Chăm Sóc Và Điều Trị Bỏng Toàn Diện (Total Burn Care – Tập 5)

46  •  Pathophysiology of the Burn Scar
468
COLLAGEN MATRIX FORMATION AND
MATURATION
Scars gradually increase in their strength, as measured by
their resistance to tearing, but never reach the strength
of normal dermis. During this process, the delicate fibers
of newly secreted collagens I and III are replaced by large
collagen I fibers that are oriented parallel to each other and
to the skin surface (Figs. 46.1 and 46.2). Maturation of
collagen fibers is largely a chemical process of remodeling
that involves covalent crosslinking of adjacent polypeptide
chains. Collagen fibers normally form and are degraded con­
tinuously in normal skin and in scars, but the processes
that control the rates of formation and degradation and the
orientation of the mature fibers are not fully understood.
Prolonged activation of the keratinocytes in the wounds
leads to reduced regulation of fibroblast collagen production
by the keratinocytes and prolonged inflammation, both of
which contribute to fibrosis. At the same time, mast cells act
to induce fibrosis through the release of histamine, tryptase,
and chymase, which stimulate collagen production, procol­
lagen synthesis, and procollagen cleavage, respectively.
CYTOKINES AND GROWTH FACTORS
Many short polypeptides, mostly cytokines and growth
factors, are responsible for the changes in cells that lead
to the stages of wound healing, including the transition
from the inflammatory to the proliferative phases, and
the formation and organization of a scar, or the matura­
tion phase. Among the most important are TGF-β, bFGF,
platelet-derived growth factor (PDGF), and VEGF.53–60 Fre­
quently the response of a particular cell type to a specific
mediator depends not only on binding to the precise cell
surface receptor, but also on simultaneous signals from
other cellular receptors. Thus the network of peptide signal­
ing is complex, and the range of possible cellular responses
is large enough to allow generation of complex structures
and considerable fine-tuning.56,61 There are many opportu­
nities for reparative processes to go wrong, to proceed in an
unbalanced fashion, or to fail to complete an appropriate
cycle of activation and regression.62–64
BIOPHYSICS OF THERMAL INJURY
Human skin cells die when their temperature is increased,
largely because of the sensitivity of the cell surface mem­
brane to disruption outside fairly narrow temperature
limits. Flame, electrical, and contact burns often lead to
pyrolysis and disruption and oxidation of some tissues as
well. Among the various cell types present in the skin, some
are likely to be more sensitive to temperature than others.
The degree of temperature elevation at a given site in the
skin also depends on the rate of heat transfer within the
tissue. The thermal conductivity of the dermis is much
greater than that of the subcutis since fat is a good insula­
tor. Perhaps for this reason thermal injury often leads to
necrosis of the entire dermis with little cell death in the
subcutis, as seen in wound biopsies. Hair follicles in some
sites typically extend well beyond the dermis into the adipose
tissue of the upper subcutis, and eccrine sweat glands are
also often present in the subcutaneous fat. Despite the
wound healing is abnormal and hypertrophic scars (HTS)
develop, this process of interlinking fibroblasts to form a
meshwork that supports tension parallel to the surface is
disrupted since nodules of collagen result that do not flatten
out normally.
INFLUX OF CIRCULATING CELLS
Many circulating cells actively migrate into wound beds
and play roles in defense against bacteria and fungi, clear­
ance of devitalized tissue components, and stimulation of
later phases of healing of the dermis and epidermis. Based
on experiments with partially selective ablation of individ­
ual cell types, the cells most important in stimulating and
maintaining tissue repair appear to be the T lymphocytes
and monocytes.43 Monocytes, which differentiate into tissue
macrophages, are responsible for synthesis and release of
many of the cytokines important in wound healing, as are
connective tissue cells and epithelial cells. Mast cell abun­
dance increases in the healing wound, and mediators
secreted by the mast cells recruit neutrophils and other cir­
culating inflammatory cells to the wound. At the same time,
mast cells induce an inflammatory response in the healing
tissue by acting on keratinocytes. In addition, circulating
stem cells enter healing wounds, where they can differenti­
ate to form fibroblasts and other connective tissue cells
needed to restore tissue integrity.44,45
MIGRATION OF KERATINOCYTES TO COVER THE
WOUND (EPIBOLY)
When the epidermis is transected, changes take place
rapidly in the basal cells of the epidermis adjacent to the
wound. The process of epidermal regeneration has been
well studied by Stenn and his colleagues.16,46,47 Altered
basal keratinocytes send out thin sheets and undergo
ameboid motion not over the wound bed, but under the
nonviable eschar and/or scab, secreting a provisional matrix
as they go.48,49 Development of this migratory phenotype is
stimulated by the plasma protein vitronectin and requires
the presence of albumin as a cofactor.16,47,50 Cell division
occurs to support this migration, not among migratory
cells, but among their precursors in the residual epidermis.
Similar processes stimulate migration and replacement of
epithelial cells from hair follicles in partial-thickness
wounds. After a sheet of epithelial cells is established over
the entire wound surface, they begin to divide and eventu­
ally create a multilayered stratified squamous epithelium
with a granular layer and keratinization. Epidermal cells
secrete substantial quantities of IL-1β and other cyto­
kines.51,52 The new proliferative epidermal basal cells also
secrete a new basal lamina composed of laminin, type IV
collagen, and bullous pemphigoid antigen; adhere tightly to
that basal lamina; and develop attachments of type VII col­
lagen between the basal lamina and the underlying fibers
of type I collagen in the scarred dermis. Also, just after the
newly formed epithelial layer completely covers the wound,
the phenotype of the connective tissue cells in the matrix
undergoes a series of changes and much less fibronectin is
found in the wound matrix.17 As noted earlier, in second-
degree burns, epidermal cells from the hair follicles regener­
ate the epidermis on the surface.

46  •  Pathophysiology of the Burn Scar
469
cC
bB
aA
Fig. 46.1  Photomicrographs of normal skin, stained with hematoxylin and eosin. (A) The hair follicles often extend through the dermis into the sub­
cutaneous adipose tissue. The epidermis forms irregular rete ridges at its base. (B) The reticular dermis of normal skin has an orderly arrangement of
collagen fibers with no preferred orientation. (C) With the Movat pentachrome stain, normal collagen fibers stain yellow-orange, and delicate intercon­
necting black elastin fibers are present between collagen fibers.
bB
aA
Fig. 46.2  (A) In a normal flat scar, the epidermis is flat and does not have any rete ridges and the dermis is replaced by collagen fibers that are oriented
parallel to the skin surface. (B) A Movat pentachrome stain of a normal scar shows mature collagen fibers stained yellow-orange and does not dem­
onstrate any elastin fibers.

46  •  Pathophysiology of the Burn Scar
470
admission, with removal of all necrotic tissue using either
tangential excision to leave most of the subcutaneous fat or
fascial excision which removes the entire subcutis. The
wound is initially covered with meshed cadaver skin from
the skin bank. Within a few days autografting is done using
meshed partial-thickness grafts from unburned regions.
Over the face and the hands, unmeshed sheet autografts are
often used to obtain the best cosmetic result. The epidermis
of the cadaveric homograft slowly degenerates, but the
dermal matrix often is incorporated into the healing wound.
The interstices of the autograft fill with granulation tissue
derived partly from the underlying fibrous or adipose tissue
and partly by migration of fibroblasts from the strands of
autograft. The autograft’s epidermis migrates over the
granulation tissue matrix, under the fibrin layer, and recon­
stitutes the epidermis without any follicles or other epider­
mal appendages. The pattern of the meshed grafts is usually
visible in the healed wound. The incorporation of dermal
connective tissue elements from the donor site may enhance
the pliability of the final scar. Occasionally epidermal inclu­
sion cysts develop within grafted burn wounds, and they
may rupture. These cysts could develop from residual hair
roots that had lost their connection to the surface, from
aberrant migration of epidermal cells during wound resur­
facing, or from trapping of epidermis by expanding connec­
tive tissue. In addition, tiny bits of hair shaft are sometimes
encountered in healing wounds, associated with a giant cell
foreign body reaction, perhaps representing hairs left
behind after necrosis of the hair follicles that originally pro­
duced them.
WOUND INFECTION
Bacterial infection frequently complicates wound healing.
The risk is increased in burn patients since large amounts
of necrotic cells and tissue are present in the wound and
provide a good culture medium for bacteria. When infection
occurs, the inflammatory component of wound healing is
greatly amplified and the processes of conversion of granu­
lation tissue to a dense scaffolding of collagen, wound con­
traction, and regeneration of the epidermis are all delayed.
Frequently the wound suppurates. Some bacteria cause
additional tissue necrosis, and some bacteria can invade
into normal tissues, leading to hyperemia around the origi­
nal wound and/or enlargement and deepening of the origi­
nal wound. In response to the bacterial infection and the
enhanced inflammatory reaction, the cytokine milieu of
the wound is altered.69–71 Grafts placed over wounds with
residual infected tissue typically do not take, and when large
numbers of bacteria are present deep in the wound bed
there is always the hazard that the bacteria may enter the
bloodstream, incite septicemia, and invade remote tissues.
These processes, which were common in the era before anti­
biotics and before the practice of early wound excision
became common, are now being seen again due to infection
with highly antibiotic-resistant strains of bacteria, particu­
larly Pseudomonas and Acinetobacter.
Hypertrophic Wound Healing
In most patients with large burns treated in our institution,
healing of the burn wounds is complicated by development
presence of adipose tissue around follicles, regenerative
capacity is frequently entirely destroyed by burns even
though there is little or no apparent necrosis in the upper
subcutis. In the most severe burns, however, the entire sub­
cutis may become necrotic, and cell death may occur in the
underlying fascia and skeletal muscle or even in underlying
internal organs.
Factors That Alter Wound Healing
CHANGES IN BLOOD SUPPLY AND PERFUSION
The study of local blood supply by ultrasound led to the
discovery that there is usually a zone of greatly increased
blood flow below a burn wound, which is not surprising as
part of a local inflammatory response to tissue injury. Above
this zone of hyperemia is a zone of tissue ischemia, in which
blood flow is less than normal. Remarkably, during the first
24 hours after a burn wound, the zone of ischemia typically
becomes significantly deeper, indicating that ischemic
injury of dermal tissues actually leads to a depth of tissue
necrosis greater than that produced by the immediate
thermal injury.65 Experiments in animals have shown that
neutrophils are involved in this progressive ischemic cell
death in injured but viable tissue deep to a burn wound.66
Altered blood flow may lead to vascular thrombosis in a
burn wound, also contributing to the risk of ischemic tissue
injury. In normal skin, there is a plexus of arteries and veins
immediately below the dermis in the upper layer of subcu­
taneous adipose tissue. This subdermal plexus is at risk of
thrombosis in deep partial-thickness burns and in full-
thickness burns, and it is vulnerable to damage in the
process of tangential wound excision, with further loss of
blood supply to the wound.
COMPROMISED WOUND HEALING:
REQUIREMENTS FOR OPTIMAL
WOUND HEALING
Long clinical experience has demonstrated clearly that
wound healing is greatly slowed and impaired when there
is deficiency of essential ingredients for construction of the
scar or of an adequate energy supply. Vitamin C deficiency
and protein-calorie malnutrition are characterized by defi­
cient wound healing, and provision of sufficient calories
and reversal of the usual protein catabolism are major goals
of general burn care. Vitamin D deficiency can impair
wound healing, whereas vitamin D addition increases
migration of fibroblasts and collagen production. Diabetic
vasculopathy is associated with deficient wound healing,
demonstrating the importance of an adequate microcircu­
lation. Heart failure similarly compromises wound healing.
Radiation, cigarette smoking, and hypoxemia also have
been associated with delayed wound healing.67 Advanced
age is associated with increased mortality from large burns
but does not in itself prevent good wound healing.19,68
BIOLOGIC RESPONSES TO WOUND EXCISION
AND GRAFTING
The current standard of treatment in our institution is early
excision of the burn wound, normally within 24 hours of

46  •  Pathophysiology of the Burn Scar
471
or clean incisions that were closed primarily.73–75 Keloids
extend beyond the initial site of injury, respond poorly to
medical therapy, persist for many years, and usually recur
after surgical excision. There is often a positive family
history of keloidal scarring, and keloids are 10–15 times
more common in dark-skinned people of African ances­
try than in northern Europeans and their descendants.
Elaborate patterns of raised scars are a symbol of status in
many African tribes, leading one to wonder whether this
practice may have exerted selective pressure during human
evolution.
HISTOLOGIC FEATURES OF
HYPERTROPHIC SCARS
Numerous HTS have been examined histologically in our
laboratory. The abnormal elevated scars consistently show
several distinct differences from uncomplicated flat scars.
The most striking is the presence of rounded whorls of
immature collagen that consist of delicate collagen fibrils,
mostly of type III collagen, small blood vessels, and plentiful
acid mucopolysaccharide. These nodules are very sharply
of elevated, thick, firm, reddish scars that itch constantly.
These hypertrophic cicatrices occur more commonly in
wounds that had become infected or took longer than usual
to become fully covered. They may cover large areas, but do
not usually extend beyond the original burn wound. These
abnormal wounds also are associated with more severe
wound contraction. In the great majority of affected cases,
these HTS enlarge for a period of months, then gradually
regress over a period of a few years, eventually becoming
flat scars with no further symptoms. In wounds that develop
HTS, there are often abnormalities of skin pigmentation,
either depigmentation or hyperpigmentation, that evolve
over time (Fig. 46.3). The largest HTS impairing function
are surgically excised, often with creation of Z-plasties or
sheet grafting to release scar contractures or the use of
lasers to ablate the scar. Generally new HTS do not develop
again. There does not appear to be a link with ethnicity for
this type of hypertrophic scarring, which occurs in about
75% of Caucasian, black, and Hispanic patients.72
Clearly this experience is quite different from that
described in the literature with keloids, which frequently
occur spontaneously or in response to puncture wounds
C
bB
aA
Fig. 46.3  Typical appearances of hypertrophic scars of burn patients. (A) The hypertrophic scar is raised above the surrounding normal skin, has sharp
borders, and is very firm to the touch. This scar recurred after complete excision. (B) Hypertrophic scars often have patterns corresponding to meshed
grafts and often are hyperpigmented, as shown here, or hypopigmented. (C) This round firm lesion developed from a minor burn on the patient’s ear.
It did not recur after excision.

46  •  Pathophysiology of the Burn Scar
472
features typical of keloids are seen as part of the spectrum
of hypertrophic scarring.
The distinction between HTS and keloids was first made
by Mancini and Quaife in 1962.76–79 The features typical
of HTS were further described by Linares, Kischer, and
others.80–83 The literature on HTS and keloids was thor­
oughly reviewed by Niessen84 and Huang.118
Because the etiology and pathogenesis of HTS are differ­
ent from that of keloids, we limit our discussion to HTS.
A number of differences distinguish between normal
scars and HTS. HTS contain more type III collagen, fibro­
nectin, and hyaluronic acid, all characteristic of the early
phases of wound repair, than do normal flat scars. HTS
are more vascular with higher cutaneous blood flow. HTS
contain significantly more T cells and macrophages than
normal scars. Larger numbers of mast cells have been found
in HTS, and indeed a clinical history of atopy and higher
levels of circulating IgE have been found in patients with
HTS. Recently much larger numbers of epidermal Langer­
hans cells have been identified in association with HTS.85,86
Immunohistochemical staining has demonstrated addi­
tional striking differences between HTS and normal scars.
Staining for α-smooth-muscle actin has consistently dem­
onstrated this contractile protein within spindle cells in the
characteristic collagen nodules of HTS. The sulfated proteo­
glycans of HTS are quite different from those of normal
scars in that much less decorin is present, and versican is
predominant in the rounded nodules. More VEGF immuno­
staining is seen in HTS. Larger numbers of small nerve
fibers have been identified by immunostaining in HTS.
These consistent findings may be providing important clues
to the pathogenesis of hypertrophic scarring, but, at this
time, they are difficult to incorporate into a single hypoth­
esis. Although the lack of a suitable animal model and the
scarcity of human tissue, in addition to the confusion sur­
rounding the proper identification of hypertrophic scar­
ring, have hampered research in this field, in recent years
the study of the biology of HTS has been enabled by the
demarcated from the surrounding scar tissue, which may
be composed of similar material or may be composed of
mature thick collagen fibers that are oriented parallel to
each other and to the wound surface, typical of mature
scars. Although the collagen fibers are clearly visible with
routine H&E staining, they are most distinctly seen with the
Movat stain, which stains mucopolysaccharides blue-green
and mature collagen fibers yellow-orange. The nodules of
HTS vary from 0.5 mm to more than 1 cm in diameter and
can be spherical, ovoid, or cylindrical in shape. The abnor­
mal dermal tissue is very firm and may reach a thickness
of several centimeters. Both normal and HTS are charac­
terized by lack of elastin, which is also visible using the
Movat stain. However there are often residual elastin fibers
in the deepest part of the dermis below zones of hypertro­
phic scarring, and sometimes there is a narrow zone of
normal elastin fibers above the HTS, perhaps derived from
the applied skin grafts. Occasionally small rounded nodules
of HTS tissue are seen scattered between intact hair fol­
licles. It is not unusual to see residual eccrine sweat glands
in the adipose tissue beneath a large HTS, suggesting that
these scars may originate in deep partial-thickness burns.
These features are illustrated in Figs. 46.4 and 46.5. In
addition, in a minority of HTS, an additional histologic
feature is seen consisting of very broad, hypereosino­
philic collagen fibers oriented parallel to each other but at
varying angles with the skin surface. In some cases such
broad, dense fibers dominate the wound. Generally they are
surrounded by whorls of circularly oriented, immature
collagen typical of HTS. These features are illustrated in
Fig. 46.6. These are the features that have been described as
typical of the histology of keloids. However, in our patient
population, typical keloids are distinctly unusual, and there
is no evidence to suggest that the patients with these thick,
eosinophilic collagen fibers have a worse prognosis or a
more delayed course of scar maturation than other patients
with HTS. Thus, in our extensive experience with the his­
tology of scars from large burns in children, the histologic
bB
aA
Fig. 46.4  Photomicrographs of hypertrophic scars. (A) Within the dermis there is a rounded nodule of collagen that has a sharp border and is distinct
from the surrounding scar tissue. (B) The border of a collagenous nodule in a hypertrophic scar. In the surrounding scar tissue, collagen fibers are
oriented parallel to the skin surface. Within the nodule, collagen fibers are very thin and are oriented circumferentially.

46  •  Pathophysiology of the Burn Scar
473
work has been done in which normal and abnormal human
scar tissue have been implanted into the athymic nude
mouse, which allows testing of potential therapies and
modification of the biological milieu in vivo.88–91 In this
model, it is even possible to irradiate the mouse and trans­
plant human bone marrow to study interactions between
immune reactions involving human cells and the human
skin grafts. Engrav and his colleagues developed a model in
the female red Duroc pig that mimics many of the features
of human hypertrophic scarring.92–100 Recent studies by
their group and others have elucidated molecular mecha­
nisms underlying HTS development as well as the effects of
antiscarring therapies at the molecular level.
development of new experimental models. Adoption of cell
culture models, culture of whole-tissue biopsies, use of
immune-deficient mice, and establishment of hypertrophic
scarring in the red Duroc pig have yielded important infor­
mation on biologic processes underlying human hypertro­
phic scarring.
EXPERIMENTAL MODELS OF
HYPERTROPHIC HEALING
The first animal model of keloids was described in 1959,
based on immunization of experimental animals with autol­
ogous skin, followed by induction of wounds.87 Extensive
B
aA
Fig. 46.5  (A) This Movat-stained slide shows a minimal hypertrophic scar consisting of a single round nodule between hair follicles. The nodule stains
light green, in contrast to the yellow-orange color of the surrounding mature collagen fibers. The greenish color reflects a larger quantity of sulfated
proteoglycans within the collagen nodule. (B) At higher magnification, numerous small blood vessels can be seen within a large, green-staining nodule
from a hypertrophic scar.
B
A
Fig. 46.6  (A) Some otherwise typical dermal nodules in hypertrophic scars contain very broad, hypereosinophilic collagen fibers similar to those typical
of keloids. This specimen is from the patient shown in Fig. 46.3C. (B) The typical appearance of the thick, dense collagen fibers that stain intensely with
eosin can be seen at higher magnification.

46  •  Pathophysiology of the Burn Scar
474
within the burn wound may lead to hypertrophic scarring
with increased fibrosis, downregulation of decorin, up-
regulation of versican, increased neovascularization, and
decreased collagenase113 The type of inflammatory response,
in addition to the magnitude and location of the inflamma­
tion, play a role in hypertrophic scarring. Characterization
of CD4+ T-helper cells revealed that, following a burn, polar­
ization of lymphocyte populations leads to a shift from a
TH1/antifibrotic phenotype to a TH2/profibrotic response.114
Decreased systemic expression of interferon-γ (IFN-γ) and
IL-4 and increased IL-4-producing lymphocytes persist for
a year following a burn injury.
PATHOGENIC CONCEPTS
Understanding of the biology of hypertrophic scarring has
been hampered by multiple factors, including problems in
gaining consensus on the definition of the lesion, the under­
use of a suitable animal model, and the consequent inabil­
ity to test hypotheses by altering the course of the disease.
Multiple concepts of pathogenesis have been proposed, with
some gaining wide acceptance while others have yet to be
experimentally excluded. It does seem clear that develop­
ment of an HTS represents an abnormality in regulation
of the normal processes of wound healing, which may
occur early, as Linares and Larson suggested.72 Failure of
the normal processes limiting collagen secretion and matrix
formation is apparent in HTS. One might suppose that the
normal processes by which tensions in the matrix signal cel­
lular responses have become defective in HTS.40,42 The roles
of the mast cell and other inflammatory cells in scar devel­
opment have become better defined; use of the mast cell
stabilizers ketotifen and sodium cromoglycate demonstrates
decreased fibrosis and wound contraction with inhibition
of mast cell activity, indicating new targets for antiscarring
therapies. Myofibroblasts are more prominent in immature
and active HTS than in normal or mature scars and are
thought to play a role in excessive wound contraction.
Dermal fibroblasts within the HTS differentiate into myofi­
broblasts. The fibrous nodules of HTS might represent per­
sistence and uncontrolled growth of a separate population
of connective tissue cells perhaps related to the perifollicular
cells that normally express versican. The formation of these
nodules may represent abnormal epithelial–mesenchymal
interactions; epidermal cells, such as Langerhans cells, and
increased IL-4 with decreased IL-1α expression have been
shown to influence dermal remodeling resulting in hyper­
trophic scarring. Since burn patients have higher circulat­
ing levels of glucocorticoids and IL-6 than do nonburned
individuals, selection of cells resistant to the usual effects
of these agents may occur following burn injury, leaving
fibroblasts that are able to withstand the normal suppres­
sive action on fibroblast proliferation. Metabolic differences,
such as higher adenosine triphosphate (ATP) concentra­
tions and greater oxygen consumption apparent within the
hypertrophic scarring, may be the emphasis on metabolic
differences. Finally, abnormal macromolecular expression
by the covering epithelium may lead to abnormal develop­
ment of the dermal scar or fail to suppress inappropriate
fibroblast functions.117 Clearly it continues to be important
to develop and test many hypotheses until the problem of
hypertrophic scarring is finally solved.
PHENOTYPIC ABNORMALITIES OF
HYPERTROPHIC SCAR FIBROBLASTS
There have been many studies of the functions and molecu­
lar biology of fibroblasts derived from HTS and keloids in
tissue culture. It does appear from these studies that there
is a significantly different phenotype of fibroblasts from HTS
that persists in culture. HTS fibroblasts have been found
consistently to secrete more TGF-β and collagen more
rapidly than fibroblasts derived from normal skin or normal
scars.101 Furthermore the depth of residence of the fibro­
blast also determines the fibrotic phenotype, with deep
dermal fibroblasts characterized by increased collagen
secretion with reduced collagenase expression, slower pro­
liferation, and an increase in α-smooth muscle actin expres­
sion when compared to superficial fibroblasts. Genomic
analysis has been done in several laboratories on HTS fibro­
blasts, with identification of numerous differences in gene
expression. In a genomic study from our institution, cul­
tured fibroblasts from HTS showed a reduced response to
IL-6 as compared to fibroblasts from adjacent normal skin,
suggesting that decreased receptor activation might be a
factor in hypertrophic scarring.102
GENE EXPRESSION IN HYPERTROPHIC SCARS
Studies of gene expression and regulatory pathways in HTS
tissue have begun to provide much better understanding
of both normal and hypertrophic wound healing. Initial
studies of HTS gene expression using transcriptome anal­
ysis showed consistent differences in the expression of
multiple collagen isoforms, growth factors, and metallo­
proteinases.103 Similar studies demonstrated the similarities
between human and porcine hypertrophic scarring.104 In
several experimental studies in animals, interventions have
been applied that alter wound expression of important genes
or signaling pathways, with substantial change in size of
the resulting wound.105–110 Studies in human patients have
shown that variation in a gene’s sequence can be associ­
ated with decreased severity of postburn hypertrophic scar­
ring; although the role of CUB and Sushi multiple domains
1 (CSMD1) in hypertrophic scarring is not yet known, a
potential modification of the TGF-β signaling pathway has
been proposed. Although more research is needed, such
studies promise possible therapeutic intervention in the
processes that lead to hypertrophic scarring.
INTERPLAY OF SYSTEMIC AND LOCAL
INFLAMMATORY RESPONSES
Both local and systemic cytokine expression impact the
development of hypertrophic scarring. In burned children
who do not develop HTS, active and total TGF-β1 levels in
plasma increased during the first 2 weeks following the
burn injury before dropping to levels below those found in
nonburned patients. In burned children who later devel­
oped HTS, however, active and total TGF-β1 levels in plasma
were diminished from the day of burn until at least 180
days later.111 Augmented levels of systemic TGFβ1 have
been correlated with increased circulating fibrocytes.112
Although elevated systemic levels of TGF-β1 may be benefi­
cial following a burn injury, prolonged expression locally

46  •  Pathophysiology of the Burn Scar
475
Further Reading
Clark RA. Basics of cutaneous wound repair. J Dermatol Surg Oncol.
1993;19:693-706.
Ingber DE. Mechanical control of tissue growth: function follows form.
Proc Natl Acad Sci USA. 2005;102:11571-11572.
Finnerty CC, Jeschke MG, Branski LK, et al. Hypertrophic scarring: the
greatest unmet challenge following burn injury. Lancet. 2016;
388(10052):1427-1436.
Tran KT, Griffith L, Wells A. Extracellular matrix signaling through growth
factor receptors during wound healing. Wound Repair Regen.
2004;12:262-268.
Zhu KQ, Engrav LH, Armendariz R, et al. Changes in VEGF and nitric oxide
after deep dermal injury in the female, red Duroc pig – further similari­
ties between female, Duroc scar and human hypertrophic scar. Burns.
2005;31:5-10.
Zhu Z, Ding J, Shankowsky HA, Tredget EE. The molecular mechanism of
hypertrophic scar. J Cell Commun Signal. 2013;7:239-252.
Conclusion
Healing of burn wounds requires activation of several host
processes, including fibrin clotting and lysis, deposition of
an immature connective tissue matrix and its reorganiza­
tion into a mature scar, and epithelial outgrowth and inter­
action between the epidermis and the dermal matrix. In
many burn patients, excessive scar tissue forms, with
adverse consequences. Continued study of this problem will
continue to be important until more effective modes of
treatment are developed.
Complete references available online at http://

475.e1
46  •  Pathophysiology of the Burn Scar
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2013;1:e25.

476
Burn Rehabilitation Along the
Continuum of Care
MICHAEL A. SERGHIOU, SHEILA OTT, APRIL COWAN, JENNIFER KEMP-OFFENBERG,
and OSCAR E. SUMAN
47 
(physical and/or occupational therapists) in order to assess
their medical status and formulate a plan of care. It is
crucial that therapists document the findings of their evalu­
ation in the patient’s medical record because these findings
will serve as the baseline upon which progress will be deter­
mined. A good burn evaluation should include (1) the
history of how the accident occurred; (2) an interview with
the patient’s caregiver to gather information regarding the
patient’s preinjury functional status and activity level; (3)
documentation of the etiology, classification, and total body
surface area (TBSA) of the burn injury; (4) documentation
of associated injuries such as fractures, smoke inhalation
injury, and exposed tendons and bone; (5) measurement of
edema, ROM, strength, and sensation if appropriate; (6)
assessment of ADL performance; (7) need for positioning of
affected areas, including splinting; (8) development of
short- and long-term treatment goals; and (9) development
and documentation of a treatment plan. The patient’s
status should be reassessed on a regular basis and after each
surgical procedure to update the plan of care as needed.
Therapists should communicate the results of their evalu­
ation and the treatment plan to the burn team and to the
patients and their families.
Positioning and Splinting of the
Burn Patient
In a study of burn survivor perceptions about rehabili­
tation, positioning and splinting routines were viewed
positively and identified as useful in order to improve move­
ment.1 Positioning of the burned patient is fundamental
to bringing about the best functional outcomes in burn
rehabilitation.2–4 Positioning programs should begin imme­
diately upon admission to the burn center and continue
throughout the rehabilitative process. The role of the burn
rehabilitation therapist is invaluable in designing a patient-
centered positioning program, one that reduces edema,
enables wound care, facilitates joint alignment, minimizes
the risk of peripheral neuropathy,2,3 and counteracts all con­
tractile forces without compromising function. In planning
and implementing an effective patient-specific positioning
program, the therapist should be aware of the patient’s
TBSA of burns, the depth of all injuries, respiratory status,
and associated injuries such as exposed tendons/joints or
fractures. Individualized positioning programs are moni­
tored closely for any necessary adjustments depending on
the patient’s medical status. The quote that “the position
of comfort is the position of deformity” applies to every
burned patient who has sustained a serious injury. The risk
Videos available at
Introduction
The physical rehabilitation of patients who have sustained a
burn injury is a serious undertaking and requires, among
other disciplines, the involvement of physical therapy, occu­
pational therapy, and exercise physiology in order to produce
the best functional and cosmetic outcomes. Recent advances
in medicine have significantly contributed to increased
patient survival rates, and this necessitates faster, more
comprehensive, and prolonged burn rehabilitation. With
severe burn injuries, as perhaps with any other order of
trauma, there is an urgent need for immediate and aggres­
sive initiation of patient-specific rehabilitation programs.
The distribution and depth of the burn injury clearly predict
the patterns of deformity and joint contractures and
mandate the establishment of therapeutic goals and the
initiation of treatment as soon as possible. As stated previ­
ously, the more extensive the burn injury, the greater the
rehabilitation challenge becomes. A seriously burned
extremity in an otherwise modestly burned patient is much
easier to restore to function than an extremity similarly
burned in a patient with full-thickness burns involving mul­
tiple anatomical surfaces. In the case of seriously burned
patients, the immediate and primary focus will always be
preservation of life and wound coverage. Today, burn reha­
bilitation specialists intervene early on in the patient recov­
ery process through the development and implementation
of rehabilitation programs intended to maximize the poten­
tial of functional and cosmetic patient recovery.
The primary short-term rehabilitation goal is to preserve
the patient’s range of motion (ROM) and functional ability.
Long-term rehabilitation goals include returning patients
to independent living and teaching patients to compensate
for any permanent functional loss suffered as a result of the
burn injury while contributing toward acceptable cosmetic
outcomes.
This chapter addresses the evaluation, positioning,
splinting/orthotics, serial casting, prosthetics, scar man­
agement, exercise, performance of activities of daily living
(ADL), and patient and caregiver education utilized in burn
rehabilitation along the continuum of care.
Evaluation of the Burn Patient
Upon admission to the burn center, patients undergo a com­
prehensive evaluation by burn rehabilitation therapists

47  •  Burn Rehabilitation Along the Continuum of Care
477
of deformity after burn injury is real, and burn scar con­
tractures should be anticipated and dealt with proactively.5,6
Anti-deformity positioning can be achieved through
multiple means: splinting, mechanical traction, cut-out
foam troughs and mattresses, pillows, strapping mecha­
nisms, serial casting, and, in some cases, through surgical
application of pins. The burn therapist needs to be aware of
physician-specific protocols and work closely with the entire
burn team to design the most effective positioning program.
Orthotics and splinting devices are vital in burn rehabilita­
tion because they are utilized extensively to obtain appro­
priate positioning of the entire body and to counteract the
contractile forces of scarring that lead to deformity. The
application of positioning strategies is used to influence
soft-tissue lengths to limit the loss of ROM due to scar for­
mation and contraction.2,3 No matter how the burn thera­
pist approaches splinting (material choice, design, and
application schedules), the goal is to achieve the best func­
tional outcome at the completion of rehabilitation. When
fabricating a splint or an orthosis, the burn therapist must
be aware of the anatomy and kinesiology of the body
surface to be splinted. Also, the therapist should be well
aware of all mechanical principles of splinting as they
relate to pressure, mechanical advantage, torque, rotational
forces, first-class levers, friction, reciprocal parallel forces,
and material strength.7
The general outcomes for the use of splints in a burn
rehabilitation setting have been identified as protection of
vulnerable structures, preservation of ROM, suppression of
scar, and correction of soft-tissue contractures.8 The goals
for positioning and splinting will vary with the phase of
burn rehabilitation. In the acute phase, the goal is edema
control and pressure relief; in the intermediate phase, the
aim is tissue elongation and graft protection; and, for long-
term rehabilitation, the target is tissue elongation.9 Posi­
tioning and splinting must be designed in a way to:
■ Allow for edema reduction
■ Maintain joint alignment
■ Support, protect, and immobilize joints
■ Maintain and/or increase ROM
■ Maintain tissue elongation
■ Remodel joint and tendon adhesions
■ Promote wound healing
■ Relieve pressure points
■ Protect newly operated sites (grafts/flaps)
■ Stabilize and/or position one or more joints, enabling
other joints to function correctly
■ Assist weak muscles to counteract the effects of gravity
and assist in functional activity
■ Strengthen weak muscles by exercising against springs
or rubber bands.7
Devices should:
■ Not cause pain
■ Be designed with function in mind
■ Be cosmetically appealing
■ Be easy to apply and remove
■ Be lightweight and low-profile
■ Be constructed out of appropriate materials
■ Allow
for
ventilation
to
prevent
skin/wound
maceration.7
Typical burn care positioning protocols describe the supine
position in great detail. More emphasis is now being placed
on the use of side-lying and prone positioning for patients
with large burns who must be immobilized for extended
periods due to newer grafting techniques that cover larger
areas with fragile skin substitutes. When designing posi­
tioning programs, the joint angles are aligned in neutral
postures and the supporting surfaces are modified to maxi­
mize the surface area to body contact while protecting bony
prominences from compression.
Side-lying may be used on a rotating basis for patients at
risk for sacral or scapular skin breakdown. In a preventive
program, the rotation is right side to supine to left side. The
order is then reversed on a 1- to 2-hour schedule. Full side-
lying at 90 degrees from supine should not be allowed for
any significant length of time due to excessive pressure over
the greater trochanter. A more appropriate position for side-
lying is approximately 30–40 degrees from the supine posi­
tion, which distributes pressure more evenly between the
head of the femur and the lateral portion of the sacrum.
The mechanics of a side-lying position can be accom­
plished using pillows or wedges made of foam or wood. The
advantage of foam or wooden wedges is that they can be
placed directly under the mattress with less manipulation
of the patient. As the rotation schedule is completed, the
wedge can either be removed for the supine position or
transferred to the opposite side of the mattress to achieve
side-lying on the opposite surface.
Prone positioning strategies are usually the position of
last resort (Fig. 47.1) and are reserved for patients who are
not successfully managed in supine or side-lying. For
example, there may be nonhealing grafts or wounds in the
rectal region that increase the risk of sepsis due to the intro­
duction of fecal matter. Other candidates for this protocol
include those with sacral pressure ulcers or posterior trunk
grafts that are not healing.
The clinician faces a host of issues that must be consid­
ered when instituting a prone positioning program. The
airway is always the first issue that must be considered
when designing a prone position mattress. The supporting
surface is cut from a solid open-cell foam mattress that is
Fig. 47.1  Patients may be positioned prone to protect posterior grafts
from shearing.

47  •  Burn Rehabilitation Along the Continuum of Care
478
In those cases where the ears are burned, they may be
protected by strapping ear cups made of thermoplastic
materials or foam.10 An ear conformer may be constructed
to prevent the rim of the ear from contracting toward the
head. Internal ear canal splints may also be fabricated and
serially adjusted as the circumference of the canal increases.
In addition, if the ear is affected, a soft circular foam can be
positioned posteriorly to the head to elevate the ears off the
surface of the bed. A nasal obturator may be required to
maintain the nostrils open. These obturators may be serially
adjusted as the circumference of the nostril increases.
Mouth splints are utilized for the prevention of oral micro­
stomia. These devices are custom-made by the therapist, or
they may be obtained commercially. Mouth splints may be
fabricated static or dynamic for horizontal or vertical
opening of the mouth.11–15 In cases of severe microstomia,
where compliance is an issue, an orthodontic commissure
appliance that attaches to the teeth may be fabricated by an
orthodontist.16 The use of stacked tongue blades is an
acceptable technique to aid in reversing oral microstomia.
Ongoing research looks at the development of a microsto­
mia device that circumferentially opens the mouth accord­
ing to its anatomy (Fig. 47.3). In the post-acute phase, facial
scar hypertrophy may require fabricating a high thermo­
plastic transparent mask, such as the Uvex and W-clear
masks, or a silicone elastomer facemask.17–19 A semi-rigid
low thermoplastic opaque mask may also be fabricated
depending on the state of scar maturation.
NECK
The neck is positioned in neutral or in slight extension of
approximately 15 degrees without any rotation. The
amount of neck extension must not be so great that traction
on the chin causes the mouth to open. Positioning may be
achieved with a short mattress supine, a rolled towel, or
foam cushion placed behind the upper back on the scapular
line. Pillows should be avoided in the cases of anterior neck
burns because they may lead to flexion contractures. In the
case of anterior neck burns, a conforming custom thermo­
plastic collar may be fabricated (Fig. 47.4).20 For burns
along the lateral surface of the neck and some long-term
placed on a wire mesh bed frame. Airway concerns are
addressed first, and the patient is evaluated for mode of
respiration. Nasal and tracheal intubation are issues to con­
sider, but these are not contraindications for the prone posi­
tion. A trough should be provided so that direct access can
be obtained for routine airway care and if breaths are
needed using an Ambu-bag. If the airway becomes compro­
mised, the prone position should be abandoned immedi­
ately until proper respiration is established.
The facial opening should be cut in a manner that maxi­
mizes weight distribution without allowing the head to
enter into the opening. Using this protocol places direct
weight-bearing pressure on the brow ridge, zygomatic
arches, and the anterior mandible. These structures should
be monitored closely, and the patient should be educated
that breakdown is likely to occur due to the limited subcu­
taneous tissue protecting the face. If burn scars are
encroaching on the eyelids, then the corneas should be
evaluated as well. Corneal abrasion can be avoided with due
diligence and prevention of the foam from contacting the
unprotected eye. Countersinking a gel cushion into the
upper portion of the foam mattress can protect the forehead
and brow ridge.
The sternum, pelvic region, and patellae are protected
with the use of an air-cell mattress that is inserted into the
mattress in a lengthwise manner. The air-cell segments are
typically supplied in standard lengths and may not reach
from the sternum to the ankles. If there is an unsupported
area between the distal portion of the mattress and the
dorsum of the foot, then the area can be supported with
open-cell egg-crate-type foam. The feet are supported at the
distal end of the mattress with a foam footboard. Extra pre­
cautions should be taken to evaluate the elevation of the
great toe from the supporting bed frame.
In the prone position, all traditional joint alignment sug­
gestions are maintained with the possible exception of the
elbows. Shoulder mobility dictates the style of prone mat­
tress that can be made for the individual burn patient. If the
patient has greater than 115 degrees of abduction, then the
mattress is modified to horizontally adduct and externally
rotate the shoulder while flexing the elbow to allow for
elevation of the hands. This minimizes edema in the hands
and allows for greater function once the prone position is
no longer needed. If the shoulders have limited abduction,
then a “butterfly” cut is used to allow for horizontal adduc­
tion of the shoulder to protect the brachial plexus, with the
hands remaining slightly dependent. This will result in
some hand edema, which can be addressed with pressure
wrapping (Coban glove) and active exercise.
HEAD
Acutely, in aiding with facial edema reduction, the head
should be positioned by placing it in midline and elevating
the head of the bed at 30–45 degrees if the patient’s hips
are not involved. In cases where the hips are burned, the
entire bed may be elevated at the head with the use of shock
blocks (wooden blocks, 12–16 inches, with recessed slots
for bed legs) or the use of the reverse Trendelenburg posi­
tion. These methods avoid positioning the hips in the flexed
position that promotes contracture formation and defor­
mity if persistent (Fig. 47.2).
Fig. 47.2  Wooden blocks are utilized to place the bed on an incline to
help with edema reduction and prevent hip contractures.

47  •  Burn Rehabilitation Along the Continuum of Care
479
needs, a soft neck collar or a Watusi-type collar may also be
fabricated as the patient’s wounds heal and contractures or
scars develop. The Watusi-type collar allows for isolated,
direct pressure to a thicker scar band.19,21,22 It has been
observed that, in some cases, acute patients rotate or later­
ally flex their neck on one side, which may lead to a lateral
neck contracture (torticollis). If the patient is to remain in
bed for a while, a dynamic head strap mechanism may be
fabricated to counteract the lateral neck contractile forces
and bring the neck into the neutral position. For the preven­
tion of torticollis, the therapist may fabricate a lateral neck
splint that conforms to the patient’s head, the lateral neck,
and anterior/posterior shoulder (Fig. 47.5).
SPINE
Contracture resulting from unilateral or asymmetric burns
of the neck, axilla, trunk, and groin will cause lateral cur­
vature of the spine (scoliosis). The level and amplitude of
curvature will vary with the site and severity of the con­
tracture. In addition, pelvic obliquity accompanying asym­
metric hip or knee flexion contracture will impose a lateral
lumbar curve. As long as the patient is recumbent, lateral
curvature can be prevented by maintaining straight
Fig. 47.3  Horizontal, vertical, and circumferential mouth-opening devices are utilized to correct oral microstomia.
Fig. 47.4  An anterior neck conformer helps prevent neck flexion
contractures.

47  •  Burn Rehabilitation Along the Continuum of Care
480
edema in the first 48–72 hours can promote the develop­
ment of a fixed deformity. Additionally, improper elevation
techniques for the upper extremity may lead to soft-tissue
calcification, increased bone density, and compressive neu­
ropathies. The recommended position for the burned shoul­
der and axillary complex is 90 degrees abduction, 15–20
degrees horizontal adduction, and external rotation toward
maximal. Abduction alone places the glenohumeral joint at
risk for anterior subluxation, if the position is maintained
for an extended period. Placement in horizontal adduction
anatomically reduces the potential for tractioning of the
brachial plexus or peripheral nerve compression. The gle­
nohumeral joint is externally rotated in order to counteract
anticipated deformities of internal rotation and adduction
and to maintain balance of the soft tissues of the shoulder
complex.
Positioning of the shoulder may be achieved with splints,
silicone-filled pillows, bedside tables, foam arm troughs,
metal abduction troughs, and thermoplastic slings sus­
pended from a trapeze mechanism (Fig. 47.7).23 Splinting
of the shoulder joint becomes more intensive as scar matu­
ration heightens the risk of contracture development. Air­
plane splints have been used for the resolution of axillary
contractures and postoperatively to protect reconstructive
procedures.24–26 Upon closer inspection of the literature, a
randomized controlled trial of adults with shoulder burn
involvement compared splinting to no splinting with regard
to functional outcomes and determined that shoulder
splints did not improve clinical outcomes in the study popu­
lation and that low adherence rates suggest splinting may
be unacceptable to patients.27 However, more recently, a
pilot study of a newly designed multiaxis shoulder abduc­
tion splint concluded that the device resulted in a significant
improvement in shoulder abduction angle compared to
unsplinted patients.28 The use of shoulder splints needs to
be studied further to determine patient types, design prin­
ciples, and timing of application.
In situations where deemed necessary, shoulder splints
can be modified. To accommodate wound dressings and
promote healing, a three-piece airplane splint may be fabri­
cated (Fig. 47.8). Foam arm wedges may be substituted
A
B
Fig. 47.5  (A) A dynamic head strap mechanism aids in positioning the
neck in a neutral position during a prolonged ICU bed confinement.
(B) A lateral neck splint is utilized to prevent lateral neck flexion con­
tractures (torticollis).
Fig. 47.6  Scoliosis resulting from a left chest, abdomen, and left lateral
trunk injury.
Fig. 47.7  Foam arm troughs are utilized for positioning the shoulders
in bed.
alignment of the trunk and neck (Fig. 47.6). However, the
curve is often insidious in onset and will not be recognized
until the patient begins to walk. Trunk list observed early in
the ambulation period can be simply a transient accom­
modation to pain and wound tightness, but a persistent list
may herald the development of scoliosis. Other subtle signs
of spinal curvature are asymmetry of shoulder levels, scap­
ular asymmetry, asymmetry of dependent upper extremity
alignment to the trunk, and asymmetry of pelvic rim levels.
A spinal mobilization exercise program is established with
the patient once a curvature is identified; however, once
there is an established asymmetric contracture it is difficult
by therapeutic means to stretch it out, so it is probably
better to deal surgically with a deforming scar early than to
permit even minor scoliosis to persist.
SHOULDER GIRDLE/AXILLA
Acutely the upper extremity positioning program focuses
on reducing edema through elevation. Failure to reduce

47  •  Burn Rehabilitation Along the Continuum of Care
481
flexion contracture and threaten posterior exposure of the
joint. Full extension is the protecting position for the elbow.
If the joint is exposed posteriorly, extension may need to be
rigidly maintained for several weeks. If the joint is not
exposed, mobilization into increasing flexion range can
begin very soon after the burn injury. The elbow is integral
to the so-called delivery system for the hand, and elbow
range to full or near-full flexion is more important for overall
function than range to full or near-full extension.
Radial head rotation for pronation and supination is less
often affected by the burn injury than is flexion and exten­
sion. The pronators and supinators are frequently injured
in electrical accidents where bone heats, being a poor con­
ductor, destroying the muscles closest to it. Forearm rota­
tion is essential for accurate hand placement, and the
rehabilitative program must address pronation and supina­
tion during functional tasks and skills training. Depending
on the location and severity of the injury, the forearm may
be positioned in neutral to slight supination. Static elbow
splints may be soft or custom-fabricated of thermoplastic
materials. An anterior elbow conformer may be fabricated
over the burn dressing. Dynamic elbow extension or flexion
splints may be utilized to provide prolonged, gentle, sus­
tained stretch and aid in the correction of contractures.30
Forearm dynamic pronation/supination splints may be
custom-fabricated or obtained commercially for the correc­
tion of contractures.19,20,22
WRIST/HAND
A comprehensive team approach from initial evaluation
through long-term follow-up is essential to maximize the
functional outcomes for individuals with hand burns.31
Treating therapists must have a thorough understanding
of the effects of thermal injury on the anatomical struc­
tures of the wrist and hand. The presence of dorsal hand
edema leads to intrinsic muscle ischemia and a resultant
“intrinsic-minus” posture. The unsupported burned hand
postures in wrist flexion, metacarpophalangeal (MCP)
hyperextension, interphalangeal (IP) flexion, thumb adduc­
tion, and thumb IP flexion. The overall appearance is that
of a claw deformity (Fig. 47.10A). Edema following a full-
thickness burn to the dorsal hand imposes the positions of
MCP hyperextension and IP flexion (Fig. 47.10B). Persis­
tence of this position results in a claw hand deformity. The
claw hand posture is primarily due to post-burn edema but
may persist throughout the course of treatment due to scar
contracture or in the presence of peripheral neuropathy.
Among the digits, the second and fifth most easily drift into
MCP hyperextension because each has a proper extensor
tendon.
While superficial burns result in minor, transient edema,
full-thickness injuries exhibit more severe and prolonged
post-burn edema. Superficial hand burns should not be
splinted in order to allow for frequent movement and the
freedom to function independently.2,3 In cases of severe
thermal injury, it is important to monitor for signs and
symptoms of vascular insufficiency or compartment syn­
drome. In treating the edematous burned hand, it is impor­
tant to position the hand above the level of the heart at all
times if it can be accomplished without compromising the
neurovascular supply to the hand.19,20,22
when the patient is in the bed postoperatively, when it is
difficult to fabricate an airplane splint. Other adaptations
may be required in the presence of amputations. Prefabri­
cated airplane splints come equipped with mechanisms that
allow for adjustments depending on available shoulder
ROM.19,20,22 A figure-of-eight axillary wrap may be utilized
in conjunction with an airplane splint to provide compres­
sion for axillary contour and elongation of skin surfaces
(Fig. 47.9). A descriptive study using the figure-of-eight
sling after scar release and skin grafting indicated that the
device is safe, comfortable, easy to use, and promotes com­
pliant use by the patient; with at least as reliable results as
the use of abduction splints.29 For successful contracture
management to the shoulder, the positioning program must
be supplemented by exercise routines for ROM, strength,
and endurance.
ELBOW/FOREARM
Acutely, elevation and extension is the desired position of
the elbow. Severe burns involving the elbow may result in
Fig. 47.8  A three-piece airplane splint may be fabricated to accom­
modate wound dressings and promote healing while maintaining the
shoulder abducted.
Fig. 47.9  A figure-of-eight axillary wrap provides a constant stretch of
the axillary skin surfaces.

47  •  Burn Rehabilitation Along the Continuum of Care
482
recommended that the optimal position for the burned
hand is wrist 0–30 degrees extension, 70–80 degrees MCP
flexion and IP joints in full extension (although some burn
centers may advocate a slight amount of IP flexion, deeming
the position to be “safe”). The thumb should be positioned
in a combination of palmar and radial abduction, with the
MCP/IP joints slightly flexed. An example of a modification
to the burn hand splint that would improve the protection
of grafted areas through the use of a “roll bar” is described
in the literature.33 What is clear is the need for controlled
studies to determine the appropriate body positions to
reduce deformity risks and to determine the most effective
methods for the use of splinting for maintaining ROM or
contracture management. All the described positions
resemble the “intrinsic-plus” position and can be achieved
through fabrication/fitting of a burn hand splint by a reha­
bilitation therapist (Fig. 47.11). The burn hand splint posi­
tions the hand appropriately to minimize soft-tissue
contractures and preserve functional mobility. Involvement
of the extensor tendon apparatus should be assumed and
protected until viability of the system is known.34 Continu­
ous splinting is recommended to manage edema, exposed
tendons, peripheral neuropathies, and uncooperative/
unresponsive patients.
In the intermediate phase, positioning and splinting are
used to prevent/correct deformities and protect surgically
reconstructed sites. Splints may be fabricated dorsal, volar,
or on the medial/lateral aspects. Contractures are a major
complication of hand burns because they affect one’s ability
to perform ADLs.5 Joint contractures have also been found
to negatively impact quality of life in burn survivors, espe­
cially with regard to physical function, role limitations,
pain, and vitality.35 Dorsal hand burns are prone to contract
into MCP hyperextension, IP flexion, and thumb adduction
and should be splinted into MCP flexion, IP extension, and
thumb palmar abduction. The most common post-burn
upper extremity contractures are wrist flexion, index finger
MCP hyperextension, index finger proximal IP flexion, and
small finger MCP hyperextension/proximal IP flexion.36 The
cupped palm deformity is functionally detrimental because
A
B
Fig. 47.10  (A) Edema following a full-thickness burn of the dorsum of
the hand: imposed metacarpophalangeal extension and interphalan­
geal flexion. (B) The deformity resulting from the persistence of this
position is that of a claw hand.
Fig. 47.11  The intrinsic plus position hand splint (burn hand splint)
positions the hand appropriately to prevent contractures and preserve
function.
Acute positioning of the wrist and hand after burn injury
is for edema control; immobilization/protection of tendons,
joint structures, and/or skin grafts; and optimal positioning
to maintain soft-tissue lengths and functional abilities.
Within the first 24–72 hours, it is recommended that the
wrist be splinted into extension, allowing the MCP joints of
digits one through five to fall into flexion due to the normal
tenodesis action of the wrist and hand. Wrist extension is
essential to control digital position and prevent a claw hand
deformity. The recommended functional position of the
wrist is from 0–30 degrees of extension.
The burned wrist and hand should be positioned to
oppose impending wound contracture. A review of the
burn literature indicates some disagreement regarding
positioning of the wrist and hand. A consensus panel of
burn rehabilitation experts discussed splinting of the MCP
joints in at least 70 degrees of flexion at night.2 Another
group of burn experts went a little further and described
the position of choice as being wrist extension, MCP
flexion greater than 60 degrees, and IP joint extension.3 A
third group, including surgeons, described the desired posi­
tion as 20–30 degrees of wrist extension, approximately 80
degrees of MCP flexion, IP extension, and thumb in
maximum abduction.32 The authors of this text previously

47  •  Burn Rehabilitation Along the Continuum of Care
483
“sandwich” splint may be fabricated that includes a burn
hand splint with a dorsal shell over the IP joints to prevent
flexion of the digits. All splints may be secured with elastic
bandage or with Velcro strapping components (Fig.
47.14).39 Individual gutter splints are used to prevent
flexion contractures, to restrict boutonnière and mallet
finger deformities, and to protect exposed extensor tendons
until wound closure. Recently, a group of hand therapists
has combined the use of digital gutter splints built into a
compression garment to improve adherence to wear sched­
ules in a pediatric population.40 C-bar splints are used to
prevent adduction contracture of the first web space.
Figure-of-eight splints are fit to correct or restrict swan neck
deformities.
Dynamic splints are utilized to provide low-load pro­
longed stretch to counteract contractile forces and are rec­
ommended for the correction of scar contractures.37
Dynamic splinting of the hand will focus on MCP extension/
flexion splints, IP flexion/extension splints, and thumb
abduction and may include prefabricated or spring-loaded
splints (Fig. 47.15).41 Patients may require dynamic splint­
ing to assist muscles weakened by peripheral neuropathy.
Fig. 47.12  The cupped palm deformity limits the hand’s ability to
grasp objects normally.
Fig. 47.13  An example of a palmar extension splint to stretch a palmar
contracture.
Fig. 47.14  The “sandwich” hand splint prevents proximal interphalan­
geal (PIP) flexion contractures.
it makes it impossible to smoothly reach around objects
(Fig. 47.12).
Burns to the volar surface of the forearm will predispose
the patient to wrist flexion contracture, whereas burns to
the dorsal surface will likely result in a wrist extension con­
tracture. If the wrist ROM becomes limited in a specific
direction, splinting the wrist in the opposite direction is
indicated. The fifth digit is occasionally pulled into extreme
abduction and hyperextension by scar contracture, muscle
imbalance, or ulnar neuropathy. The thumb may become
similarly displaced into adduction and retroposition. It is
important to remember that the likelihood for MCP joint
problems exists throughout scar maturation. Palmar hand
burns are prone to MCP flexion and thumb opposition con­
tractures and should be splinted into palmar extension and
thumb radial abduction.
Static positioning with custom thermoplastic splints can
be relatively efficient to implement in the clinical setting;
however, a review of the literature indicates that there is no
strong evidence for the use of static splinting in preventing
scar contractures.37 More recently, a group of surgeons and
therapists collaborated to look at serial splintage of the
upper limb after burn injury and found that the preopera­
tive use of splints may lead to lesser surgical interventions,
and minor contractures may be completely corrected.38
Two common faults are seen in custom splints that are
designed to gain MCP flexion and to position the thumb in
MCP flexion/radial abduction. If the distal transverse fold
of the splint is not proximal to the MCPs of digits 2–5, the
splint will impede rather than favor MCP flexion. If the
thumb component of the splint applies volar pressure rather
than medial pressure, the MCP will extend and the first
metacarpal will become correspondingly more adducted.
The first MCP joint should be maintained in slight flexion,
and pressure from the splint should be applied just to the
medial surface. Any degree of first metacarpal adduction
contracture increases the likelihood that the proximal
phalanx will be pushed into hyperextension and eventually
into subluxation.
In the case of circumferential hand burns, a palmar
extension splint is fabricated to prevent flexion contractures
and a cupping deformity of the palm (Fig. 47.13). The burn
hand splint and an extension splint may be alternated. A

47  •  Burn Rehabilitation Along the Continuum of Care
484
flexion. Deep anterior burns may expose the joint, occasion­
ally destroying the patellar tendon. Deep posterior burns
result in bridging scar formation. The appropriate position
for the knee is full extension to be maintained by splint or,
in severe cases, skeletal traction until there is efficient quad­
riceps function and the patient is ambulatory. Thereafter,
night splints must be used until scar contracture is no
longer a threat. Knee splints may include a posterior
custom-made thermoplastic knee conformer or a soft knee
immobilizer.
Persisting bilateral knee flexion contractures will impose
hip flexion. Persisting unilateral contractures may impose
pelvic obliquity and scoliosis. As with the hip, posture alter­
ation may be so subtle as to be overlooked. Correction of
even a slight contracture should be a surgical priority, as
should elimination of a soft bridging scar band that does
not prevent complete willful knee extension but causes the
patient habitually to hold the knee in slight flexion.
FOOT/ANKLE
Ankle equinus is the most frequently occurring deformity
involving the foot. Initially, it is related more to gravity and
failure to support the foot at neutral at the talotibial joint
than to the early effect of the burn. Loss of deep and super­
ficial peroneal nerve function will compound the problem
by encouraging the foot to drift into inversion as well as
equinus because of loss of dorsiflexion and eversion motors.
In the end, the total deformity for the unsupported foot may
be ankle equinus, hindfoot inversion, and forefoot varus
and equinus. Ankle equinus quickly becomes a resistant
deformity so that, within a few days or even hours, the foot
can no longer be positioned at 90 degrees of dorsiflexion in
the neutral ankle position. Eventually the contractures of
scar, muscle, and capsular structures combine to fix the
deformity.
The therapist monitors dynamic splinting closely and makes
frequent adjustments in order to provide effective tissue
mobilization. Additionally, the fit of dynamic splints is
checked frequently to ensure that the anatomical structures
remain properly aligned.
HIP
When anterior burns extend from the abdomen to the
thigh, hip flexion is the position of comfort. If the hip is fixed
in any degree of flexion, posture will be modified. Bilateral
symmetric contractures impose increased lumbar lordosis,
knee flexion, or both. Asymmetric contracture will cause
pelvic obliquity and scoliosis. In adults and older children,
thighs are more likely to be held in adduction than in abduc­
tion, whereas in preambulatory infants the secondary com­
ponent of the contracture is abduction. Thus, for the hips,
the preventive position is full extension, 0-degrees rotation,
and symmetric abduction of 15–20 degrees. If elevation of
the upper body is needed for edema reduction, then the
entire frame of the bed is elevated with the use of wooden
shock blocks placed at the head of the bed or the bed is
placed in reverse Trendelenburg with support of a padded
footboard. Soft mattresses should be avoided because they
may promote hip flexion. Hip positioning is accomplished
with the use of abduction pillows and other strapping
mechanisms that eliminate hip rotation. If the patient
wears bilateral foot splints, then connector bars may be
utilized on the splints to bring about the desired bilateral hip
positioning stated earlier. Hip flexion contractures may be
serially corrected with an anterior hip spica or with a three-
point hip extension splint (Fig. 47.16).19,20,22 Subtle hip
flexion contractures can be easily overlooked when the
patient stands, there being only a slight increase in lumbar
lordosis or forward or lateral shift of the trunk. If estab­
lished hip flexion contractures are not surgically corrected,
body posture is likely to be permanently altered with scolio­
sis or exaggerated lordosis.
KNEE
Burn injury to the anterior or posterior surface of the lower
extremity that crosses over the knee joint may result in knee
Fig. 47.15  A dynamic metacarpophalangeal (MCP) extension splint
promotes functional use of the hand.
Fig. 47.16  An anterior hip spica splint is utilized to prevent anterior hip
flexion contractures.

47  •  Burn Rehabilitation Along the Continuum of Care
485
yields inconsistent results. The correction achieved is often
just to neutral or to slight dorsiflexion. The Ilizarov tech­
nique has been used with generally satisfactory immediate
results in severe cases.42 No matter how correction is
achieved, if there are no dorsiflexion motors and if the
range of ankle motion is only a few degrees, ankle fusion
may in the end yield the best functional result.
The most common intrinsic deformity of the foot is
extreme extension of the toes due to dorsal scar contrac­
ture. This deformity is insidious in onset and is difficult to
prevent because there is no type of nonskeletal splinting
that will hold the toes flexed. In its extreme, the deformity
includes dorsal metatarsophalangeal (MTP) subluxation,
which may involve one or all toes depending on the location
of the scar. The metatarsal heads become prominent on the
plantar surface and walking may be painful. Correction of
the deformity requires dorsal surgical release of the con­
tracture, manual correction of the deformity, and, in severe
cases, intrinsic or extrinsic pinning of the digit or digits in
an overcorrected position (i.e., MTP and interphalangeal
flexion). The deformity will commonly if not inevitably
recur to some degree unless the patient, after the operation,
is able to achieve active MTP flexion in all digits.
Dorsal scar contractures extending from leg to foot to toes
may pull the foot into marked inversion if the scar is medial
or into eversion if the scar is lateral. The fifth and first toes
may be separately displaced by the same scar bands. These
contractures must always be surgically corrected. Their
persistence will lead to bone deformity in a growing child
and will permanently adversely affect foot and ankle func­
tion. Even slight inversion, whether imposed by scar con­
tracture or motor weakness, will increase pressure on the
lateral border of the foot, leading to callus formation and a
painful, inefficient gait. Occasionally the base of the fifth
metatarsal is so offensive as to require partial surgical
osteotomy.
When there is both anterior and posterior scar contrac­
ture, the talus will remain aligned with the calcaneus in a
relatively plantar flexed position as the midfoot and forefoot
are pulled into dorsiflexion. The result is so-called rocker
bottom foot with the head of the talus being the principal
weight-bearing feature. This deformity once established
defies correction by usual surgical means because of the
shortage of soft tissue and because vessels and nerves
cannot be stretched to accommodate the corrected position.
The Ilizarov technique may offer a partial solution to the
problem. Removal of the head of the talus may give a rea­
sonable weight-bearing surface. With chronic painful ulcer­
ation, amputation is the best treatment.42
Orthotic Treatment of the Lower Extremity
Multiple articles have been written about surgical interven­
tions for burns to the feet in both adults and children.43–46
The approach of the orthotist in treating the injured foot
depends on the extent of the burn injury. Contracture defor­
mities of the feet after burn injuries present a complex
problem for all members of the burn rehabilitation team.47
The options for management include orthopedic shoes with
and without modifications, orthotic inserts, ankle–foot
orthoses (AFOs), and heel lifts. Orthopedic shoes, which are
the fundamental component of lower extremity orthotics,
may be utilized with some modifications in correcting
Equinus deformity and the attending inversion and fore­
foot varus can be prevented by accurate and unyielding
support of the foot in neutral alignment or slight dorsiflex­
ion. If the patient must be nursed prone, the feet must be
allowed to fall free from the mattress. Static splinting, if not
performed correctly by an experienced therapist, is often
unsuccessful because of the patient’s desire and tendency
to plantarflex strongly, displacing the splint and leading to
ulcers of the heel, malleoli, toes, and where the splint edges
touch the skin. A stable footboard may be effective if the feet
are kept securely and totally against it. For large burns and
particularly for circumferential burns of the lower extremi­
ties, skeletal suspension incorporating calcaneal traction
will support the foot at neutral if the traction pin is placed
in the calcaneus well behind the axis of ankle motion. A
balanced traction system demands that the knees be sup­
ported in flexion with tibial pins at the level of the tibial
tubercle. Calcaneal pins will not prevent forefoot equinus.
If traction must be employed for several weeks, proximal-
pull dorsal pins in the first or first and second metatarsals
may be required for support of the forefoot. Transmetatar­
sal pins are useful as well when calcaneal traction alone is
not sufficient to correct equinus.
Minor established equinus deformity can be corrected
with a standing and walking program. At the outset, gradu­
ated heel lifts may be used to accommodate to the deformity.
If the patient must be bed-confined, skeletal traction
through the calcaneus may be the quickest and most effi­
cient way to correct the deformity. Traction is effective even
if scar contracture contributes to the deformity. Serial cor­
rective casts or posterior splints alone are useful mainly for
minor contractures. For the treatment of circumferential
foot/ankle burns, anterior foot splints are also fabricated
and their application is alternated with the posterior foot
splints in preventing plantar or dorsal foot contrac­
tures.19,20,22 The Multi Podus System foot splints may be
utilized for the positioning of the burned foot/ankle because
they relieve heel pressure and prevent pressure ulcers (Fig.
47.17). For fixed, unyielding deformity, scar release com­
bined with tendo-Achillis lengthening with or without pos­
terior capsulotomy is a standard surgical procedure that
Fig. 47.17  The Multi Podus splint is utilized to position the burned foot
appropriately and prevent heel and malleoli skin breakdown.

47  •  Burn Rehabilitation Along the Continuum of Care
486
knee–ankle–foot orthosis, hip–knee–ankle–foot orthosis or
a trunk–knee–ankle–foot orthosis may also be designed for
the best functional outcome.48
SERIAL CASTING
Multiple authors have identified serial casting as a treat­
ment option for burn scar contracture management.5,49–54
Casting has been used in patients with burns for postopera­
tive immobilization to promote graft adherence and to mini­
mize scar contracture during the remodeling phase of
healing.54 Circumferential casting after skin grafting to the
lower extremity has been an effective means of providing
protection to the grafted area.55 Serial casting has been used
successfully on outpatients with burns when active ROM is
limited due to scar tissue formation.52 Dewey, Richard, and
Parry described serial casting as an alternative to the use of
orthotic devices for contracture management in the pres­
ence of burn scars.9
The literature has several examples of casting being
used as an anticontracture device for the hand,56–61
wrist,54,60 elbow,54,62 axilla,63,64 knee,54 and ankle.53,54 In
a retrospective study published in 2000, Richard, Miller,
Staley et al. compared patients treated with a multimodal
approach of scar massage, therapeutic exercises, and pres­
sure therapy to those treated with a progressive approach
that included static or dynamic splints and serial casting;
the authors found significantly fewer days were required
to correct the burn scar contractures in the progressive
treatment group.50
Casting works based on the biomechanical principle of
stress relaxation in much the same way as a static splint
design does.9 Similar to static splinting, serial casting is a
rehabilitation approach used to increase elongation of scar
tissue.2 The application of a series of casts provides a low-
force, long-duration stress that can cause a permanent,
plastic deformation of connective tissue.51 The goal of serial
casting is gradual realignment of the collagen in a parallel
and lengthened state by constant circumferential pres­
sure.53 Prolonged, gentle, sustained stretch provided by the
cast aids in tissue elongation for the correction of contrac­
tures (Fig. 47.19). Burn scar under constant traction shows
collagen formation in parallel alignment along the forces of
stress.65 Low-intensity force with prolonged duration of
stretching can be applied to connective tissue whether it is
scarred, contracted, or surgically shortened.66
A review of the literature indicates that serial casting is
typically used when the patient is noncompliant, does not
tolerate splints, there is persistent ROM limitation, or a skin
graft site requires protection or immobilization.51,53,54 Serial
casting can be a relatively simple, fast, and painless inter­
vention and provides an alternative to complex splinting
when patient compliance is an issue (e.g., in pediatric
patients or patients with decreased arousal). Bennett, Helm,
Purdue, and Hunt casted 35 patients with scar contractures
at an average of 161 days after burn injury and found that
all had significant improvements in ROM, which raises the
question of why serial casting is so often considered a last
resort.54
Additionally, clinicians may be hesitant to apply a cast
because of open wounds, despite the fact that serial casting
has been advocated for protection of involved sites after skin
deformities of the burned foot. Modifications of these shoes
may include arch pads, molded foot thermoplastics, tongue
pads, and metatarsal bars. The ideal shoes should distribute
all forces to the foot appropriately, reduce pressure on sensi­
tive or deformed structures, and encourage total surface
weight-bearing along the plantar aspect of the foot. Inserts
for plantar foot support, such as the University of California
Biomechanical Laboratory (UCBL)-type, may be utilized as
indicated.
During the preambulation stage, the patient may be fitted
with those orthotic devices mentioned earlier; if properly
utilized, they can position the ankle joint in a balanced posi­
tion, assist in preventing or correcting plantar/dorsal con­
tractures, and correct inversion/eversion of the foot.
Leg length discrepancies are seen frequently in the cases
of severe lower-extremity burn injuries and should be
addressed with a shoe lift. The ankle–foot complex is diffi­
cult to address, especially in the case of a severe thermal
injury. In most cases, the resultant deformity is the equin­
ovarus foot. Both conventional and thermoplastic systems
may be designed to treat the equinovarus or equinovalgus
foot. Such systems may include a metal AFO, polypropylene
plastic posterior AFO (solid ankle or with an articulation),
an AFO with stirrup attachment, or an AFO with stirrups
and patellar tendon support. A dorsiflexion spring assist
may be incorporated in the AFO to aid weak ankle motion.
Different straps, such as a valgus correction strap, may be
attached to the AFO for the correction of specific problems.
Interface materials, such as silicone, Plastizote, and Ali­
plast, can be incorporated into an AFO to provide protection
of the soft tissues, provide for total surface weight-bearing,
and accommodate any anatomical anomalies that may be
present (Fig. 47.18). In the event that a return of ROM is
anticipated, an AFO could be fabricated that can be modi­
fied as the patient progresses. As described, the ankle joint
is incorporated into the AFO; however, the device is left solid
and articulated at a later date.
During more complicated cases, and depending on the
anatomy and function of the lower extremities, a
Fig. 47.18  Specialized materials may be required to accommodate
anatomical anomalies. Standard ankle–foot orthoses can be fabricated
utilizing silicone materials to accommodate excessive scarring and
limb loss.

47  •  Burn Rehabilitation Along the Continuum of Care
487
harden, an exothermic reaction occurs causing the tem­
perature within and beneath the cast material to rise,
which leads to elevated temperatures and the risk of burn
injuries. The greatest risk of thermal injury occurs when
a thick cast using warm dip water is allowed to mature
while resting on a pillow.67 Excessively thick casts and a dip-
water temperature of higher than 24°C should be avoided.
Placing the limb on a pillow during the curing process of
the cast puts the limb at risk for further injury and should be
avoided.68
A variety of materials are available for the fabrication of
casts. The most widely known would probably be plaster-of-
Paris. Plaster is fast setting when reacting with lukewarm
water. Plaster casts are inexpensive, strong, and easy to fab­
ricate. However, they require longer drying times (24–48
hours), are prone to indentations and skin irritations, and
are heavy. Other disadvantages of this technique include
decreased water resistance and breakage if not constructed
strongly enough. Plaster casts may be removed with a cast
saw or moistened and removed with scissors.
Fiberglass casting material is an alternative to plaster-of-
Paris. Fiberglass casting tape is fast setting when reacting
with cool water. Fiberglass materials require a shorter
drying time (15–30 minutes), are lightweight and durable,
and offer resistance to dirt and water. Fiberglass casting
methods are costlier than plaster. Because of fiberglass’s
abrasive properties, therapists must wear gloves when han­
dling the materials during cast fabrication and removal.
The patient’s skin and clothing should be protected from
contact with the fiberglass casting tape, as well as with
fiberglass fibers during cast removal. Fiberglass casts require
a cast saw for removal.
Recently, nonlatex polyester materials such as Delta-Cast
have been utilized as alternatives to plaster and fiberglass.
These materials, which resemble fiberglass, are very light­
weight, flexible, and, because of their elastic properties,
conform very well. These casts may be cut in a bivalve
fashion so that they can be removed and reapplied after
wound care, hygiene, and exercise.69
After cast fabrication is complete, the clinician should
check the firmness of the cast, neurovascular status of the
extremity, sharpness of cast edges, and any signs of the cast
rubbing adjacent structures. When casting is completed,
the patient should feel a gentle but not painful stretch. The
first cast should be removed at approximately 24 hours;
thereafter, depending on the patient’s tolerance, it could be
applied for up to 1 week at a time. In the literature, the
reported frequency of cast change ranges from daily to
every 10 days.53,54,57,60,62,63 In cases of casting over open
wounds, the cast should be removed every 1–2 days to avoid
complications in wound healing.53,55 The use of insert
material for scar management under casts has been docu­
mented and found to be useful.53 Serial casting is termi­
nated when either normal ROM has been restored or no
further functional gains are achieved.
According to a consensus summit of burn care profes­
sionals, the traditional thought processes regarding the use
of serial casts with the burn patient need to be re-evaluated,
casting regimens need to be standardized, and studies are
needed to evaluate serial casting at various stages of burn
recovery and the overall effectiveness of the modality for
contracture management.2
grafting.55 Ricks and Meagher evaluated cast application
immediately after skin grafting in 36 patients with lower-
extremity burns.55 They found that the casted group had
significantly fewer days from skin grafting to wound closure,
a higher rate of graft adherence, and needed fewer surgical
treatments for deficits in ROM. The use of serial casts is
often advocated as a last-resort treatment when a patient
does not respond to traditional therapy and is often used
primarily in the long-term phase of recovery.2
The process of cast fabrication has been described for use
in both the adult and pediatric patient populations.51,55,56,59
A precasting assessment should include goniometric mea­
surements, end-feel assessment of the involved joints to
determine the structures involved, duration of limitation,
skin or wound status, neurovascular status, functional
needs, and cognition of all involved parties. The patient is
educated on the position in which the cast will be applied,
the expected duration of casting, and any restricted activi­
ties. Ridgway described the serial casting technique and
sequence: (1) skin hygiene, (2) scar massage with moistur­
izer, (3) ROM exercises and assessment, (4) wound dress­
ings, (5) application of a silicone insert, 6) extremity in
figure-of-eight wrap or tubular bandage, (7) padding over
bony prominences, and (8) one therapist to position and
one therapist to fabricate cast.53 Clinicians need to provide
adequate pressure relief over bony prominences, however,
to prevent skin breakdown. The clinician should only allow
a minimal time lapse between cast removal and cast reap­
plication. Serial casting may be supplemented with static
splinting of the adjacent joints.
Patients may require premedication and may also benefit
from soft-tissue preconditioning (heating) for stretch prior
to cast application. Precautions should be taken to ensure
proper and evenly applied padding, including extra layers
at the proximal and distal ends of the cast. The casting
material should be rolled out and handled with an open
hand as much as possible. Aggressive molding or overtight
applications are to be avoided and can lead to compression
neuropathies or vascular compromise. When cast materials
Fig. 47.19  Serial casting provides prolonged, gentle, sustained stretch
and aids in tissue elongation and correction of contractures without
pain.

47  •  Burn Rehabilitation Along the Continuum of Care
488
amputee includes splinting for the prevention of contrac­
ture. An upper extremity splint may extend past the distal
end of the residual limb to match the length of the whole
limb, thus assisting a patient in retaining the concept of
length. Initially, therapists must address: promotion of
wound healing; pain management, residual limb shaping,
prevention of contractures, skin desensitization techniques
(tapping, massage, scar mobilization, pressure application),
edema control, and coping mechanisms for adjustment and
grief. With early socket fitting, some skin problems will be
encountered, but these are not usually of major signifi­
cance. Silicone gel or urethane socket inserts have been
used successfully for pressure relief to burn-scarred skin. As
wound healing progresses, prosthetic training will begin to
focus on care of the prosthetic device, don/doff methods,
skin inspection routines, weight-bearing with the device,
and progressive functional skills.
Just as upper extremities are different from lower extremi­
ties, so, too are upper- and lower-extremity prostheses. The
minimum requirements for successful use of an upper-
extremity prosthesis are trunk control to support an upright
posture, sufficient upper body strength to selectively acti­
vate the control devices, and static and dynamic balance
skills. The patient will need to be trained on specific body
movements to develop control of the upper-extremity pros­
thesis. Glenohumeral flexion provides excellent power and
reach for functional routines. It can be used to flex the
elbow, activate the terminal device, and for activities away
from the midline of the body. Scapular protraction is also
trained for activation of the terminal device and facilitation
of fine motor tasks at midline or close to the body. The other
motions of glenohumeral depression/elevation, extension,
and abduction are most frequently used to lock or unlock
an elbow joint.
Different types of upper-extremity prostheses are avail­
able along a continuum from mostly passive or cosmetic to
primarily functional. Most devices fall somewhere in the
middle range between cosmesis and function. Cosmetic
prostheses are difficult to keep clean, expensive, and ulti­
mately sacrifice function for appearance. Functional pros­
theses fall into two categories. They can be designed to be
body-powered (using cables) or externally powered (myo­
electric or switch control). Body-powered prostheses are
moderate in cost and weight, more durable, and offer higher
sensory feedback. However, they require more gross limb
movement and can be less cosmetically appealing. Exter­
nally powered prosthetic devices allow for more proximal
function, greater strength for grasp/prehension, and
improved cosmesis. Additionally, they may be heavy and
expensive, offer less sensory feedback, and require more
regular maintenance. Regardless of the type of prosthesis
planned for, fitting of an upper-extremity body-powered
prosthesis within 7–30 days correlates with higher accep­
tance and success rates.73 Body-powered prostheses are
most commonly used in burn rehabilitation, and Table 47.1
describes the components of upper-extremity prosthetic
devices.74,75
The rehabilitation upper-extremity prosthetic goals
should include stability of the shoulder girdle to allow pre­
hension, overall ease of movement of the entire limb, energy-
efficient use of the device, and the appearance of a normal
upper extremity. Table 47.2 describes upper-extremity
Prosthetic Interventions
A prosthesis is a device used to replicate the function and
appearance of a missing limb. Amputations among the
burn patient population most often occur as a result of
electrical insults but can also result from more severe
thermal injuries as well. They have a significant physical
and psychological consequence, which impacts quality of
life.70 Prosthetics are designed, fabricated, and fit by a certi­
fied prosthetist. Each device is individualized based on the
needs of the patient. But, in general, the prosthesis should
be comfortable to wear, easy to don/doff, lightweight, of
durable construction, and be cosmetically appealing. The
prosthetist and rehabilitation professional will consider the
following when designing the prosthesis and its compo­
nents: level of amputation, shape and contour of the resid­
ual limb, functional expectations, cognitive abilities,
vocational requirements, hobbies/leisure pursuits, and
financial resources. Standard prosthetic texts are useful in
providing broad basic information and explanations of the
many components available and their use.71,72
Patients who have sustained severe burns and subse­
quent amputations have complex, long-term impairments
and face considerable functional deficits.
Severely burned patients tend to have sensorimotor limi­
tations in the intact extremities that may affect their ability
to utilize a prosthesis. Their limitations and strengths are
important considerations when planning treatment. These
patients may exhibit muscle weakness not usually seen at
the same amputation levels in the nonburn patient. Areas
of weakness should be noted and compensation, such as
increasing joint stability through alignment or componen­
try, should be provided. Burned individuals may use their
remaining functioning extremities differently than patients
without total body involvement. Prosthetic rehabilitation
should enhance adaptations and necessary compensatory
methods. The challenge to the prosthetist is to design a
device that is maximally useful to a person who may have
multiple limitations. To be useful, a device must be as easy
to use as possible. Simplicity often determines whether the
device is successful or discarded.
Prostheses may be preparatory or definitive. Preparatory
devices are those fitted while the residual limb is still matur­
ing. A preparatory prosthesis is provided when reduction
of stump volume is anticipated or when fitting over a bulky
dressing is necessary. These devices are usually simple,
passive devices that allow for early motion skills and weight-
bearing through the affected limb. Some patients will
continue to use their preparatory prosthesis for extended
periods of time while other areas of the body are treated.
Prior to definitive fitting, body weight, residual limb volume,
and wear and use patterns should be stable in order to opti­
mize the long-term result with the definitive prosthesis. The
definitive prosthesis is fitted when the residual limb is fully
mature. The use of a preparatory prosthesis is not manda­
tory, but the use of one will improve the fit and control
of the definitive prosthesis and may, secondarily, reduce
the amount of time needed for rehabilitation post-burn
injury.
Prosthetic preparation in burn rehabilitation begins in
the postsurgical phase. Early prosthetic treatment of an

47  •  Burn Rehabilitation Along the Continuum of Care
489
tolerate pressure and weight-bearing. Lower-limb devices
may be either preparatory or definitive. Table 47.2 details
types of lower-extremity amputations by level and identifies
the appropriate prosthetic and components.74,75
Two common sequelae of traumatic amputations are
phantom sensation and phantom pain. Phantom sensation
is the perceived sense that the amputated limb is still present.
It is not typically characterized as painful by the patient.
The patient may report feeling that the amputated limb has
shrunk (telescoping). In contrast, phantom pain is the sensa­
tion of pain originating in the amputated part. Upon assess­
ment, the pain may or may not be dermatomal in
presentation. The patient may report constant burning,
stinging, cramping, or a feeling of awkward positioning.
Phantom pain is most intense acutely, gradually becomes
intermittent, is worse at night, and is often exacerbated by
stress/anxiety. From a therapy standpoint, phantom sensa­
tion may be managed by desensitization techniques,
whereas phantom pain may be responsive to transcutane­
ous electrical nerve stimulation.
amputations by level and identifies the appropriate pros­
thetic device to address the patient’s functional needs.74,75
The rehabilitation program for successful use of lower-
extremity prosthetics begins with donning/doffing of the
device, transfer skills, activities to build wearing tolerance,
practice to reinforce balance reactions, and preambula­
tion skills. Preparatory weight-bearing treatment for use
of a lower-extremity prosthesis usually begins on a tilt
table, progressing to standing and then ambulation in the
parallel bars. The rehabilitation goals should address sta­
bility, ease of movement, energy efficiency, and the appear­
ance of natural gait.76 Table 47.1 outlines the common
components of lower-extremity prostheses and their
functions.
Lower-limb prosthetics require the following minimum
requirements for successful use: upright trunk control, suf­
ficient upper body strength, adequate lower-body stability
and control, static and dynamic balance skills, and good
postural alignment. Lower-extremity prosthetic fitting
begins when the patient’s wounds are well-healed and will
Table 47.1  Prosthetic Components
Upper Extremity
Functions
Lower Extremity
Socket
Interface between prosthesis and residual limb
Socket
Selective loading/pressure relief
Suspension
Holds prosthesis to residual limb
Suspension
Force transmission for function
Control system: Usually movement
of the shoulder or chest
Links movement of a body part to the prosthesis
Control system: Usually movement
of the hip or knee
Interposed elbow joint
Performance of hand to midline
Interposed knee joint
Provides support during stance phase, smooth swing phase, and
motion for sitting and kneeling
Interposed wrist joint
Attaches socket to terminal device; orients terminal device in space
Shank (pylon)
Terminal device
Restores cosmetic appearance
Prosthetic foot
Replicates anatomic joints
Replaces hand/ankle function
Stable, weight-bearing surface
Shock absorption
Table 47.2  Types of Amputations and Prosthetic Needs
Types of Amputations
Prosthetic Needs
Upper extremity
Transphalangeal
Passive for cosmesis
Transmetacarpal
Oppositional devices
Transcarpal
Body-powered hand or hook
Wrist disarticulation
Transradial
Forearm socket, wrist component, and terminal device
Elbow disarticulation
Transhumeral
Proximal arm socket, elbow hinge (passive, active, or externally powered),
forearm lever arm, wrist component, and terminal device
Shoulder disarticulation
Harness system and transhumeral components
Interscapulothoracic disarticulation
Harness system, shoulder socket and transhumeral components
Lower extremity
Transphalangeal
Toe disarticulation
Ray amputation
Transmetatarsal
Transtarsal
Toe-filler
Foot plate
Partial foot to tibial height prosthesis
Syme
Socket to knee, low-profile foot
Transtibial
Knee disarticulation
Socket with foot and ankle
Transfemoral
Socket, knee joint, and ankle/foot complex
Hip disarticulation
Hemipelvectomy
Socket is total contact shell, hip/knee joints, and ankle/foot complex

47  •  Burn Rehabilitation Along the Continuum of Care
490
burn injury is, the higher the risk for the development of
hypertrophic scars. Also, the longer a wound remains open,
the higher the chances for hypertrophic scar formation.80,81
As the wound begins the healing process, collagen fibers
develop to bridge the wound surface, forming an immature
(active) scar, which appears as a red, raised, and rigid
mass.82–85 Abston reported that pressure therapy while the
scars were active led to flatter, softer, and more devascular­
ized scars.86 Burn scars may take up to 2 years or longer to
mature. Factors contributing to the formation of hypertro­
phic scars may include wound infection, genetics, immuno­
logical factors, repeated harvesting of donor sites, altered
ground substance, age, chronic inflammatory process, loca­
tion of the injury, and tension.87 Scar hypertrophy may be
evident at 8–12 weeks after wound closure.88
SCAR ASSESSMENT
A thorough burn scar assessment should be carefully con­
ducted by the burn therapist because the burn scar has
serious implications on the final functional and cosmetic
outcome at the completion of the rehabilitative process.
Over the years, several scar assessment scales and individ­
ual scar assessment tools have been developed to quantify
burn scars to determine the efficacy of scar management
interventions. These scar assessment scales and tools are
either objective (provide a quantitative measurement of the
various scar characteristics) or subjective (provide an over­
view of the quality of the scar as measured by an observer).
The Vancouver Burn Scar Assessment developed by Sulli­
van and colleagues is a subjective way of rating the burn
scar pigmentation, vascularity, pliability, and height, and it
is widely used among clinicians.2,89 Despite the fact that the
Vancouver Burn Scar Scale is a subjective scale, it continues
to be the most frequently utilized burn scar assessment
scale by researchers to date. Baryza and Nedelec have
attempted to improve the Vancouver scale through the
years, and they have somewhat succeeded in doing so.90–92
Other scar scale assessments include the Patient and
Observer Scar Assessment Scale (POSAS) and the Manches­
ter Scar Scale (MSS). The majority of scar scale assessments
available are thought to be subjective in nature and are
criticized for their lack of validity and reliability. Hambleton
and colleagues studied the thickness of scars with ultra­
sonic scanning. This method, which is completely noninva­
sive, allows for a comparison of the thickness of dermal
tissue in the traumatized area with that in normal skin at
regular intervals following initial healing.93 Darvey et al.
described a technique for the objective assessment of scars
utilizing a video camera image on a computer and quanti­
tatively analyzing the color of the scars using a custom-
written computer program.94 Esposito used a modified
tonometer to measure skin tone, which correlates to skin
pliability and tension.95 Bartell and co-workers used the
elastometer properties of normal versus injured skin. In his
study, Bartell showed that scars, if left untreated, will show
improvement over time.96 Hosoda utilized laser flowmetry
to determine the perfusion of hypertrophic scars versus
nonhypertrophic scars.97 Other studies suggest that laser
Doppler flowmetry and monitoring of transcutaneous
oxygen tension may in the future be ways of determining
scar maturation.98,99
The overall process of prosthetic evaluation and fitting
is described in Fig. 47.20. Satisfactory use of a prosthetic
device in burn rehabilitation requires continuous dialogues
among the patient, therapist, prosthetist, and surgeon.
Return clinic visits should include consistent prosthetic
re-evaluation. However, ultimately, the use of a prosthetic
device depends largely on patient motivation.74 Most pros­
theses can be expected to last at least 3–5 years with standard
daily use. Children will need more frequent modifications or
adjustments as they grow and develop.77 In general, the
simplest system that provides the most functional–cosmetic
level is accepted by the amputee as the best choice.
Burn Scar Management
HISTORICAL REVIEW
The burn wound, like any other wound, heals by the forma­
tion of scar at the injured site to replace the destroyed
tissues. Scar is defined as the fibrous tissue replacing normal
tissues destroyed by injury or disease.78 In the case of a burn
injury, the scar, if not managed appropriately, has the
potential of becoming thick and raised, resulting in scar
hypertrophy. Hypertrophic scars are not cosmetically
appealing, and, if they cross any joints, they may restrict
movement and function. Pressure therapy for scar manage­
ment is a very old and established component of a recover­
ing burn patient’s continuing rehabilitation program.
Extensive historical notes on the earliest references to scar­
ring are provided by Linares and colleagues, who attribute
the first full medical description of scars to Petz in 1790.18
They also state that the first medical reference to the use of
pressure for treatment was written by Johnson in 1678
referring to the work of Ambroise Paré in the sixteenth
century.18 Other historical events noted by Linares et al. are
the first known accounts of the use of pressure for treat­
ment of children in 1859, use of elastic bandages in 1860,
adhesive plaster for pressure in 1881, and use of traction
to treat scars in 1902. Linares’s review includes descrip­
tions of Nason’s work in 1942, in which he noted that
ischemia produced by pressure arrests the overproduction
of scar tissue, “where the imprint of the elastic of an under­
garment or a belt may be seen—no keloid is present.”18
Another historical review by Ward79 reveals that Blair in
1924 reported the positive influence of pressure on healing
wounds. Nason’s application of the “constant pressure”
principle included developing a type of neck splint made of
a piece of dental impression compound or a piece of heavy
felt strapped tightly over the scar for 6–8 weeks and possibly
longer. Later, various splints were developed utilizing pres­
sure and immobilization.80 In the 1960s, Silverstein and
Larson observed the influence of pressure on fresh scars.
Their observations led to the manufacture of custom pres­
sure garments that revolutionized scar management in the
1970s and continue to be the most preferred method of
managing scars to date.18,79
THE SCAR
As the burn wound closes, or after skin grafting operations
take place, scars begin to form. Generally, the deeper the

47  •  Burn Rehabilitation Along the Continuum of Care
491
rehabilitation has yet to be developed.101 Individual scar
characteristic assessment devices may, in some instances,
show some reliability and validity; however, they are cost-
prohibitive and impractical to use in the clinic on a daily
basis.102
Fearmonti et al. have compared several scar assessments
and individual scar measurement devices and have high­
lighted their insufficiencies and limitations.100 A compre­
hensive, reliable, and valid burn scar assessment that is
inclusive of all major scar characteristics relevant to burn
Preprosthetics
Prosthetics
Preop consultation
Postop consultation
Upper extremity
Lower extremity
Splinting
Initial stance/
ambulation
Air bag
system
Provision of
preparatory prosthesis
Additions to
Ilizarov
device for
ambulation
Ischial weight-
bearing
prosthesis-
orthosis
Cast &
measurement
Fabrication of
prosthesis
Early fitting
Postponement
factors
Limited
range of
motion
Increasing
functional
demands
Prosthetic
use/therapy
Adjustment
prosthetic
Cast &
measurement;
fabrication of
prosthesis
Contracture
prevention
Concept
of length
Definitive
prosthesis
Contralateral
U/E involvement
Bilateral
considerations
Due to increasing
range of motion
Preparatory
prosthesis
Adjustment
for growth
Finalize prosthetic
for home use
Follow-up
Adjust or replace,
improve function
RX change
Skin tolerance
Initial fitting
of prosthesis
Prosthetic use
and therapy
Adjustment of
prosthesis
Increasing
weight
bearing
Adjustment
for growth
Adjustment or replace,
improve function,
definitive prosthesis
Rx change
Increasing
range
of motion
Completion of
preparatory prosthesis
for home use
Follow-up until
definitive fitting
Skin
tolerance
Fig. 47.20  Algorithm showing the process of prosthetic evaluation and fitting.

47  •  Burn Rehabilitation Along the Continuum of Care
492
problems due to interference with growth.118,119 We recom­
mend that these patients should be closely monitored for
normal facial and dental development by physicians, includ­
ing dental specialists. The elastic hood and underlying sili­
cone face pad present special problems for patients, and
some extreme challenges for the adults trying to assist a
burned child or adolescent. The elastic mask and hood, cov­
ering head, face, and hair, effectively hides the identity of
the person wearing it. It is perceived by children as sinister,
associated with “bad men” or monsters, and most children
who have worn this garment can relay stories of being ridi­
culed by strangers who did not know the purpose of the
garment. Emotional expressiveness, usually apparent in
facial movements, is hidden by the hood. More than one
child has explained nonadherence with the prescribed
wearing of the elastic mask with a statement similar to “I
want my friends to see me laugh.” A study by Groce et al.
compared the elastic mask and hood with silicone pad to
the transparent silicone face mask and found no significant
differences between the amount of pressure applied by each
to the forehead, cheeks, and chin.120 Many children have
expressed a preference for, and seem to wear more readily,
the transparent mask. This study should make it easier for
them to be granted their choice—an important event
during a time when so much is happening to them outside
of their control.
PRESSURE THERAPY
As long as the scars are active, they may be influenced by
pressure therapy. However, not all burn scars require pres­
sure. Patients with burn wounds that heal within 7–14
days do not need pressure therapy. Those patients whose
wounds heal within 14–21 days are closely monitored for
pressure therapy needs and may be generally advised to use
pressure garments prophylactically. A wound that heals
after 21 days will require the use of pressure garments.103
The correct amount of pressure in suppressing the hyper­
trophic scar has not yet been determined. Pressure of as
little as 10 mm Hg may be effective in remodeling the scar
tissue over time. Pressures over 40 mm Hg, however, may
be destructive to tissues and cause paresthesias.88 Early use
of pressure therapy may improve scar outcome and acceler­
ate time to scar maturity.121 The use of conforming thermo­
plastics along with elastic bandages may also be utilized as
means of early pressure therapy.122 Once the wounds are
almost or completely closed, tubular elastic bandages such
as Tubigrip may be utilized. These tubular bandages are
offered in different sizes and accommodate all anatomical
circumferences. Care should be taken in applying these
tubular bandages so that the fragile skin or the freshly
applied skin grafts do not shear or that the minimal dressing
underneath is not disturbed. The burn therapist should be
aware that these tubular bandages are materials made of a
single elastic thread spiraling through the weave of the
fabric, and disturbance of the continuous elastic by cutting
holes into it will alter the pressure gradient provided by
these materials. The tubular elastic bandages should be
doubled over the skin surface area treated to provide ade­
quate pressure.123 Early pressure application over the hand
and digits can be accomplished through the use of thin,
elastic, and self-adherent wraps such as Coban (Fig. 47.21).
TREATMENT OF HYPERTROPHIC SCARS
To date, hypertrophic scars remain very problematic and
difficult to manage. Even though the mechanism of scar
maturation is not yet well understood, clinically, the
accepted protocol to treat hypertrophic scars includes the
use of pressure therapy, which should be instituted early on
in the maturation process of the burn scar. Means of pres­
sure therapy include pressure garments, inserts, and con­
forming orthotics. Once the skin has healed enough to
withstand shearing, massage and heat modalities may be
utilized as an adjunct in scar management. The use of pres­
sure in effectively depressing scars was well documented by
Silverstein and Larson in the 1970s; their observations and
studies sparked the near-universal use of pressure gar­
ments. When an active scar is compressed, it blanches,
which indicates decreased blood flow in the area.88 Less
blood leads to decreased oxygen in the tissues, which in
turns leads to decreased collagen production, which brings
a balance between collagen synthesis and collagen break­
down (lysis). When a balance in the production and break­
down of collagen is established, the resultant scar appears
flatter.103 Kealey et al. conducted a prospective randomized
study to compare the efficacy of pressure garment therapy
in patients with burns. Patients were randomly assigned to
receive either pressure garment therapy or no pressure
garment therapy. Assessment of the maturity of scar
included use of the Vancouver Burn Scar Assessment Scale.
The results on 113 patients studied in the follow-up revealed
no significant differences between groups when age, body
surface area burned, length of hospital stay, or time to
wound maturation were compared.104 In addition to this
study, other studies have reported problems related to lack
of adherence and discomfort, blistering, ulceration or scar
breakdown, swelling of extremities, and skeletal and dental
deformity due to excessive pressures, which often leads to
cessation of treatment, significant side effects, and
deformity.88,104–109
On the other hand, studies have also reported benefits of
pressure garments.110–112 The reader is referred to various
recent excellent review articles on the efficacy or lack of
efficacy of pressure garments in the management of hyper­
trophic burn scars.113,114 The reason for the absence of
unequivocal evidence is that garments must be worn con­
tinuously for a least 23 hours a day, making compliance or
adherence difficult.18,107,114 In addition, the optimal pres­
sure that must be applied to the scar for treatment is not
known.107,115–117 Thus the studies and debates continue,
and, at least until more evidence is gathered, pressure
therapy with the familiar elastic garments is still prescribed.
Patients and families would no doubt feel relieved if the data
eventually show that pressure does not make a significant
difference in long-term outcomes. However, it should be
noted that the studies thus far include neither the examina­
tion of burns over joints nor do they include burns of the
hands, neck, and face. In addition, none of the studies to
date addresses the use of pressure in the form of splints,
another source of discomfort and tension for burned chil­
dren and their families.
None of the known studies has yet broached the face with
an attempt to determine the efficacy of pressure versus no
pressure. Facial pressure garments in children may pose

47  •  Burn Rehabilitation Along the Continuum of Care
493
garments prior to ordering custom-made garments is to
allow for the patient’s weight to stabilize (post-acute hospi­
talization) and any remaining edema to subside. In some
cases where obtaining custom-made garments on regular
intervals (approximately 12 weeks) is not an option, the
recommendation should be that interim garments should
be the choice for long-term pressure therapy. Once the
patient’s weight has stabilized, edema has subsided, and the
skin is able to withstand some shearing (approximately 3–4
weeks post-wound closure), measurements are taken for
the fabrication of custom-made pressure garments (Fig.
47.22). Today, several companies specialize in the fabrica­
tion of these garments. Clinically, custom therapeutic pres­
sure for the prevention, control, and correction of scar
hypertrophy averages 24–28 mm Hg, which is approxi­
mately equal and opposing to the capillary pressure (25 mm
Hg). At this pressure level, many researchers believe that
scars may be altered.107 In order for pressure therapy to be
effective, pressure garments need to be worn at all times,
day and night. They should only be removed for bathing
and on occasion during exercises should they interfere with
movements. Each order is duplicated so one set of garments
can be worn while the other is being washed. Today, pres­
sure garment companies offer multiple colors of materials
and, for the pediatric population, cartoon characters may
be sewed on the garments to make them cosmetically
appealing and improve patient compliance.124,125 The
burn therapist should choose a reputable company that
provides excellent service and support for the patient and
the therapist. The company’s willingness and flexibility to
manufacture nonstandard garments, availability of special
options, cost, and turnaround time should be taken into
This form of pressure is excellent for adult and pediatric
patients for controlling edema, and it aids in the early scar
management of hands when the shearing forces of a glove
cannot be tolerated. Small children are excellent candidates
for Coban gloves versus a garment glove because of compli­
ance issues, comprehension of instructions in assisting
with the application of a custom glove, and difficulties in
obtaining accurate measurements for a custom glove.
Coban may be applied over the burn dressings or directly
onto the healed digits. The burn therapist needs to be aware
that if Coban is wrapped too tightly, it may deform the inter­
osseous structures of the healing hand. However, if Coban
is wrapped too loosely it may encourage swelling of the
hands when used in combination with arm elastic gar­
ments. Coban strips are pre-cut approximately twice the
length of the digits to be wrapped. Each strip is wrapped in
a spiral fashion beginning at the nail bed of each digit,
overlapping half of the Coban width and ending in the adja­
cent web space. Each fingertip needs to be exposed so that
blood circulation can be monitored at all times. The Coban
is stretched from 0% to 25% of the entire elasticity of each
strip. Once all web spaces are covered, the rest of the hand
is wrapped with Coban, extending approximately 1 inch
past the wrist joint. No skin areas should be visible once the
Coban glove is completed. If small hand areas remain
uncovered, a small piece of Coban is stretched over the area
and adheres to the rest of the Coban. When the glove is
completed, the therapist should very superficially lubricate
the entire glove with lotion to eliminate the adherent effect
of the Coban and allow for the functional use of the hand.
Coban should be removed on a daily basis by the therapist
or caregiver. Removal of Coban should be done carefully by
cutting off or unwrapping each digit individually to avoid
disturbing any wound healing.
The use of prefabricated interim pressure garments is
widely accepted and utilized in burn rehabilitation. These
garments are available commercially from different compa­
nies, and they include pieces for the entire body. Interim
garments, which are made of softer materials, introduce
the burn patient to circumferential pressure and protect
newly healed skin. Another reason for using these
Fig. 47.21  A Coban wrap can be used to decrease edema and aid in
the effective management of hand scar hypertrophy.
Fig. 47.22  Custom-made pressure garments may be fabricated for the
entire body.

47  •  Burn Rehabilitation Along the Continuum of Care
494
function needs to be preserved while pressure is applied.
These foam inserts also work best for applying pressure to
contour surfaces on the face (around the eyes, mouth, and
nose) while protecting these sensitive areas from excess
and rigid pressure. Elastomer putties such as Otoform K
or Rolyan Ezemix form semi-rigid but still elastic inserts
for different areas of the body where the scar can toler­
ate more pressure, such as in the web spaces to prevent
syndactyly.130
High-thermoplastic transparent masks were developed in
1968 by Padewski to be applied directly to the face to
prevent, control, and reverse scar hypertrophy. These masks
require the moulaging of the patient in creating a negative
facial mold. A positive mold of the face is fabricated with the
use of plaster. The patient’s positive facial mold is then
sculpted in an attempt to recreate the patient’s nonburned
face. A high thermoplastic material such as Uvex or W-Clear
is then pulled over the positive mold to create the transpar­
ent face orthosis (Fig. 47.24A). Holes for the eyes, nose, and
mouth are cut. The transparent face orthosis is worn with
various harness systems designed to secure it to the face to
address facial scar management.132 The use of three-
dimensional scanners can replace the traditional methods
of face orthosis fabrication. Using a scanner greatly reduces
patient anxiety by achieving the same accuracy as moulag­
ing in a fraction of the time without physically touching the
patient’s face. The scan is sculpted on a computer and a
positive tool is manufactured out of foam off-site. The posi­
tive tool is then sent to the facility for face orthosis fabrica­
tion. In the past, scanners were so large that facilities had
to dedicate an entire room to their use; today, scanners are
small enough to fit in a portable case and are run by laptops.
These newer portable scanners give a therapist the freedom
to scan patients in any setting in the hospital including
intraoperatively. In cases of significant scar hypertrophy on
the face, the positive mold is sculpted sequentially over a
period of time to avoid excessive pressure over facial scar
that could lead to skin breakdown. A silicone elastomer
face mask may be created utilizing the existing positive
facial mold and is worn under facial pressure garments
consideration when selecting the burn center’s pressure
garment provider.126
INSERTS
Inserts are widely utilized in burn rehabilitation as an
adjunct to achieving effective pressure over certain ana­
tomical locations where pressure garments do not provide
adequate pressure. These locations include concave body
areas such as the face, neck, antecubital fossae, sternum,
palm of the hands, web spaces, upper back, and arches of
the feet. These materials come commercially prefabricated
or may be custom-made by the burn therapist. Inserts come
in different forms, such as silicone/nonsilicone gels or gel
sheets, elastomers, putties mixed with a silicone catalyst,
skin care silastic pads, foam, and even in the form of hard
thermoplastic materials contouring to different anatomical
locations. The experienced burn therapist chooses the
appropriate insert material best suited for the patient
according to the stage of scar maturation and skin sensitiv­
ity. Generally, pressure therapy begins with a soft, thin, and
elastic insert and progresses to a more rigid insert in depress­
ing the more unyielding burn scar. Inserts need to be worn
underneath pressure garments, starting with a few hours
of application and progressing as tolerated toward a
23-hour application.127 The inserts should extend approxi­
mately 5 mm beyond the scar margins and should be
applied for several hours the first day then increased by
2-hour increments every other day until the patient is able
to wear it for up to 23 hours per day.128 They should be
removed frequently for cleaning (warm water and soap), to
avoid scar maceration and skin breakdown. Patients may
be allergic to certain insert materials so the burn therapist
may try different inserts until one is found to be best toler­
ated by the patient’s skin. In cases of scar maceration, blis­
ters, skin breakdown, contact dermatitis, a rash, or an
allergic reaction, inserts should be removed immediately
until healing occurs. Silicone, a polymer based on the
element silicon, appears to be the trend in the treatment of
hypertrophic scars. To date, the mechanism of how silicone
affects the burn scar is not known. Clinically, silicone has
been observed to depress the height of hypertrophic scars,
prevent shrinking of fresh skin grafts (hard elastomer sili­
cone pads vs. silicone gel pads), and increase the pliability
of scars, thus allowing for increase in the ROM of affected
joints. Silicone, being occlusive, may cause the collection of
excessive moisture and cause skin maceration if not
removed frequently for cleaning and drying. Its disadvan­
tages are that it is very expensive and short-lived.129–131 The
therapist should look for silicone gel pads with a nonshear­
ing protective medium on the nonskin surface in order for
the gel to last longer. Also, buying larger gel pads and
cutting them to fit the patient’s need may be a cost-effective
method for working with today’s shrinking clinic budgets.
Other insert materials include liquid silicone elastomer,
which when mixed with a catalyst forms a solid but elastic
insert (Fig. 47.23). The experienced therapist is able to create
custom inserts for difficult anatomical locations such as the
face and web spaces using this technique. Prosthetic Foam
is a liquid-based silicone elastomer which, when mixed
with a catalyst, solidifies in the form of a very pliable foam
insert that works best for the palm of the hands, where
Fig. 47.23  Silicone elastomer inserts for the dorsum of the hand and
web spaces are utilized for the prevention of syndactyly and depres­
sion in scar tissue.

47  •  Burn Rehabilitation Along the Continuum of Care
495
increased extensibility of connective tissue.137 Heat relaxes
tissues and makes them pliable in preparation for mobiliza­
tion. Heat modalities may include hot packs, paraffin wax,
fluidotherapy, and ultrasound. Even though the use of ther­
apeutic heat as an adjunct to rehabilitation is well-
documented, therapeutic heat modalities are infrequently
utilized in burn rehabilitation.138,139
Caution should be used in the application of heat modali­
ties on patients who have sustained a burn injury. Patients
may not be able to tolerate heat over areas of healed or
grafted burns due to hypersensitivity. Conversely, patients
with diminished sensation are unable to determine if the
temperature is appropriate and are at risk for further injury.
Although caution needs to be taken, the use of therapeutic
heat in burn patients can provide an effective method for
increasing burn scar extensibility.
The use of passive stretch in conjunction with therapeu­
tic heat greatly increases the effectiveness of the treatment.
Studies have shown that the use of therapeutic heat during
a slow load prolonged stretch is an effective method for
attaining rapid and lasting increases in ROM when com­
pared to low load prolonged stretch alone.140 Warren et al.
reported that low loads for prolonged periods of time were
found to produce significantly greater residual length in rat
tail tendon, especially at elevated temperatures.141
Hot packs can provide superficial heat to burn scars and
assist with stretching contractures. Common treatments in
burn rehabilitation include using hot packs alone before
treatment or in conjunction with therapeutic exercise such
as active ROM or prolonged stretch. Because of the shallow
depth of heat penetration, hot packs may have little effect
on deeper layers of scar tissue.137
Ultrasound has been used by rehabilitation therapists to
increase temperatures deep within the tissue. Reported ben­
efits of ultrasound in the treatment of burn scar include
increased extensibility of collagen tissue, increased blood
flow, and elevation of pain thresholds.137 Application of
topical therapeutic ultrasound to scar tissue has been
reported to produce a tissue temperature rise that leads
to an increase in the extensibility of collagen.142 The com­
bination of ultrasound and passive stretch was found to
further increase tissue elongation.137 Paraffin is an effec­
tive heat modality used most commonly for the hands or
feet. Heated paraffin encourages collagen extensibility and
may also be beneficial because of the softening of the scar
by the mineral oil in the paraffin.137 The use of passive
stretch in conjunction with paraffin has been shown to
increase joint ROM and was found to make patients’ skin
noticeably softer and more pliable after use.143 Similar
to other heating modalities, paraffin has been found to
increase ROM in conjunction with stretching compared to
stretching alone.144
Burn scar management is a complicated and lengthy
process, and, for it to be successfully completed, the patient
and caregivers should be committed to follow the therapist’s
recommendations. Extensive training should take place
addressing the use and care of pressure garments, inserts,
lubrication, and other therapeutic scar management proce­
dures to be performed by patients and their caregivers.
Lubricants that do not contain perfume and other skin irri­
tants should be selected and applied (at least 2–3 times
daily) to the healing skin. Lubricants with a sun protection
(Fig. 47.24B). The use of the clear and silastic masks is
preferred over the use of just a facial garment because these
masks provide conforming pressure around facial openings
(eyes, nose, and mouth). Frequently, the burn therapist
manufactures the clear orthosis to be worn during the day
and the silastic mask along with the facial garment to be
worn at night.17,18,133,134
BURN SCAR MASSAGE
Once the burn scars have matured enough to tolerate
shearing forces, massage may be incorporated into the scar
management regimen. Scar massage is an effective modal­
ity for maintaining joint mobility in the case of contrac­
tures. It aids in softening or remodeling the scar tissues by
freeing adhering fibrous bands, allowing the scars to become
more elastic and stretchy, thus improving joint mobility. Ini­
tially, the therapist may utilize a nonfrictional massage
applying mostly stationary pressure to skin blanching and
mobilizing the skin surface without friction. Utilization of
lubricants during this massage technique should be avoided.
As the skin begins to tolerate frictional massage, the scar
tissue is manipulated in circular, parallel, and perpendicu­
lar motions, using a lubricant and mobilizing the skin to
blanch when performing the desired technique.135,136 Clini­
cally, scar massage is found to alleviate itching and is uti­
lized for desensitization purposes. An electrical massager
with a heat attachment may be used along with lubrication
because heat and massage in combination may increase
scar pliability. Massage should be performed at least twice
daily; the recommendation is three to five times daily for
5–10 minutes on each treated body surface. The burn ther­
apist should frequently assess the skin condition to avoid
further injuries. The patient and/or family are instructed on
home massage techniques, and electrical massagers may be
issued for home use. To decrease the effects of scar tissue, a
burn therapist must utilize all available options to achieve
a functional outcome. Therapeutic heat is the most common
modality used in burn scar management. Application of
heat may permit easier elongation of scar tissue through
A
B
Fig. 47.24  (A) A Uvex clear face mask or (B) a silicon elastomer face
mask provides pressure to the face to prevent scar hypertrophy and
preserve facial features.

47  •  Burn Rehabilitation Along the Continuum of Care
496
each individual patient, with independent living being the
ultimate goal throughout the rehabilitation continuum.
Therapeutic exercise begins immediately following the
burn injury. For a patient being treated conservatively,
movement helps maintain strength and ROM and aids in
circulation and healing. Exercise is initially painful, and the
very first repetition is often the most difficult. Discomfort is
due to stretching skin that has lost its natural lubricating
mechanism and has become dry and tight. Movement itself
decreases pain. Each subsequent repetition will be easier as
the skin stretches and the muscle pumping action of active
movement helps resolve edema, thus significantly reducing
pain.
To show the progression of exercise throughout a
patient’s stay after a burn injury, exercise will be discussed
in terms of the rehabilitation phases described by Richard.154
Exercise During the Acute Rehabilitation Phase
The acute rehabilitation phase is defined as the time from
admission until about the time that a patient’s wounds are
50% closed or skin grafting for wound closure has begun.154
Early therapeutic intervention on the burn unit has long-
term implications for restoration of function.146 Early initia­
tion of burn rehabilitation with an emphasis on several
factors including early ambulation and a focus on prevent­
ing joint contracture through stretching exercise has been
shown to be effective in reducing contractures.155
During the early part of the acute rehabilitation phase,
the exercise goals are resolution of edema, maintenance of
joint mobility, and prevention of respiratory complications,
which can often be performed without interfering with life-
saving measures.150
During this phase, patients spend long periods in bed due
either to their medical status or postoperative immobiliza­
tion after skin grafting. Results of patient immobilization
due to burn injury include decreased cardiovascular fitness,
disuse osteoporosis, increased risk of thromboemboli, pul­
monary complications, decubiti, and muscle atrophy.150
Due to the patient’s medical status during the acute reha­
bilitation phase, the patient may not be able to tolerate vig­
orous exercise. It is therefore recommended that exercise
programs focus on increased frequency of treatment ses­
sions that are shorter in duration.
Active ROM exercises are significant in the reduction of
edema in the extremities and can begin within 24–72 hours
after burn injury.150 Active ROM exercise is performed inde­
pendently by a patient. This is the form of exercise most
recommended because it stretches healing skin and pro­
vides strength-inducing benefits. Frequent exercise per­
formed actively (with voluntary muscle contribution) by a
patient promotes the greatest increase in movement. Active
ROM exercises are vital during burn rehabilitation to coun­
teract the effects of prolonged bed rest and muscle atrophy,
as well as to maintain ROM and prevent contractures. The
best exercise for a joint affected by burns is complete active
ROM.149 Active ROM more adequately addresses the
patient’s functional physiological and psychological needs
than does passive ROM.156 Although active ROM may be a
superior form of exercise for a burn patient, its use during
the acute burn phase may be somewhat limited. Medical
status and intubation, as well as fear and anxiety may all
make active ROM exercises difficult to carry out.
factor (SPF) of at least 15 are recommended.145 Written
instructions with pictures and diagrams along with videos
addressing scar management should accompany the patient
home on discharge from the hospital. Follow-up visits to the
burn or rehabilitation clinic for the assessment of overall
recovery, including garments, inserts, and other home ther­
apeutic interventions, are needed so that the patient may
successfully complete his or her burn rehabilitation during
the first two years after the injury. The therapist’s knowl­
edge, creativity, and continuing research in improving the
currently existing scar management techniques may be the
key to positive outcomes in pressure therapy.
THERAPEUTIC EXERCISE
Burns often result in devastating injuries that severely affect
a person’s ability to perform functional activities through
severe deconditioning, ROM limitations, weakness, and
fatigue.146,147 Therapeutic exercise is one of the central
interventions used by physical and occupational therapists
to combat the multitude of problems associated with burn
injuries. Therapeutic exercise is defined as scientific supervi­
sion of bodily movement with or without apparatus, for the
purpose of restoring normal function to diseased or injured
tissues.148 The use of therapeutic exercise in conjunction
with a comprehensive rehabilitation plan helps to prevent
deforming contractures and to maintain strength in both
involved and uninvolved extremities.149
Even though painful and extensive therapy is required
during the long rehabilitation process, the results are for the
most part dependent on the patients’ and families’ under­
standing, involvement, and dedication to the treatment.138
The goals of therapeutic exercise in burn rehabilitation
are to:
■ reduce the effects of edema and immobilization,
■ maintain functional joint motion and muscle strength,
■ stretch the scar tissue,
■ return the patient to optimal level of function.
Exercise prescription is an ongoing process that is altered
according to the patient’s medical status and changing
needs.150 In the conservative treatment of burn wounds, a
vigorous physical therapy program is instituted immedi­
ately so as to maintain function.151 Postoperatively, exer­
cises involving autografted skin over joints are usually
discontinued for 4–5 days. Escharotomies, fasciotomies,
heterografts, and synthetic dressings are not contraindica­
tions for exercise.152 Early mobilization to decrease edema,
proper exercise techniques, and accurate documentation of
function are more important than the type of wound
closure.151
One of the most common and clinically significant com­
plications after severe burn injuries is burn scar contrac­
tures that lead to decreased ROM and joint deformities.147
Scar contracture and joint mobility limitations are the
result of the shortening of immature connective tissue.
Therapy aims to prevent deformity and the subsequent limi­
tation of movement. In circumferential burns, both the
flexor and extensor surfaces are at risk of contracture. Ther­
apeutic exercise in conjunction with splinting should
promote agonist and antagonist movements around those
joints to maintain mobility.153 Treatments are tailored to

47  •  Burn Rehabilitation Along the Continuum of Care
497
lotion and zinc oxide which, when applied over the grafted
lower extremity (six layers), hardens to a semi-rigid dressing
resembling a plaster cast. This cast-like total contact dress­
ing provides uniform support to the fresh skin graft and
facilitates early ambulation. An Unna boot may be applied
for up to 7 days post-grafting, though it could be removed
earlier for inspection of the skin graft. If removed, a new
Unna boot needs to be fabricated depending on the burn
center’s lower-extremity postoperative immobilization
protocol.163
Primary goals of ambulation include maintaining
lower-extremity ROM, reducing the risk of thrombophle­
bitis, preventing decubiti, providing mild cardiovascular
conditioning, and maintaining or increasing strength and
endurance.150 Ambulation exercises may also help increase
appetite. In addition, ambulatory patients have fewer
problems with lower-extremity contractures and physical
endurance.152
All wounds must have the proper dressings applied prior
to ambulation. Lower-extremity burn wounds should be
wrapped with elastic bandages in order to facilitate capil­
lary support. Wrapping that incorporates the figure-of-
eight pattern has been reported to provide better pressure
than the spiral wrap, perhaps due to increased vascular
support.164
As with other exercise, proper positioning facilitates
proper gait.153 The patient who has been allowed to assume
a position of comfort will have difficulty extending the hips
and knees during ambulation. The ankle may be tight, lim­
iting plantigrade position when in the upright position. If
the joints are in normal alignment, the amount of pain and
energy needed to mobilize these joints are greatly reduced.
In the past, it was common practice to have patients
placed on bed rest for long periods of time after autograft
application to the lower extremities, approximately 5–10
days after autograft application.165–167 More recently,
however, several studies have shown the benefits of earlier
postoperative ambulation.166,168–171
The proposed benefits of early ambulation include
decrease in the incidence of pulmonary embolism, deep
vein thrombosis, and joint stiffness, as well as a shorter
hospital length of stay.168 Other benefits include maintain­
ing strength and endurance, increased independence, a
decrease in fear, and fewer complaints of pain.170
In preparing for ambulation, therapists may use a tilt
table with patients who lack the capacity to stand and mobi­
lize their lower extremities (Fig. 47.25).162,164,172,173 Tilt
tables provided passive weight-bearing with no active
muscle contraction needed. Tilt tables provide gradual
weight-bearing through the lower extremities and are also
an effective treatment for orthostatic hypotension.162
However, therapists should keep in mind that a tilt table
represents a mostly passive introduction of gravity to the
body and does not promote proper alignment of the
musculoskeletal system. Creative efforts and aggressive
techniques are sometimes necessary to encourage ambula­
tion in patients who first appear incapable or unprepared to
begin erect weight-bearing exercise.
Patients tend to perform much better when given an
achievable goal, such as walking a specific distance or to a
certain place. Children do well when provided with a desired
incentive such as an age-appropriate activity or a game.
If a patient can actively participate in movement
but cannot move actively through his or her full ROM,
active-assistive ROM is appropriate. Active-assistive ROM
exercises utilize the same principles as active ROM, but a
patient is assisted by an outside force (therapist or assistive
device) to achieve the full ROM. A patient will achieve
improvements in strength and ROM, but not equal to those
provided by active exercise. Therapists should use their
judgment in letting the patient perform as much of the
exercise as possible actively and only assisting when needed.
While active range may be the most beneficial, it can be
difficult to initiate after admission due to the patient’s
medical status and level of responsiveness. Critically ill,
septic, and heavily medicated patients are often unable to
cooperate in active exercises.150 In these conditions, passive
exercise is used to maintain ROM, assess joint motion, and
elongate tissue.157 Passive ROM exercises are an important
factor in preventing contractures and maintaining ROM
when a patient cannot or does not willing actively move
through his or her available ROM. Although passive ROM
requires less energy expenditure, it does not fulfill as many
of the patient’s needs as active exercise.156 The use of a
continuous passive motion (CPM) device has been docu­
mented to be an effective modality for improving joint
ROM.152 Rehabilitation advances have shown CPM treat­
ment to be a viable option because of its benefits to soft-
tissue remodeling, joint nutrition, wound healing, and
venous dynamics.158,159 Care must be taken when applying
CPM devices to reduce risk of shearing against skin.
Early exercise activity is beneficial in shortening the
acute care hospitalization stay post burn injury, with
studies currently being researched further. Strengthening
exercises are of great importance throughout the con­
tinuum of burn rehabilitation to combat muscle atrophy
and can begin during the acute rehabilitation phase. Resis­
tive exercises are used to maintain or increase strength,
ROM, proprioception, and coordination.160,161 Due to the
patient’s level of consciousness and comprehension during
the acute rehabilitation phase, strengthening exercises
may be difficult to institute and should start with simple
exercises progressing as the patient’s status improves. Iso­
metric exercises are beneficial to maintain muscle strength
when a patient is on bed rest and are comfortable for the
patient to perform while requiring a minimal amount of
energy expenditure.157 The benefit of isometric exercise
is that the patient will not “forget” how to contract the
muscle, a common phenomenon occurring with periods of
prolonged immobilization. Isometric exercise also helps in
maintaining muscle strength. Manual resistance can also
be applied gently by the therapist as the patient contracts his
muscles and attempts motion against the resistance, or the
patient is asked to maintain a position and then resistance
is applied.150
Another important aspect of a patient’s recovery is the
ability to ambulate. Ambulation can begin as soon as pos­
sible after admission as long as the patient is medically
stable.160 Severe weakness, impaired motor control,
decreased cognitive status, pain, and risk of graft shearing
are all factors that can make ambulation a difficult task.162
An Unna boot may be applied at time of skin grafting to the
lower extremity and contribute to early patient ambulation.
The Unna boot is a bandage impregnated with calamine

47  •  Burn Rehabilitation Along the Continuum of Care
498
Sustained stretching exercises are performed with a
slow, prolonged force. Gentle, sustained stretch is more
effective than multiple repetitive movements in gaining
length of burned tissues. Slow sustained stretch is consid­
ered to be one of the most effective methods to combat the
strong destructive forces that lead to contracture forma­
tion.175 Connective tissue has the characteristic of plastic
elongation under constant tension. Therefore, correction
of contractures around joints can be accomplished most
effectively by the application of prolonged stretching to
the shortened connective tissues.176 When applying a sus­
tained stretch, two factors may be considered when apply­
ing pressure to an extremity: blanching of the scar tissue
and the patient’s response.160 While this is an effective
treatment for ROM limitations, it can be uncomfortable
or painful for patients. It is important to impart enough
force on the affected extremity to produce plastic elon­
gation without causing trauma to the tissues or to the
patient.
Strengthening exercises move from manual resistance
toward the use of weights and resistive tubing. Areas to be
concentrated on should include areas of weakness found
during strength assessments as well as muscles opposing
scar tissue contractures.157
Concerning ambulation, it is important that the therapist
set daily goals for the patient to achieve and to encourage
the patient to walk farther while providing the least amount
of support needed. As the patient begins to ambulate more,
it is important that the rehabilitation therapist frequently
assesses the patient’s gait. Any gait deviations must be iden­
tified and corrected before they become lasting habits.
As patients begin to ambulate farther with less assis­
tance, they become more confident in their abilities.
Increased independence provides the patient with a sense
of functional independence.156
Long-Term Rehabilitation Phase
The long-term phase occupies the timeframe from wound
closure or discharge from the acute hospital setting until
such time as the patient has received maximal benefit from
rehabilitation services.154
As patients near discharge from the acute hospital setting,
they will be given more responsibility over their exercise
program. As patients progress, they will be expected to
perform beyond their daily rehabilitation treatment ses­
sions. Patient compliance with home exercise programs is
vital to increasing functional independence.
During the long-term rehabilitation phase, patients
should progress to independently ambulating community
distances. Gait pattern should be refined to become more
efficient without any gait deviations. If the patient is able to
progress further, rehabilitation therapists can challenge the
patient by having him or her ambulate on uneven surfaces,
navigate around various obstacles, and climb stairs. It is
important that the patient be able to ambulate in normal
surroundings, not just in the confines of the rehabilitation
department.
Most burn rehabilitation programs emphasize functional
gains and prevention of contractures, with only modest
attention to aerobic conditioning.177 If ROM is lacking, the
therapist’s priority should be to treat the limitation in
motion rather than strengthening the patient because
Frequent rest periods may be necessary secondary to
decreased endurance levels or pain.
Exercise During the Intermediate
Rehabilitation Phase
The intermediate phase is the time surrounding closure of
the wound and extending up until the time of complete
wound closure.154 The prevention of functional impair­
ments becomes the focus of therapeutic exercise as patients
begin to achieve wound coverage. The goals of exercise
during this timeframe include the stretching of healing
skin, maintaining full joint ROM, preserving motor skill
coordination, promoting functional independence, and
maintaining strength and endurance to minimize muscle
atrophy.150,174
As wounds close, scar formation begins, which leads to
contractures that limit ROM and impede function, which
makes exercise even more important. As a patient’s medical
status continues to improve and operations become less fre­
quent, more time can be allotted to spend in rehabilitation.
Increased alertness and improved medical status also lead
to increased involvement of the patient in rehabilitation. As
the patient advances medically, the therapeutic course
should become more challenging.
While purely passive ROM should be utilized less during
the intermediate phase of rehabilitation due to the patient’s
increased ability to move actively, it still serves an impor­
tant purpose. Passive ROM provides an opportunity to
assess joint movement and determine if the patient can
attain as much movement actively as the therapist can
passively.160
Another form of passive movement that can be utilized
by a rehabilitation therapist is the sustained stretch. Sus­
tained stretch becomes an important intervention as the
formation of burn scars leads to contractures.
Fig. 47.25  The tilt table may be utilized prior to ambulation for those
patients who may have difficulty assuming the upright position.

47  •  Burn Rehabilitation Along the Continuum of Care
499
concomitant to the burn. These include pre-existing condi­
tions such as chronic cardiovascular, pulmonary, and meta­
bolic diseases. The objective of the exercise evaluations is to
obtain information to optimize safety during exercise testing
and training and also to develop a sound and effective exer­
cise rehabilitation program.
Health screening before exercise evaluation should begin
with the collection of subjective data. This should include
evaluation of exercise or sports interests, objectives, level of
activity prior to burn, functional limitations (e.g., loss of
digits, lower-body bilateral amputee), and other pertinent
information. To our knowledge, there are no burn-specific
physical activity questionnaires. However, simple question­
naires for assessing pre-burn physical activity exist and can
be modified to fit a specific given population.187–189 This
evaluation can consist of muscle strength, cardiopulmo­
nary status, and muscle/joint flexibility testing. The infor­
mation gathered during the subjective and objective
evaluations can then be used to design a structured exercise
program or plan to be carried out at home or at an exercise
facility. Finally, a plan to periodically re-evaluate subjective
and objective data and the exercise program itself should be
incorporated.
Subjective Data
A patient’s limitations or problems should be characterized.
Obtaining a history of pre-burn physical activity or habits,
present medical complaints, symptoms, and limitations is
crucial to develop a sound exercise program. Symptoms or
limitations that may affect exercise tolerance may include
pain during ambulation, weakness in ambulation, itching,
joint contractures, amputations, shortness of breath, or
easy fatigability. In addition, the therapist should note
present medications and the possible effects of these. Fol­
lowing the evaluation of subjective data, an exercise evalu­
ation to gather objective data on the patient’s exercise or
physical capacity should be performed.
Objective Data
Assessment of objective data includes age, height and
weight, percent TBSA burn, and percent full-thickness
burn. Variables before, during, and after a cardiopulmonary
exercise test (CPET) should be obtained if possible. These
include heart rate, blood pressure, Borg’s rated perceived
exertion (RPE), basic electrocardiogram (ECG), and spirom­
etry.190,191 However, if a CPET is not possible, an effective
exercise program can still be designed. Assessment of upper
and lower body muscle strength should also be done. This
includes assessment of peak strength levels (if possible), as
well as determining the loads or weights that will be used
during the resistive component of the exercise program.
The assessment of peak muscle strength can be accom­
plished during knee or elbow extension but can also be
accomplished during a handgrip.180,192,193 These tests
involve peak-to-maximal efforts, and good communication
between patient and tester must exist. In addition, a certain
level of developmental mental maturity must exist in order
for many of these objective data to be maximally helpful.
We recommend a chronological age of 7 years or older,
although children as young as 3–4 have also been tested
successfully.194 Finally, major muscle/joint flexibility should
be assessed using measures such as sit-and-reach or
normal healthy muscle is unable to generate the force
required to elongate burn scar tissue.157
The Role of Exercise Physiology in
Burn Rehabilitation
EXERCISE FOR THE OUTPATIENT
This section describes the methodology used in designing
an exercise training program for persons with severe burns
who have been discharged from the hospital. Exercise train­
ing is defined here as “a planned, structured and repetitive
body movement done to improve or maintain one or more
components of physical fitness.”178,179 The evidence for the
use of exercise in the outpatient setting and the methodol­
ogy presented here are based primarily on the outpatient
exercise program implemented in severely burned children
at Shriners Hospitals for Children in Galveston, Texas, and
in some severely burned adults.180 This exercise program is
supplemented by physical and occupational therapy. The
program has proved beneficial in children 7–18 years of
age.180,181 In addition, the effects of a music- and movement-
based exercise program on children younger than 7 years
of age has been assessed in a small study also performed at
Shriners Hospitals for Children in Galveston. The effects
include increases in as well as maintenance of ROM in chil­
dren who participated in a movement and music program
versus those who did not.182 The principles in designing an
exercise program for children and adults with severe burns
is based largely on guidelines offered to healthy, nonburned
children and adults (Fig. 47.26).178,179,183–186
EXERCISE EVALUATION
It is important to perform an initial evaluation of risk
factors and/or symptoms for various chronic conditions
History of medical problems
History of physical activity (pre-burn)
Present medications
Exercise evaluations
Generate problems and realistic objectives
Formulation of a plan: safe, fun,
and effective
• Intensity: 45% to 95% of HRR
• Duration: 20 to 60 minutes
• Frequency: 3–5 days per week
• Mode: Involves large muscle groups, rhythmic, sustained
• Progression: Variable, based on goals, pain tolerance
Assessment
Interpretation
Prescription
Fig. 47.26  Basic diagram depicting various components involved in
the design of an exercise program.

47  •  Burn Rehabilitation Along the Continuum of Care
500
mid-thigh, pelvis, and trunk. All patients should be famil­
iarized with the equipment before the actual test starts. We
recommend that the procedure first be demonstrated by the
person administering the test. Second, the test procedure is
explained to the patient, and then the patient is allowed to
practice the actual movement during three submaximal
repetitions without load as warm-up. Third, after the three
submaximal warm-up repetitions, 10 maximum voluntary
muscle contractions (full extension and flexion) can be per­
formed consecutively without rest in between. The amount
of repetitions and the number of repetition sets can be
varied. For example, we recommend 10 repetitions and two
sets, with a 2-minute rest interval between sets. Values of
peak torque, total work, and average power are calculated
by the Biodex software system, and progress of muscle func­
tion can be monitored.
Three-Repetition Maximum Test (3RM)
Typically, before starting a resistive training program, it is
useful to determine a safe and effective load for patients to
use during workouts. To determine the amount of weight
or load that can be used as a baseline or starting load, the
repetition maximum (RM) method can be used. We recom­
mend the three-repetition maximum load (3RM), which
is determined as follows. After an instruction period on
correct weight-lifting technique, the patient warms up
with a lever arm and bar (or wooden dowel) and is allowed
to become familiar with the movement. After this, the
patient lifts a weight that allows successful completion of
four repetitions. If the fourth repetition is achieved suc­
cessfully and with correct technique, a 1-minute resting
period is allowed. After the resting period, a progressively
increased amount of weight or load is lifted at least four
times. If the patient lifts a weight that allows successful
completion of three repetitions, with the fourth repeti­
tion not being volitionally possible due to fatigue or inabil­
ity to maintain correct technique, the test is terminated
and the amount of weight lifted from the successful set is
recorded as the patient’s individual 3RM. We recommend
the order of exercises to be from exercises that involve large
muscle groups to ones that involve smaller muscle groups:
bench press, leg press, shoulder press, leg extension, biceps
curl, leg curl, and triceps curl. Another alternative is to
bypass the 3RM test and use 8–12RM method or 15RM
method. These methods are typically easier to implement in
children.
Body Composition Measurement
Patients with severe burns lose a significant amount of lean
body mass (LBM). Therefore assessment of LBM should be
made. Additionally, assessment of bone mass and fat mass
should be made. We assess body composition using dual-
energy X-ray absorptiometry (DXA). DXA with pediatric
software can measure the attenuation of two X-ray beams;
one high energy, the other low energy. These measurements
are then compared with standard models of thickness used
for bone and soft tissue. Subsequently, the calculated soft
tissue is separated into LBM and fat mass. This is a great
measurement to also assess the progress of the program
and, if applicable, nutritional interventions. However, the
DXA machine is expensive. It is not known if other methods
to measure body composition, such as underwater
goniometry for ROM. Other types of tests may include neu­
romuscular tests such as gait analysis, balance time, or
reaction time. Finally, assessment of functional perfor­
mance can also be done, such as sit-and-stand scores, timed
walk or jog, and/or lifting. The results of these evaluations
will be used to identify major problem areas, write an exer­
cise prescription, design the exercise program, and assess
progress during and after it.
EXERCISE TESTING
The objectives for exercise testing involve many factors. The
primary objectives during cardiopulmonary testing are to
evaluate physical work capacity and cardiorespiratory or
aerobic fitness, observe cardiorespiratory and metabolic
responses, establish bases for an appropriate exercise pre­
scription, and assess changes in fitness due to exercise train­
ing. The primary objectives during muscular function
testing include measuring muscle strength (absolute and
relative to body weight), measuring antagonist-to-agonist
muscle ratios, assessing changes in body composition (lean
mass, fat mass, and bone density), and providing a basis for
the progressive resistance exercise prescription. Exercise
testing should be conducted prior to the start of any exer­
cise rehabilitation program and again at the end to evaluate
its efficacy. Sometimes if the program is of long duration, a
mid-point evaluation can be done.
Peak Oxygen Consumption or Aerobic Exercise Capacity. All
patients should undergo a standardized exercise test to
objectively evaluate peak aerobic exercise capacity. We use
the treadmill exercise test and the modified Bruce treadmill
protocol. Note that other treadmill protocols, such as the
“ramp protocol,” can also be used.195,196 In addition, if it is
not possible for the patient to be tested on a treadmill, a
cycle ergometer or arm ergometer can also be used to evalu­
ate or assess physical conditioning before starting exercise
rehabilitation or a training program. In addition, estima­
tion of aerobic capacity is also possible with exercise field
tests such as the Cooper 12-minute test or the 1.5-mile run
test. Heart rate can be easily obtained with monitors.
Oxygen consumption (VO2) should be measured if possible,
but requires more expensive equipment that can perform
continuous breath-by-breath analysis of inspired and
expired gases, flow, and volume. For the Bruce protocol,
speed and grade begin at 1.7 mph and 0%, respectively.
Thereafter, the speed and level of incline are increased every
3 minutes. Patients are constantly encouraged to complete
3-minute stages, and the test is terminated when peak voli­
tional effort is achieved. Additional variables that can be
collected during the test include blood pressure, Borg’s
RPE,197,198 basic ECG, and spirometry. The peak VO2 and
peak heart rate, together with resting values, can then be
used to establish or guide the intensity at which patients
will exercise during the program.
Strength Measurements. Isokinetic dynamometry strength
testing should be performed to assess muscle function and
to later evaluate progress. If using the Biodex Isokinetic
dynamometer, the test can be done on the dominant leg
extensors and/or the leg with burns. We recommend testing
at various angular velocities, such as 150 degrees/s, 90
degrees/s, or 180 degrees/s. The patient is seated and his
position stabilized with a restraining strap over the

47  •  Burn Rehabilitation Along the Continuum of Care
501
moderately fast during the endurance phase, but might
conclude the warm-up period with slow, easy walking.
However, a moderate walk (e.g., 3.5 mph) can be a warm-up
for a patient who jogs at 5.5 mph during the endurance
phase. Heart rate may be monitored or assessed if needed
to ensure that the warm-up activity is not too strenuous.
Endurance Stage
The endurance phase develops cardiorespiratory or aerobic
fitness and includes 20–60 minutes of continuous or inter­
mittent (minimum of 10-minute bouts accumulated
throughout the day) aerobic activity. Duration depends on
the intensity of the activity; thus moderate-intensity activ­
ity should be conducted over a longer period of time (≥30
minutes), and, conversely, individuals training at higher
levels of intensity (i.e., vigorous exercise) should train for at
least 20 minutes.201 The most effective exercises for the
endurance phase employ large muscle groups in activities
that are rhythmic or dynamic in nature. Sports such as
soccer, basketball, or tennis also have aerobic conditioning
potential if a sufficient amount of time for inducing aerobic
improvement is achieved (minimum of 20 minutes total).
On the other hand, activities like golf and bowling are
unlikely to elicit a cardiovascular training effect, but are
enjoyable and may yield health-related, as well as psycho­
social, benefits.
Recreational Activities
The inclusion of enjoyable recreational activities during (or
immediately after) the endurance phase often enhances
compliance with the exercise program. Game rules may
need to be modified to accommodate skill level requirements
and competition, and to ensure safety. The outcome of the
game (winning or losing) should be of lesser importance
than the safety, participation, and enjoyment of the patient.
It is important to remember that recreational activities
complement the endurance phase and should not consis­
tently replace it. Recreational activities may also promote
development or improvements in psychosocial health by
increasing the patient’s amount of social interaction.
Cool-Down Stage
At the end of the activity session, about 2–5 minutes of
cool-down
activities—slow
walking
and
stretching
exercises—are recommended to gradually return heart rate
and blood pressure to normal levels. This period includes
exercises of diminishing intensities: slower walking or
jogging, calisthenics, and stretching exercises. This part of
the exercise session is important in reducing the chance of
a hypotensive episode after the exercise session, as well as
other cardiovascular complications.
Exercise Prescription
Some basic exercise physiology principles should be kept in
mind when designing an exercise program for burned
patients. Two such principles are progressive overload and
specificity principles. The progressive overload principle
refers to the observation that a body system must be exer­
cised at a level above that to which it is presently accus­
tomed in order for a training effect to occur.178 The system
weighing or bio-impedance, are applicable to patients with
burns because of the presence of hypertrophic burn scars.
When to Implement an
Exercise Program
Traditionally, a 12-week exercise training program has
been implemented immediately after discharge.199 However,
we have also reported improvements in function and psy­
chosocial health when the 12-week exercise program is
implemented at the 6-month post burn time point.200
Recently we have started a small pilot study to add aerobic
exercise to standard physical therapy and occupational
therapy. The aerobic exercise is quantitative because it
incorporates the use of an arm ergometer in which the
revolutions per minute and the load in watts can be adjusted.
COMPONENTS OF AN EXERCISE PROGRAM
An exercise program typically consists of a warm-up phase,
an endurance phase, recreational activities (optional), and
a cool-down phase. While aerobic training activities should
be done 3–5 days per week, complementary flexibility and
resistance exercises may be performed at a lower frequency
(2–3 days per week).201 Flexibility exercises can be included
as part of the warm-up or cool-down, or be done at a sepa­
rate time. Resistive training is often performed on alternate
days to aerobic training; however, both types of activities
can be combined into the same workout session. Typically
the warm-up period will be of approximately 5–10 minutes,
though it can be longer. This will be followed by a stimulus
or endurance phase of 20–60 minutes and a cool-down
period of approximately 5–10 minutes. Aerobic and resis­
tance training should be prescribed in specific terms of fre­
quency, intensity, duration, and mode of exercise. Each of
these terms will be discussed in greater detail later. An
optional recreational game may occasionally substitute the
endurance phase. However, because of potential difficulties
in setting an appropriate intensity for an appropriate length
of time, it is suggested that recreational activities be done
to complement the endurance phase. If a recreational activ­
ity is added to the endurance phase, then shortening the
endurance phase should be carefully considered, although
maintaining a minimum of 20 minutes.
Warm-Up Stage
Prior to the endurance phase, a variety of very light exer­
cises or low-intensity calisthenics should be done to improve
the transition from rest to the endurance phase of the exer­
cise session. The emphasis at the onset of an exercise session
is to gradually increase the level of activity until the proper
intensity is reached to begin the endurance phase. Stretch­
ing exercises to increase the ROM of the joints involved in
the activity were previously included in the warm-up.
However, recently, evidence has been introduced to contra­
indicate the inclusion of stretching during the warm-up
period.202,203
In fact, evidence suggests that a pre-exercise warm-up
that consists of only light aerobic exercise to increase body
temperature is adequate for increasing flexibility before an
exercise session.179 For example, patients might walk

47  •  Burn Rehabilitation Along the Continuum of Care
502
scale of 6–20, and the revised or category-ratio scale of
0–10. It is reported that the category-ratio scale uses termi­
nology better understood by the subject, thereby providing
the tester with more valid information. It has been found
that an aerobic training effect and the threshold for the
start of anaerobic training are achieved at a rating of
“somewhat hard” to “hard,” which approximates a rating
of 12–16 on the category scale or 4–5 on the category-ratio
scale.205 Finally, if a patient cannot use the heart rate
method or the RPE method, the “Talk Test” can also be used
as a highly consistent method to set and monitor intensity
of exercise.206
The “Talk Test,” or the point at which speech first becomes
difficult, approximates exercise intensity almost exactly
equivalent to the ventilatory threshold. The patient is
advised to exercise at an intensity at which speech is com­
fortable. When speech becomes uncomfortable, one can
assume, based on previous studies, that exercise intensity is
consistently above ventilatory threshold or above the desired
intensity of exercise needed for general improvements in
fitness.206 It must be noted that when setting the exercise
intensity, safety and effectiveness are linked. An appropriate
intensity should also be well suited to result in a long-term,
active lifestyle.
Duration
The duration of an aerobic exercise session is closely linked
to the intensity of the activity (i.e., a longer duration of
low-intensity exercise can be accomplished than of high-
intensity exercise). In general, the duration of exercise for
burned patients once discharged should be from 5 to 20
minutes in the first week. This will depend on the patient’s
functional status and also pain tolerance.
If the patient tolerates up to 20 minutes, then this dura­
tion is appropriate. The objective should be 20–60 minutes
of aerobic activity. This can be accomplished continuously
or intermittently throughout the day, with a minimum of
10-minute bouts. Typically a duration of 20–30 minutes at
between 40% and 50% and up to 85% of HRR (excluding
time for warm-up and cool-down) should induce health and
fitness improvements.201,207
In burned patients with extremely low aerobic capacity
or endurance, four to six 5-minute bouts with rest periods
between bouts will provide benefits. The duration of the
exercise sessions (or bouts) can be progressively increased
over time. However, as mentioned earlier, a high intensity
of exercise or a very long duration of exercise is not needed
to achieve health-related benefits, particularly during the
initial stages of outpatient exercise rehabilitation.
Frequency
It is reported that deconditioned persons may improve
cardiorespiratory fitness with only twice-weekly exercise.201
However, it is generally agreed that optimal training fre­
quency appears to be achieved with 3–5 workouts per week.
The additional benefits of more frequent training appear to
be minimal, whereas the incidence of lower-extremity inju­
ries increases abruptly. For those exercising at 60–80%
HRR, an exercise frequency of 3 days per week is sufficient
to improve or maintain VO2peak. When exercising at the
lower end of the intensity continuum, exercising more than
3 days per week is not deleterious. Patients with extremely
or tissue gradually adapts to this overload. The typical vari­
ables that comprise overload include the intensity, duration,
and frequency (days per week) of exercise. The principle of
specificity refers to the concept that the training effect is
specific to the muscle fibers involved in the activity. Specific­
ity also refers to types of training used in a very specific
manner to produce a very specific adaptation or outcome.
If a muscle is engaged in endurance-type exercise, the
primary adaptations are in capillary and mitochondrial
numbers, which increase the aerobic capacity of the muscle.
These principles are applicable to burned patients; however,
it must be noted that a high intensity of exercise is not
needed to achieve health-related benefits. On the other
hand, to achieve athletic performance or competitive-
related goals, moderate to high levels of intensity will be
required. Another consideration that should be kept in
mind when designing an exercise program is the patient’s
age. Prepubescent children are very different in their physi­
ological and mental response to exercise training than are
postpubescent children. Older adults also have different
health and physical problems than younger adults. It is for
these reasons that medical exams as well as exercise evalu­
ations are strongly recommended prior to starting an exer­
cise program. It is beyond the scope of this chapter to
address these differences and/or problems. However, general
guidelines for both children and adults are offered, and the
reader should seek additional information for population-
specific recommendations or position stands on exercise
and physical activity from associations such as the Ameri­
can College of Sports Medicine (
publications/positionStands.htm), the American Academy
of Pediatrics (), the American Medical
Association (), or the American
Heart Association ().
AEROBIC TRAINING
Intensity
To improve aerobic fitness, generally the intensity of exer­
cise should be between 65% and 95% of the peak heart rate
or between 45% and 85% of the heart rate reserve (HRR).204
The heart rate reserve is the difference between peak heart
rate obtained during a CPET and resting heart rate. The
range of heart rate values associated with the exercise
intensity needed to induce an improvement in cardiovascu­
lar fitness is termed the “target heart rate zone.”
The peak heart rate (HRpeak) is obtained from the CPET.
However, when this is not possible, one simple method to
estimate HRpeak is to use the formula (220 minus age).178
This formula may not be applicable to young children, so
we recommend that, in children, rated perceived exertion
(RPE; see later discussion), together with the heart rate
obtained during a maximal exercise capacity test, be used.
The RPE scale can also be used as a guideline in setting
the intensity of exercise.197 The RPE is a valuable and reli­
able indicator of both exercise tolerance and intensity. This
method of monitoring exercise intensity is useful when it is
impossible to obtain an HRpeak or if patients are on medica­
tions that affect heart rate, such as β-blockers. There are
currently two RPE scales that are commonly used: the origi­
nal or category scale, which rates exercise intensity on a

47  •  Burn Rehabilitation Along the Continuum of Care
503
activities to activities that are more difficult to perform. This
method of progression decreases the potential for inducing
excessive muscle soreness that might cause new injuries or
aggravate old ones. The emphasis on slow to moderate
walking as the primary activity early in the fitness program
is consistent with this recommendation, and the partici­
pant must be educated to not move too quickly into more
demanding activities. For example, if the individual can
walk about 1–2 miles without fatigue, then the progression
to a walk-jog or jogging program is a reasonable
recommendation.
The recommended rate of progression in an exercise con­
ditioning program depends on functional capacity, medical
and health status, pain tolerance, location of burns, age,
individual activity preferences and goals, and an individu­
al’s tolerance to the current level of training. For burned
patients, the endurance aspect of the exercise prescription
can be divided into three stages of progression: initial,
improvement, and maintenance.179
Initial Conditioning Stage.  The initial stage should include
light and moderate muscular endurance activities (e.g.,
40–60% of HRR). These exercises typically have a low
potential for injury and induce minimal muscle soreness
low functional capacities may benefit from multiple short
(5 days per week) exercise sessions. Clearly the number of
exercise sessions per week will vary depending on the
patient’s limitations, but also on the patient’s and caregiv­
er’s lifestyles.
Mode
The most important consideration in choosing the mode of
exercise for the endurance phase of the sessions is to engage
large muscle groups in activities that are rhythmic or
dynamic. The greatest improvements in aerobic fitness
result when exercise involves the use of large muscle groups
over appropriate periods of time (Fig. 47.27). The mode of
exercises includes treadmill walking/running, rowing, or
cycling. If no treadmill is available, then walking or jogging
at a track or field is appropriate. Swimming is also an appro­
priate mode of exercise, although closure of burn wounds
should be ensured to minimize wound infection or the con­
tamination of others. Endurance games are also appropri­
ate modes of exercise.
Progression of Exercise
We recommend starting slowly and safely progressing in
duration and intensity, but also in transitioning from early
Fig. 47.27  Aerobic training should incorporate the use of large muscle groups over appropriate time periods.

47  •  Burn Rehabilitation Along the Continuum of Care
504
overload principle and specificity principle are applicable.
Strict rules of proper technique and safety must be observed
to reduce potential for injury or accidents. A normal
breathing pattern should be maintained, with breath-
holding avoided. Breath-holding during lifting can induce
excessive increases in blood pressure that, in individuals
with hypertension, diabetes, or other medical risks, can be
dangerous.
Similarly to the aerobic exercise program, testing or
evaluation of muscle function precedes the resistive exer­
cise program. This helps individuals identify problem
areas (areas in need of required improvement), set goals,
and track progress. In addition, muscle strength tests
have value in determining back-to-work status.208 Some
of these tests involve peak to maximal muscular efforts.
These tests can be done on weight machines or using
dumbbells.
Typically, these tests are done at 100% of one-repetition
maximum (1RM), but can also be done at 3RM. For
extremely deconditioned individuals or for very young chil­
dren, modification of these guidelines can involve testing
using 3RM up to 12RM if needed. An important point to
remember is that safety of the individual is crucial. There­
fore, correct technique during all testing and training must
be observed. The order of exercises or muscles tested is also
important. It is recommended that large muscle groups are
tested first and alternate between upper body and lower
body. For example, a 3RM test may be done in the following
order of exercises: bench press, leg press (or squats), shoul­
der press, leg extension, biceps curl, leg curl, and triceps
curl. The 3RM load can be determined as follows. After an
instruction period on correct weight-lifting technique, the
patient warms up with a lever arm and bar (or wooden
dowel) and is allowed to become familiar with the move­
ment. After this, the patient lifts a weight that allows suc­
cessful completion of four repetitions. If the fourth repetition
is achieved successfully and with correct technique, a
1-minute resting period is allowed. After the resting period,
a progressively increased amount of weight or load is lifted
at least four times. If the patient lifts a weight that allows
successful completion of three repetitions, with the fourth
repetition not being volitionally possible, because of fatigue
or inability to maintain correct technique, the test is termi­
nated and the amount of weight lifted from the successful
set is recorded as the individual 3RM. This weight is then
used to determine the amount of weight or load that will be
used during the first 1–2 weeks (of, e.g., a 12-week program)
as a baseline load.
Exercise Type
There are many resistance training exercises. However,
these can be divided into core exercises and assistance exer­
cises. Core exercises recruit one or more large muscle groups
(e.g., chest, shoulder, and back). Assistance exercises typi­
cally recruit smaller muscle groups such as biceps, triceps,
and calves. A good program should typically involve both
types of exercises.
Training Frequency
The number of days to train varies according to the indi­
vidual’s training status. For severely burned individuals, we
recommend 2–3 days per week of resistance training.
and pain. Exercise adherence may be compromised if the
level or intensity of exercises in the program is initiated too
aggressively. The amount of time spent in this stage varies
depending on the individual’s adaptation to the exercise
program. We recommend at least 4 weeks of initial condi­
tioning. The duration of the exercise session during the
initial stage may begin with approximately 15–20 minutes
and progress up to 30 minutes, at least three times per
week. Deconditioned individuals should be allowed more
time for adaptation at each stage of conditioning. The age
of the individual should also be taken into account when
progressions are recommended because adaptation to con­
ditioning likely takes longer in older individuals, but also in
extremely debilitated individuals.201
Improvement Stage.  The goal of the improvement stage of
training is to provide a progressive increase in the overall
exercise stimulus, which will allow for significant improve­
ments in aerobic fitness. The improvement stage of the
exercise-conditioning program differs from the initial stage
in that the participant is progressed at a more rapid rate.
This stage is reported to usually last from 4 to 5 months,
during which intensity is progressively increased within
the upper half of the target range of 50–85% of HRR.
However, our experience in a 12-week training program
in children 7–18 years of age indicates that after 3–4
weeks of initial conditioning, some patients are able to
start the improvement stage. In this stage, duration may
be increased consistently every 2–3 weeks until partici­
pants are able to exercise at a moderate to vigorous inten­
sity for 20–30 minutes continuously. During this stage,
interval training may also be beneficial, provided the total
time engaged in moderate to vigorous exercise is at least
20 minutes.
Maintenance Stage.  The goal of this stage of training is the
long-term maintenance of the cardiopulmonary fitness
level developed during the improvement stage. This stage of
the exercise program may begin at any time the participant
has reached previously agreed objectives. During this stage,
the individual may no longer be interested in continually
increasing the conditioning stimulus. Also, in this stage,
further improvement may be none to minimal, but continu­
ing the same workout routine enables individuals to main­
tain their fitness levels, as well as develop the healthy
exercise habit. At this point, it is suggested that program
goals be re-examined and new goals or objectives set.
RESISTIVE TRAINING
Strength is defined as the ability to produce force, and the
ability to produce force over an extended period of time is
referred to as muscular endurance. Both muscle strength and
endurance affect ADLs because it requires a percentage of
an individual’s muscular capacity to perform these every­
day tasks. Severe burns result in extensive and prolonged
loss of muscle mass; therefore resistance training, which
increases LBM, should be part of an exercise rehabilitation
program for burned individuals.180
Just as when designing the aerobic portion of an exer­
cise program, the resistive training portion of an exercise
program follows similar principles of training. Both the

47  •  Burn Rehabilitation Along the Continuum of Care
505
Exercise Order
There are many methods of ordering resistance exercises.
One of these is to arrange core exercises, then assistance
exercises.212 Another method is to arrange large muscle
groups and then small muscle groups.213–215 Yet another
method, which allows the individual to recover more fully
between exercises, is to alternate upper-body with lower-
body exercises. This is especially well-suited for decondi­
tioned or untrained individuals.213,214 For example, in
severely burned children, we have successfully implemented
the following order of resistive exercises: bench press, leg
press or squats, shoulder press, leg extension, biceps curl,
leg curl, triceps curl, and toe raises. These exercises can be
done on variable resistance machines or free weights.180
Free weights, bands, or variable resistance machines are
appropriate for burned individuals wishing to participate in
an exercise program (Fig. 47.28).
Rest Periods
As a general rule, it is important to allow enough time
between exercises to perform the next exercise in proper
form. The rest period also varies depending on the individ­
ual’s training status and specific training objectives.
Progressive Overload
In order for improvements to continue over time, it is
important to carefully monitor and chart the individu­
al’s workouts or loads lifted. Progressive overload can be
applied in a variety of ways, such as increasing the weight
lifted, increasing repetitions while keeping load constant,
or decreasing rest periods. A conservative method termed
the “2-for-2 rule” is suggested. This rule states that “if
an individual can perform two or more repetitions above
his or her assigned repetitions goal in the last set, for
two consecutive workouts for a specific exercise, then
weight or load should be added to that specific exercise
for the next training session.”215 For example, say that
the assigned number of sets and repetitions is three sets
of 8–12 reps in the chest press machine and the indi­
vidual can perform 12 reps in all three sets after several
workout sessions (the specific number of sessions depends
on many factors). If the individual is able to complete 12
reps in the third set (i.e., the last set) for two consecutive
workout sessions, then, in the following training session,
the load for that exercise should be increased. The amount
of weight (load) that should be added depends on factors
such as the physical condition of the individual (strong
or weak) and the body area (upper body or lower body).
In general, an increase of 1–2 kg for a less trained,
weaker individual is suggested for upper-body exercises,
while an increment of 2–4 kg is suggested for lower-body
exercises.185
Example of an Exercise Program
An example of our exercise rehabilitation program is
described here (Table 47.3). The results of this program are
published.17,133,134 This program has been successfully
implemented at discharge from hospital, but also at 6
months post-burn.
Type of Contraction
Resistance exercise programs or exercises that emphasize
accentuated lengthening or contractions (eccentric) are
not recommended for severely burned individuals. These
types of contractions have a high potential for acute
delayed onset of muscle soreness while having similar
outcomes to concentric or isometric muscle contrac­
tions. The muscle soreness, if severe enough, has the
potential to discourage further participation in exer­
cise activities. The movements during weight-lifting
should be rhythmic and done at moderate repetition and
duration.
Amount of Load Lifted
Commonly, a certain percentage of the 1RM or 3RM is used
as a guideline for choosing a training load. The amount of
load lifted can be as much as 100% of 1RM or as little as
lifting no load. We recommend initially, during the first
week of training, allowing the individual to become familiar
with the exercise equipment and to be instructed on proper
weight-lifting techniques. Initially, the weight or load the
subjects will lift should be set at 50–60% of their individual
3RM for 12–15 repetitions for the first 1–2 weeks. Thereaf­
ter, the load lifted can be increased to 70–75% (8–10 repeti­
tions) of their individual 3RM and continued for weeks 2 or
3, to week 6. After this, the training intensity can be
increased to 75–85% (8–12 repetitions) of the 3RM and
implemented from weeks 7–12 or longer. Note that these
guidelines provide an estimate of training load and have
some limitations.185 Another method of determining train­
ing load is to perform multiple RMs based on the number of
repetitions planned for the specific exercise. For example, if
8 repetitions were desired for biceps curl, then one would
test the individual by having him or her perform 8RM
testing sets.
Number of Repetitions
It is believed that muscle strength and endurance can be
obtained simultaneously by performing a specific number
of repetitions within a certain range (e.g., 6–10 repeti­
tions). The number of repetitions will depend on load lifted
(% of 1RM) and on the objective or goals set at the start of
the exercise program. We recommend 8–12 repetitions
done at moderate to high intensity to improve both muscle
strength and endurance.180
Number of Sets
There are very limited data in children as to whether
three sets or one set is required to increase muscle
strength. Much of the adult-based literature supports
similar responses in muscle strength, muscle endur­
ance, and hypertrophy for single- and multiple-set resis­
tance training programs.201,209–212 Finally, it is important
to stress two points: (1) the difference in strength gains
is typically more pronounced in trained individu­
als, and (2) both single and multiple training increases
strength. The first point is usually not the case with
burned patients, and the second point stresses the fact
that an increase in strength is expected with resistance
training compared to the standard of care in burned
individuals.

47  •  Burn Rehabilitation Along the Continuum of Care
506
Fig. 47.28  Resistance training consists of exercises with free weights or variable resistance machines.
Table 47.3  Brief Description of the Shriners Hospitals for Children—Galveston Hospital Outpatient Exercise Rehabilitation
Program
AEROBIC WORKOUT
  Intensity
70–85% of each individual’s previously determined individual peak aerobic capacity. However, heart rate
and rated perceived exertion are obtained at regular intervals during aerobic exercise
  Duration
20–40 min
  Frequency
3–5 days per week
  Mode
Aerobic exercise on treadmills, cycle ergometers, arm ergometers, rowing machines, and outdoor activities
such as soccer or kickball
RESISTANCE WORKOUT
  Exercise type
Upper and lower body of core and assistance exercises
  Amount of load lifted
and number of
repetitions
The weight or load-lifted set at approximately 50–60% of each individual 3RM and lifted for 4–10
repetitions for three sets. During the 2nd week, the lifting load increased to 70–75% (3 sets, 4–10
repetitions) of their individual 3RM and continued for weeks 2–6. After this, training intensity is increased
to 80–85% (3 sets, 8–12 repetitions) of the 3RM and implemented from weeks 7–12
  Frequency
2–3 days per week; alternating days of work with days of recovery
  Number of sets
2–3 sets
  Exercise order
Bench press, leg press or squats, shoulder press, biceps curl, leg curl, triceps curl, toe raises, and abdominals
  Type of exercises
Eight basic resistance exercises done using variable-resistance machines or free weights: 4 for upper body,
3 for lower body, and abdominals
  Rest period
A rest interval of approximately 1 min between sets
Note: Each exercise training session consists of resistance and aerobic exercises, with aerobic exercise preceding resistance exercise. This outpatient exercise
program should be supplemented with outpatient physical and occupational home therapy or home activities.

47  •  Burn Rehabilitation Along the Continuum of Care
507
the amount of time you exercise in order to continue
improving (if part of the original goals).
■ The exercise professional or individual should keep an
exercise diary or logbook to help chart progress.
■ If the patient loses motivation, try setting new goals or
try a new activity (or activities). Sometimes bringing a
friend or family member into the program may help in
motivation. Incorporate variety into the exercise
routine.
■ Finally, work on conveying to the patient or client that
a fun and safe exercise program can result in mainte­
nance of lifelong physical as well as psychosocial
healthy habits (Fig. 47.29).
Patient and Caregiver Education
When patients are being discharged from an acute hos­
pital stay, it is vital that they leave with an individualized
home exercise program. Splinting and positioning, ADL
performance, scar control measures, and psychosocial
issues should also be addressed. This program can then
be advanced to allow for progression during the phases
that the burned individual goes through in what may be
in excess of a 2-year recovery period. During follow up
visits, the patient’s progress is assessed and adjustments
to the home exercise program are made as indicated.
This detailed knowledge of the patient’s status will allow
the burn team to coordinate care so that recommenda­
tions can be followed through. Providing the patients
with a checklist is a valuable tool to enable him or her
to assume some control of the rehabilitation process,
track progress, and encourage continuation of the
program. Many patients and their caregivers are often
overwhelmed by the rehabilitation program. It takes an
extraordinary amount of time and energy to plan and
participate in a home exercise/instruction program. Con­
tinuous communication among the patient, caregiver,
and the burn team will ease the patient’s transition into
recovery.
One way of helping patients with the exercise program is
to establish communication with a community-based exer­
cise center, such as a commercial or hospital-based facility.
Often, direct and constant communication between a burn
hospital’s rehabilitation department, exercise physiologists
and/or physician, and a community-based exercise facility
(i.e., personal trainer) will maximize the potential for adher­
ence to and efficacy of such home exercise programs by
adding supervision and structure.
Conclusion
The rehabilitation of burn patients, although challenging,
can be rewarding to all involved in their care. Continuous
evaluation of the interventions provided will ensure each
patient’s maximum functional outcome. Experience, educa­
tion, and research will produce therapeutic interventions
that will optimize each patient’s recovery. Ultimately, the
goal of the rehabilitation team is to provide the patient with
the means for a productive life.
IMPORTANT CONSIDERATIONS
■ The ultimate goal of an exercise rehabilitation program
should be to improve physical function. However, the
means by which this is achieved are also important. An
exercise program should be challenging, effective, but
also must be safe and fun. It should also promote life­
long healthy habits. This will maximize compliance
with the exercise program.
■ The American College of Sports Medicine (ACSM) has
an extensive list of absolute and relative contraindica­
tions to exercise and exercise testing that should be
carefully considered when designing an exercise
program for adults or children. These contraindica­
tions will also pertain to individuals with severe burns.
■ Individual goals should be established early in the exer­
cise program. Whenever possible, they should be devel­
oped by the participant with the guidance of an exercise
professional. The goals or objectives must be realistic,
and an intrinsic or extrinsic rewards system should be
implemented at that time.
■ It is recommended that exercise professionals work
together with an occupational and/or physical thera­
pist to avoid duplication of services, as well as to iden­
tify areas in need of special attention.
■ Based on our clinical experience with children and
adolescent patients, individuals with severe burns
should participate, as soon as possible after hospital
discharge, in a structured exercise program. This
program should be supervised and, if possible, con­
ducted in the presence of a trained professional.
However, if this is not possible, the exercise program,
with some common sense guidelines, should offer a
choice for safe and effective participation.
■ For adults, a careful medical and exercise evaluation
should be conducted prior to starting an exercise
program. Cardiovascular or pulmonary problems, as
well as other conditions such as diabetes, must be iden­
tified prior to starting an exercise program to avoid
potential fatal or near-fatal complications.
■ It is important to get the burned individual started
with an exercise program or a more active lifestyle as
soon as possible, but it is never too late to get started
regardless of the time post-burn.
■ When beginning the exercise program, it is better to
start slowly and build up gradually than to start too
fast and risk injury.
■ For children, avoid using very intense or maximal
(1RM) resistance training or testing. Gradual progres­
sion is of utmost importance to avoid injury and to
promote exercise adherence.
■ The individual should listen to his or her body. During
and after workouts, the individual (and supervisor)
should be alert to signs of a potential health problem
as a result of overexertion. Signs may include pain,
shortness of breath, dizziness, or nausea.
■ Be flexible and allow individuals to be flexible. Do not
rigidly stick to a schedule if the patient does not feel up
to it. If he or she is overly tired or under the weather,
take a day or two off.
■ Monitor the individual’s progress. Reassess fitness
every 6 weeks. You may notice that you need to increase

47  •  Burn Rehabilitation Along the Continuum of Care
508
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Further Reading
American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing
and Prescription. 8th ed. Philadelphia: Lippincott Williams & Wilkins;
2009.
Borg G, Hassmen P, Langerstrom M. Perceived exertion related to heart
rate and blood lactate during arm and leg exercise. Eur J Appl Physiol
Occup Physiol. 1987;56(6):679-685.
Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 5th ed.
Philadelphia: FA Davis; 2007.
Fig. 47.29  Overall long-term burn rehabilitation should result in lifelong physical as well as psychosocial healthy habits and improvements in quality
of life.

508.e1
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Kinetics; 1998.

509
Musculoskeletal Changes
Secondary to Thermal Burns
KELLY CARMICHAEL, DAVID YNGVE, and CARLOS JIMENEZ
48 
osteoporotic, and in persons with generalized burns, the
bones of deeply burned extremities may show more pro­
found mineral loss than is observed in nonburned extremi­
ties or in the axial skeleton (Fig. 48.1). This tendency for
more osteoporosis in severe burns was also noted by Pandit
et al.,11 who found that 56% of postburn patients had radio­
graphic evidence of osteopenia. Van der Wiel et al.7 found
in an X-ray absorptiometry study of 16 adults with frac­
tures of one tibia that there was eventual loss of bone
mineral density in the contralateral femur and in the
lumbar spine but to a lesser degree than in the ipsilateral
femur. These findings, although not strictly analogous to
those observed in burns, nevertheless point to the occur­
rence of generalized osteoporosis in other trauma states
and the difference in loss of bone density relative to local
factors. In fractures or in burns, impaired mobility and local
hyperemia could account for this difference.
Another characteristic of the osteoporosis of burns that
seems to set it apart is its persistence, not just until restora­
tion of the anabolic state but also for months and years after
the burn has healed (Fig. 48.2). This phenomenon may be
most clearly observed in patients who have survived 90%
burns, but Klein et al. record less than normal bone among
even moderately burned children as long as 17 months
after injury.2 Muscle atrophy or the failure or inability of the
person to return to the preburn level of physical activity
may account in part for this protracted state of reduced
bone mineralization.
There is no way to prevent osteoporosis in a patient
whose burn is of such severity as to require an extended
period of bed confinement. Methods of medical treatment
described by Klein12 and Rousseau et al.13 include anabolic
hormones, bisphosphonates, and cholecalciferol. Cholecal­
ciferol was noted to have a positive effect on muscle health
but little effect on bone. The advance of bone atrophy can
at least be favorably modified even among patients with
large burns if mobilization and active exercise are initiated
soon after the burn. The bones of the axial skeleton, the
pelvis, and the lower extremities are most efficiently stressed
by weight bearing. Thus, standing is a priority measure, and
it is common practice now to walk patients to tolerance
before permanent wound cover. Muscle contraction alone
may help forestall bone atrophy, and bone is better stressed
if the contraction is resisted. Isometric muscle contraction
is possible from even extensively burned patients and is
important for bone stress and for maintaining muscle tone
and muscle. Passive motion has no effect on bone and thus
does not figure in the prevention of osteoporosis. Other pre­
ventive measures, such as closure of the wound and main­
tenance of nutrition, are routine in critical burn care.
Treatment of established osteoporosis involves the more
aggressive use of measures for prevention. There are no
Acknowledgment
This chapter was originally written by E. Burke Evans, MD.
He passed away in May 2012. We are indebted to his knowl­
edge of burn care. Care was taken to preserve as much of
his original material while adding new information.
Introduction
Burn injuries have a tendency, even as they heal, to create
musculoskeletal deformity. In addition, the protracted burn
illness that accompanies severe burns may result in other
skeletal changes. Box 48.1 presents a classification of
musculoskeletal changes secondary to burns; from this, the
most commonly occurring and clinically significant altera­
tions have been selected for discussion.
Changes Confined to Bone
OSTEOPOROSIS
Osteoporosis is the most frequently occurring postburn
change involving bone. Klein et al.’s ongoing studies suggest
that, among persons with serious burns, reduction of bone
mass density is pervasive.2 Stated causes of osteoporosis in
thermal burns are bed confinement, immobilization, hyper­
emia,3 reflex vasomotor phenomena,4 and adrenocortical
hyperactivity.5 In Chapter 26 of this book, Klein reviews the
effects of burn injury on bone metabolism.2,6 Klein et al.9
noted very limited bone formation after a severe burn. Other
endocrine changes that lead to loss of bone after burns have
been described by Dolecek et al.10 This coupled with the
relatively high resorption leads to osteopenia postburn.
Endogenous corticosteroid production is likely responsible
for the decreased bone formation, and inflammatory cyto­
kines are responsible for the bone resorption. In this section,
only what is clinically apparent is discussed.
The more extensive the burn and the greater the number
of complications, the longer the patient may be confined to
bed and relatively immobile. The onset of osteoporosis is
accelerated, and its intensity is more marked in the burn
illness that features a hypermetabolic state. Klein et al.
found that osteoblasts and probably osteocytes underwent
apoptosis in response to the glucocorticoid stress hormones.
The overall effect of burn is catabolic, and muscle wasting
is also noted. If a single extremity of an otherwise normal
person is immobilized for a long period of time because of
local trauma, as with a fracture, loss of bone density can be
easily seen on plain radiographs. So, with burns isolated to
the extremities, the bones of affected extremities become