may rapidly lose ROM in more than one joint. Once the contracture begins to develop, there can be a constant struggle to achieve full motion, so preventative measures are necessary to minimize contracture development. Early compliance is essential to ensure the best possible long-term outcome while also relieving pain and aiding exercise regimens.
It is very important not to ignore patients with relatively minor burns because they can develop severe and debilitating contractures that can be easily avoided with positioning, splinting and exercises.
The risk of contractures is greater when burns occur on the flexor side of a joint or limb. This is because the comfort position is a flexible position; also, flexor muscles are generally stronger than extensors, so if a burn occurs in the extensor direction, patients can use the strength of the flexors to stretch a specific area. The bent position is the functional position, such as clasping the hand, bending the shoulder forward, and bending the neck. The goals of anti-contract positioning are to counteract this natural tendency to flexion, as shown in the table below.
Positioning a patient may require reflection to achieve the required position and prevent the patient from slowly returning to the contracted position.
The use of materials such as pillows and drip trays (for height) readily available in the ward can be used as effective positioning tools.
Simple but consistent positioning from Day 1 can have a significant impact in making contractures preventable. Many burn contractures can be completely minimized or prevented with early intervention.
Splints are a highly effective method to help prevent and manage burn contractures and are an integral part of a comprehensive rehabilitation program.  Splinting helps maintain an anti-contracture position, especially for patients who experience excessive pain, difficulty in alignment, or burns in an area where positioning alone is inadequate. If the injured area is above the articular surfaces, special precautions should be taken to identify all possible joint contractures. A well-designed splinter program along with active and passive mobilization is required to prevent and transform joint contractures and deformities. [one]
Splinting can provide a taut position that provides an easier starting point for exercise and stretching regimens. Scars are not only contracted, but also follow the shortest possible path, often causing webbing at the naturally concave and joints such as the neck, knee and axilla; splints appear to help reshape scar tissue while creating and maintaining anatomical contours. Splinting is the only therapeutic method that applies controlled gentle forces to soft tissues for sufficient time to induce tissue remodeling.  Prevention is always more effective than treatment. Early application of splints is important to prevent the development of scar contracture after burns in the acute stage. [one]
Splints can be made from a variety of different materials. The ideal material is a low-temperature thermoplastic because it is lightweight, easily moldable and detachable, and conforms very well to contours. However, this is not the only material from which splints are made and this material may not always be available, in which case alternatives and improvisation may be necessary.
MATERIALS FOR SLINTING
Easily available materials are used to make the splints.
Plaster of Paris – this material is excellent in the early stages, the patient is immobile and heavy dressings are applied; however, it tends to absorb exudate, is heavy, and breaks easily. It is usually applied after surgery to immobilize and position a limb; but after it is discarded it must be replaced with something else.
Cardboard – This material also makes an excellent early splint material and is particularly good for positioning and stretching burns on children’s hands. The use of disposable dressing boxes to manufacture easy, lightweight, disposable splints also minimizes cost. A dorsal block can be applied over the steps to increase stretch, and a firm (but not too tight) bandage maintains the required position of the hand. Other rest splints can also be made quite simply out of cardboard with a little creativity.
Foam and blown polystyrene – Of these, quite good positioning tools can be made to maintain the position of large joints, especially when the patient is at bed rest, for example, in the axilla in abduction. They are useful for adjusting the position of patients at night. They can also be used in combination with other materials to create hand splints, such as forming splints with PVC.
PVC tubing – These materials can be easily converted into lightweight, effective splints that can be worn comfortably by patients. It can be cut with a saw and rough shaped with heavy scissors to create knee arm and finger extension splints, and hand splints can be created by adding foam and other materials such as blown polystyrene.
PVC elbow tubing can be cut to length, filled and worn as very effective axilla splints.
PVC can also be heated (using an electric heat gun) and molded to create splints with similar compatibility to those made from thermoplastic materials. Unlike low-temperature thermoplastics, it cannot be molded directly into the patient due to its high melting point, but can be heated and removed until a good fit is achieved.
PVC can be used to manufacture elbow extension splint – same method is applied for knee and finger extension splint. The production of hand splints from PVC provides ease and comfort when obtaining the patient’s consent.
Splinting materials are ubiquitous around us, and with a little creativity, everyday materials can be used to create splinting tools every day.
FLEXING AND FIRST MOVEMENT
Joints affected by burns must be moved and stretched several times a day, and the patient is likely to require assistance from burn team and family members to reach full range of motion. Therapists use clinical judgment based on the appearance of the tissue to determine whether passive range of motion (ROM) or active ROM is performed, as well as when to resume ROM after immobilization.  Patients need to develop patient-specific movement habits from the day of injury, not from the day the surgery is completed or the wound begins to heal partially or completely.  Children may need additional encouragement, so parental understanding and involvement is crucial from an early stage as they will help the child achieve the exercise and stretching regimen. Games that involve therapy goals such as stretching to catch a ball, reaching and bilateral use of the hands, depending on the site of injury and therapeutic needs, should be encouraged. Pain control is necessary to make this process as easy as possible for the patient, because for patients they are extremely reluctant and afraid to move if it will cause severe pain. Patients should be encouraged to take action as soon as possible after injury. Stiffness is common in burn patients, both in the joints affected by the burn injury and in other joints when immobilized from time to time. Splinting should be accompanied by regular exercise regimens because contractures can occur and also contractures in those desired positions if the patient is consistently positioned and constrained by that position.  Patients should be encouraged to get out of bed and exercise as soon as they are fit enough. Therapeutic exercise includes ambulation of joints, consideration of neurovascular integrity, improvement of cardiovascular and respiratory capacity, coordination, balance, muscular strength and endurance, exercise performance, and functional capacity.  Exercise also helps the patient experience a general sense of well-being, confidence, and achievement.
Before starting to mobilize a patient, it is important to check for recent surgery; such as skin grafting and medical issues that indicate whether the patient is fit to stand up and move. If you monitor vital signs closely and make ongoing assessments, aim to activate all patients as soon as possible. If the patient will not eventually experience mobility problems, ask relatives to provide ongoing support to the patient for exercise. Give self-confidence encouragement and start slowly, gradually building the patient’s confidence and exercise tolerance; patients often get tired quickly, so that’s how it should be.
INCENTIVE ACTIVITIES OF DAILY LIFE
Burn patients often feel as if they have lost their ability and role to participate in their normal activities in life. Activities of daily living play an extremely important role in achieving a successful outcome for the burn patient. The most difficult parts of rehabilitation can be easily handled if a patient accepts responsibility for self-exercise and activities of daily living.  It is very important to involve patients in daily activities such as self-feeding and washing themselves as soon as possible. Family members should refrain from completing these activities for the patient’s sake, as completing these exercises emphasizes the patient’s ‘disease role’ and increases the patient’s reluctance to participate actively in rehabilitation. The highest level of independence should be encouraged in all activities of daily life as early as possible.
Quickly participating in their own care gives the patient a greater sense of well-being and control over the environment. An increase in the ability to perform activities of daily living leads to an increase in self-esteem, self-worth, and a sense of independence, and an increase in motivation levels and a desire to develop. Bathing, toileting, feeding, grooming, dressing, and professional skills include health benefits; such as increased ROM and power, precise motor movements and balance. It is important to remember that a child’s vocation is play; Children should be encouraged to play and participate in their normal routines as part of their rehabilitation.
It is important to educate the patient at every stage about the various aspects of burn rehabilitation and why their participation in rehabilitation is so important to achieve the best possible outcome. Education is of paramount importance along with a consistent approach from all members of the multidisciplinary team.  Some people may want the information to be repeated many times and it is important to make sure that patients fully understand what they need to do and why. Continuing education will help the patient take responsibility for his own rehabilitation and, accordingly, improve his compliance. Initial reluctance due to frustration, pain and fatigue will be relieved by encouragement and education.
NEW REHABILITATION STAGES
Except for the most superficial burns, we are, by definition, treating a chronic condition. There is an opinion and literature that strongly supports the use of early intervention and a bio-psychosocial model in other patient populations. This model is especially relevant for burn victims. 
Psychological difficulties may arise at any stage following a burn injury. Some people find that the impact of the trauma of the first event can only begin to affect them after they are discharged from the hospital. Initially, the patient may appear to have coped well with their injuries and changes in circumstances; however, after the persistence of the condition becomes a phenomenon and the rehabilitation process becomes long-lasting, the patient may begin to experience psychological difficulties in the form of depression, anger and anxiety; they may also grieve for their former life, personality, and functions, and experience feelings of loss. If the individual is affected in this way, it is important that they receive the right support and reassurance. Children may show signs of retardation in their development and temporarily become more dependent on their parents prior to their burn injury.
Hypertrophic scarring is common after burn injury and can cause significant functional and cosmetic impairment.  The longer a wound takes to heal, the more likely it is to develop hypertrophic scars; The risk increases significantly when a wound takes 21 days or longer to heal. Hypertrophic scars are an exaggerated response to the body’s healing process; they have a high blood flow and high collagen levels and become overactive; These scars have a high rate of contraction and have other symptoms associated with them, including itching, dryness, and lack of yawning. Hypertrophic scars are usually at their most active during the first 4-6 months after healing. Initially, a wound may appear flat when first healed, but it is important to monitor scars closely as they may suddenly begin to show signs of hypertrophy. It is common for patients to be discharged from the hospital with a full ROM; however, after a few weeks, if corrective measures are not taken against the contractile strength of the scar, the ROM is lost and the scar contracture occurs. Scar management in post-burn injuries is a long and often painful process; It is not something that can be done for a few weeks and then abandoned, but something that needs to be continued for months to minimize the occurrence of post-burn complications. There is no consensus on the best treatment to reduce or prevent hypertrophic scarring;  Little can be done to prevent the formation of scar tissue, but multiple treatment interventions are used to prevent the disease of scar tissue contracture  and reduce the impact of the scarring process.
While the person is at rest, encouraging the person into the anti-contracture position should be continued for months after the injury.
The prescribed splints are necessary not only for positioning, but also for stretching and lengthening of contracted scar tissue.  Early splinter removal only for exercise and certain functional activities can maximize long-term outcomes and persist for 6 months post-recovery in children up to 2 years, or sometimes longer in children. Initially, splints are worn for most parts of the day, day and night – sometimes for months depending on scar activity. The splinting regimen should be gradually reduced to overnight splinting while the ROM is maintained. Mechanical stretching will increase the overall length of the scar tissue after splinting is performed  because splinting is the only viable treatment modality that applies a controlled gentle force to soft tissue over an extended period of time to induce tissue growth.  Continued use of splints helps to stretch scar tissue as it forms, apply pressure to problem areas and maintain anatomical contours – for example hands, axilla and neck. A well-fitting splint is extremely effective in maximizing long-term functional outcomes; sometimes it can compromise function in the short term. Splinting and positioning should always be accompanied by an active exercise and stretching regimen. Range of motion measurements are critical guidelines for defining splint effectiveness. 
Stretching and Exercise
In the early stages, post-wound healing scars are extremely active and dynamic, and the force of contraction is at the highest level. If the burn is near or over a joint, it should be stretched to prevent loss of ROM and prevent the development of a postburn contracture. Preventive and maintenance exercises and splinting programs used before the development of contractures are very important to maintain the required functional soft tissue length and soft tissue glide.  Stretching the affected joints to their maximum functional range several times a day, in combination with a splinting regimen, appears to help elongate the scar tissue that maintains ROM. However, if compliance with this regimen is not maintained frequently for months, the scar will narrow once again.
It is important for the individual to maintain a good exercise regimen which will help improve exercise tolerance and maintain a positive mental state as well as stretching the scar tissue.
Massage and Humidification
Scar massage is widely advocated as an integral part of burn scar management; While the exact mechanisms of its effects are unknown, it appears to help in several ways:
Moisturizing Applications – burn scars are often lacking in moisture, depending on the depth of injury and the extent of damage to skin structures. They can be very dry and uncomfortable, and this can cause the scar to crack and deteriorate. By massaging with an unscented moisturizer or oil, the upper layer of the scar becomes softer and more supple and therefore more comfortable; this also helps reduce itching, which can be a common problem.
As scars thicken and rise, they retain additional fluid, which reduces their plasticity. The effect of this excess fluid can be reduced by deep massaging the scar using your thumb or fingertips. Massaging while stretching helps increase the ROM of a burnt-affected limb.
Burn wounds contain four times more collagen than other wounds, which are rapidly expelled in rings and bundles. Deep massaging of the scar in small circular motions is thought to help align the scar tissue as it forms.
Sensory disturbance and changes in skin sensation are common in burn scars. Regular massage and touching the scars helps to desensitize hyper-sensitive scars.
An unsightly scar can also be reduced by the individual’s psychological factors, who have trouble coming to terms with what they’re feeling, by touching the scar and learning to accept how it looks and feels.
Pressure therapy is the primary method for burn scar management, although clinical efficacy has not been scientifically proven.  Applying pressure to a burn is thought to reduce scars by accelerating scar maturation and promoting the orientation of collagen fibers into uniform, parallel patterns, as opposed to the coiled pattern seen in untreated scars.  There is little written evidence around its mechanism, thought to produce localized hypoxia to the scar tissue by reducing blood flow to hyper-vascular scars, thus reducing collagen flow and reducing scar formation. As soon as the wounds are completely closed and can tolerate the pressure, the patients are put on pressure garments. 
When available, it is made to measure the pressure garments of individuals using them at an appropriate pressure level. In the event that the pressure of the clothes cannot be measured, effective spare parts can be used; such as tubi-grip ‘elastic support bandages, ‘lycra’ swimwear and cycling shorts, sports caps and wrist bands, bandages and breathable tapes in small spaces. Compression garments help:
to reduce scar thickness/bump
reduce scar redness
to reduce swelling
to relieve itching
to protect newly healed skin/graft
prevent contractures / protect contours
Pressure garments should be applied as early as possible for maximum effect and removed only to wash and cream the wounds and be worn for 23 hours. However, in hot climates, some patients experience difficulties due to heat and humidity, in which case the wearing time may need to be adjusted for more regular removal. If a patient has taken a long time to recover and has had a skin graft, a pressure garment should be provided as soon as possible after recovery. If there is an extensive burn and scattered small unhealed areas remain, a pressure garment may be applied with small topical dressings applied underneath.
Silicone is another method used to treat hypertrophic scarring. The precise mechanism of action of silicone in the prevention and treatment of hypertrophic scars is unclear, but it is likely that wound healing influences the collagen remodeling phase.  Softens, smoothes and bleaches scars, soothes them and improves their appearance. 
Activities of Daily Living
Individuals should be encouraged to return to their normal daily routines as soon as possible and be reintegrated as much as possible into their role in life before their burn injury.
After a burn injury, some people may feel lonely and isolated from society. Patients may find it difficult to reintegrate into society and continue with the lives they knew well before the injury. They may feel like they are the only people who have suffered such an injury and may not know how to re-enter society, especially if they have visible burn scars. These individuals should be encouraged to find themselves again in their social and professional life as soon as possible, and family members should be encouraged to encourage this behavior. For children, this means re-entering school as soon as they’re ready, meeting up with friends, and participating in activities and sports they enjoy. Sometimes relatives can be very protective of the individual for fear that something might happen again; their care and protection to keep the individual safe can sometimes hinder the reintegration process. Life after a burn injury, especially in a major injury, can make some important adjustments with the right support and rehabilitation, and patients with burn wounds can lead a happy life.
Rehabilitation of burn injury is a long process that starts from day one and requires continuity of care until scar maturation and beyond. It involves a team of multidisciplinary professionals and full patient involvement. However, sustaining burn injuries, major or minor, can have a dramatic impact on an individual’s physical and psychological well-being and requires teamwork and solidarity to help each individual overcome the challenges they may face. Although the path is not always easy, with the right support and therapeutic intervention, the patient can receive maximum physical, psychological and functional feedback after treatment with the commitment of the team to not accept even a contracture and to ensure that they understand the psychological and social challenges.
1. Kwan M, Kennis W. Splinting Programme for patients with Burnt Hand. Hand Surg. 2002;7:231–41.
2. Edgar D, Brereton M. ABC of Burns Rehabilitation after burn injury. Br Med J. 2004;329:343–5.
3. Edgar D. Active Burn Rehabilitation Starts at Time of Injury: An Australian Perspective. J Burn Care Res. 2009;30:367–8.
4. Fess EE, McCollum M. The Influence of Splinting on Healing Tissues. J Hand Ther. 1998;11:157–61.
5. Richard R, Baryza MJ, Carr JA, Dewey WS, Dougherty ME, Forbes-Duchart L, et al. Burn Rehabilitation and research: Proceedings of a Consensus Summit. J Burn Care Res. 2009;30:543–73.
6. Richard R, Ward RS. Splinting Strategies and Controversies. J Burn Care Rehabil. 2005;26:392–6.
7. Bloemen MC, Van der Veer WM, Ulrich MM, Van Zuijlen PP, Niessen FB, Middelkoop E. Prevention and Curative Management of Hypertrophic Scar Formation. Burns. 2008;35:463–75.
8. Smith FR. Causes of and treatment options for abnormal scar tissue. J wound Care. 2005;14:49–52.