Functional outcomes and quality of life after burn injury

Overview¶

For most of the modern era of burn care the dominant outcome was survival. That compass no longer points where it once did. Mortality after thermal injury is now low, around 5 to 6 percent, and has changed little in nearly 30 years ^[3]. As survival has plateaued, the relevant question for the great majority of patients has shifted: not whether the patient lives, but what kind of life they return to. Aspects such as quality of life and return to baseline activity belong in any honest assessment of outcome after burn ^[3]. Improved survival has itself enlarged the population living with long-term impairments, activity limitations, and participation constraints ^[4].

Burn injury commonly causes long-term physical impairments and psychosocial limitations that shape survivorship ^[7]. The clinical reality is that a patient who heals their wounds and leaves the unit has not finished recovering; they have started a longer course of regaining motion, strength, independence in daily tasks, the ability to work, and a tolerable quality of life. Over the last decade the field has matured around this reality, building a conceptual framework for disability assessment, describing long-term outcomes in the burn population, and pursuing basic-science work aimed at hypermetabolism, inflammation, scar modulation, and other drivers of functional recovery ^[1].

Two cautions frame everything below. First, this is a recovery topic measured across many instruments and few trials; much of what follows is observational, single-center, and heterogeneous in how it defines and times "function" and "quality of life." Second, the interventions clinicians most want to credit, from exercise programs to scar management, often show clearer effects on impairment-level measures than on the participation-level outcomes patients care about most. Both points are developed in the Controversies section and should temper how confidently any single result is presented to a patient.

Epidemiology¶

Burns remain a large global source of non-fatal disability even as rates fall. A Global Burden of Disease analysis from 1990 to 2021 found age-standardized prevalence, incidence, mortality, and disability-adjusted life years all in significant decline, while the absolute number of incident cases is projected to rise from roughly 9.3 million in 2022 toward 9.4 million in 2036 as population grows ^[6]. The 15-to-19-year age group carries the highest incidence at about 172 per 100,000, and a lower Socio-Demographic Index correlates with higher mortality and disability burden ^[6]. The non-fatal burden is substantial: standardized years-lived-with-disability estimates for 2017 were 281 per 100,000 in Australia, 279 in New Zealand, and 133 in the Netherlands, with disability weights ranging from 0.046 for small burns more than two years out to 0.497 for burns over 20 percent TBSA in the first month ^[8].

The functional stakes concentrate in the hands. Hands are the most commonly burned body part and are involved in over 90 percent of severe burns, so the morbidity is disproportionate to the surface area given how much daily function depends on working hands ^[90]. That anatomic fact runs through the rest of this page: a large share of the functional-outcome and assessment literature is about the upper extremity.

Assessment and the ICF framework¶

The organizing structure for burn functional outcomes is the World Health Organization's International Classification of Functioning, Disability and Health (ICF), which separates body functions and structures from activity (what a person can do) and participation (engagement in life roles), modified by environmental and personal factors. The ICF proved highly useful for comparing the content of frequently used generic and burn-specific instruments ^[36]. Incorporating measures at all ICF levels supports a holistic, patient-centered approach that surfaces the complex impairments affecting activity and participation, with a view to targeting therapy ^[5].

When existing burn instruments are mapped onto the ICF, a consistent imbalance appears. A systematic review of 132 studies and 151 instruments linked 356 extracted concepts to 99 ICF categories and found nearly 46 percent linked to body function and only about 20 percent to activities and participation, with health condition, body structures, and personal and environmental factors barely represented ^[36]. Content analyses of the Burn Model System assessments and of the multicenter benchmarking outcome questionnaires reached the same conclusion from both directions: the body-function and activities-participation components dominate, while body structures and environmental factors are not extensively covered, and the authors of both called for rebalancing item composition ^[38,39]. A dedicated review of return to "activities and participation" found that, despite the ICF's promise, its application in burn recovery has been minimal and few studies examined the same subtopics or used comparable measurements ^[40]. The practical reading is that burn assessment has historically over-measured impairment and under-measured the participation outcomes patients rank highest. What that under-measured level looks like is concrete: community integration is the ability to be active in one's expected community role at home and to participate in leisure and in productive activities such as work, school, or volunteering, and school-reentry programs are generally viewed positively but a one-time school visit is insufficient and ongoing support and assistance for families are needed ^[94]. When participation is measured directly, the levels are modest; self-perceived participation and autonomy were medium-to-low at one and three months post-discharge, with financial situation, pain level, activities of daily living, acceptance of disability, and hope accounting for 77.5 percent of the variance three months out ^[95].

Instruments cluster into generic and burn-specific. Among burn-specific tools, the Burn Specific Health Scale (BSHS) and its brief form are the most commonly used quality-of-life instruments in burn survivors ^[46]. A systematic review of measurement properties concluded that no instrument had enough evidence to be highly recommended for routine use, but that the BSHS-B was easy to use, widely accessible, and showed sufficient evidence for most measurement properties, and that generic instruments rested on only weak evidence in this population ^[41]. When a generic and a burn-specific instrument were mapped together, the BSHS-B covered the most ICF domains and was the only scale including personal factors, the SF-36 covered only one activity-limitation domain, neither it nor the EQ-5D captured contextual factors, and the authors concluded a combined burn-specific-plus-generic approach is effectively obligatory to capture the full spectrum of dysfunction ^[91]. Systematic reviews of patient-reported outcome measures in adult burn research reinforce the caution: 77 different measures appeared across 117 studies, but only 17 had psychometric evidence appropriate to English-speaking adults with burns, and existing burn-specific measures still require supplementation to cover the bio-psycho-social model ^[42,43].

Several instruments have specific validation evidence in burns. The EQ-5D showed high feasibility, small floor and ceiling effects, good construct and criterion validity against the SF-36 and BSHS-B, and discrimination by burn severity, supporting its use for HRQoL after burn ^[44]. The Functional Independence Measure (FIM) demonstrated construct validity and reliability in 7,569 inpatient burn-rehabilitation subjects, with internal-consistency values above 0.95 in each major domain ^[45]. For early functional independence, the Functional Assessment for Burns (FAB) score was developed to measure independence in major-burn ICU patients, improved significantly between admission and discharge measurement, and predicted discharge destination well enough to guide early discharge planning ^[92]. Task-oriented and manual-ability measures fill the upper-extremity gap, including a validated Taiwanese Manual Ability Measure for Burns with excellent test-retest reliability and concurrent validity against the QuickDASH ^[47], and the Canadian Occupational Performance Measure, which proved feasible in an acute tertiary setting at roughly nine minutes to administer and surfaced return to work as the single most-impacted daily activity for 51 percent of participants ^[48]. A recurring critique is that many hand and upper-extremity measures are discrete and impairment-level and do not measure clients' actual occupations, prompting proposals for occupation-based additions to assessment batteries ^[50]. Accurately assessing function and disability after hand burns is itself framed as imperative to better management, and the ICF Core Sets for Hand Conditions provide guidance on what to measure, though few instruments are validated specifically in hand burns ^[49].

Physical and functional recovery¶

Inpatient rehabilitation works at the impairment and activity levels. A prospective pilot study found significant improvement in range of motion, hand function, and balance from admission to discharge in burn-rehabilitation inpatients (mean TBSA 41 percent, length of stay 35 days) ^[54]. A structured shoulder-treatment flowchart produced good range of movement at discharge and 12 weeks in both high- and low-risk axillary-burn patients, with no significant difference between risk strata ^[56]. Functional independence measured by the FAB improved significantly between early and later inpatient assessment ^[92]. For the hand specifically, recovery is steep early then slows: in a prospective cohort of hand and upper-limb burns, QuickDASH scores improved significantly at each time point with the most substantial gain between discharge and three months, the Functional Assessment for Burns indicated high independence at discharge, and 60 percent had returned to work by three months and 70 percent by six, though first-web-space involvement predicted poorer early recovery ^[57].

The deep hand burn shows the ceiling on these gains. In survivors of deep full-thickness hand burns (mean TBSA 58 percent), digit involvement was severe, more than half had amputations, 40 percent had poor functional range with total active motion under 180 degrees, and Jebsen hand-function scores fell below normative values; yet intact flexor muscles still allowed a modified grasp and independence in most daily tasks ^[58]. Patient narratives capture the same arc qualitatively. People recovering from severe hand burns describe recovery as a process that changes over time across physical, daily-activity, and psychosocial sub-themes, a dual task of healing the injury while learning to live with it, suggesting recovery is better described in terms of performance than impairment and needs continuous monitoring ^[60]. Acute hand-burn patients similarly recall the trauma of the incident, fear of pain during therapy, and stigma, alongside personal growth from regaining independence, and they emphasize that a holistic approach addressing physical, psychosocial, and emotional needs is paramount ^[59].

Pain and mood are not separate from physical recovery; they drive it. Over two years, pain and physical function improved while depression stayed stable, and both pain and depression were associated with poorer physical function over time, with the pain-function link strongest among those with higher depression scores; the two appear to contribute independently, so their co-occurrence carries even greater risk for reduced function ^[30]. In hospitalized patients, daily functioning improved in all domains between day 7 and discharge as pain, depression, and dissatisfaction with appearance fell, and pain emerged as the most crucial predictor of functional status ^[32]. An older but still-relevant finding is that physical and mental-health recovery run on partly separate tracks: at three months post-burn, preinjury mental health predicted mental-health status while physical factors predicted physical disability, and physical status was not significantly related to mental-health outcome ^[31].

Several persistent symptom burdens undercut function long after wounds close. Post-burn pruritus and neuropathic pain significantly impair quality of life across psychosocial well-being, sleep, and daily activities ^[33]. Sleep disturbances are common, persist for years, and are associated with pain, itch, distress, and reduced quality of life ^[34]. Perceived fatigue is highly prevalent and persistent, reported in 5 to 78 percent of survivors across cross-sectional studies and declining only partially over the first two years in longitudinal work, with measurement heterogeneity limiting comparison ^[35]. These are the symptoms that keep a "healed" survivor from functioning normally.

Exercise is the best-supported active intervention, with the caveat that benefit is clearer on body-structure and activity measures than on participation. A controlled trial of intensive cardiovascular and resistance exercise after thermal injury produced significant improvements in lower-extremity and upper-extremity function, strength, fitness, and burn-specific HRQoL with no adverse events ^[61]. An unsupervised exercise program improved lower-extremity strength and functional activities regardless of burn severity, but, mapped onto the ICF, produced no change at the participation level except in the high-level-burn cohort's functional-activity domain ^[4]. Meta-analyses converge cautiously: exercise training shows beneficial effects on body composition, need for contracture-release surgery, and HRQoL, with limited and somewhat inconsistent effects on peak oxygen uptake and strength and a noted lack of safety data ^[62]; physiotherapist-led exercise significantly improved aerobic capacity and muscle strength but did not improve quality of life ^[63]; and a meta-analysis of therapeutic exercise found significant improvement in burn-specific HRQoL, particularly the simple-abilities and affective domains, with no significant effect on interpersonal relationships and substantial heterogeneity requiring cautious interpretation ^[64]. Sensorimotor training added to conventional physiotherapy improved stability, balance, mobility, strength, and quality of life after lower-extremity burns ^[65].

Targeted occupational and device interventions address specific activity deficits. An occupation-based (CO-OP) intervention was as effective as traditional therapy for hand and upper-extremity function, daily activities, and quality of life, with changes not differing significantly between groups ^[69]. Adaptive devices restore concrete tasks: a forearm-pronation assistant tableware let severely burned patients accomplish independent eating with shorter duration and higher quality and satisfaction than a standard universal cuff ^[66]. Even garment choices involve trade-offs, with pressure-garment work gloves decreasing grip, pinch, and functional sensation yet improving select gross and static fine-motor task performance and earning unanimous patient preference ^[67]. A systematic review of hand-therapy programs framed within the ICF found improvements in body function, structure, activity, and participation in the acute and convalescent phases, but only in body functions and structures in the chronic phase, and noted that environmental factors went unreported across all phases ^[68].

Return to work and employment¶

Return to work is the participation outcome survivors and clinicians treat as the marker of recovery ^[9], and it is reached by most but not all. Across the systematic-review literature, an average of about 66 percent of patients return to work, with higher rates in smaller burns and a wide range in time to return, from under five weeks to 24 months, and burn severity is the single most significant barrier ^[11]. A pooled analysis found that by a mean of 41 months post-burn, 72 percent of previously employed survivors had returned to some work, leaving nearly 28 percent who never return to any employment; the determinants are burn location and size, treatment variables, age, pain, psychosocial factors, and job factors ^[9]. Older two-center data showed mean time off work of about 10 weeks, %TBSA as the most important predictor, reduced return probability with psychiatric history and extremity burns, and 66 percent and 90 percent returned by 6 and 24 months, but only 37 percent returned to the same job with the same employer without accommodation, underscoring how much job disruption persists even among "returners" ^[10].

Contemporary cohorts confirm the same shape with sharper predictors. In Western Australia (2006 to 2024), 38 percent had returned by 6 weeks and 92 percent by 12 months at a mean of 40 days; reduced return within a year was predicted by contact and electrical burns, male sex, multiple admissions, and prolonged wound healing, while more occupational therapy at 1 to 3 months and more early psychology sessions were associated with less reported work impairment ^[12]. A Burn Model System analysis found preinjury employment the strongest predictor of postburn employment (odds ratio 8.1), with lower odds for older patients, women, longer hospitalizations, acute amputation, and high pain interference at discharge, and notably found burn size itself was not a significant independent predictor at 12 months once these factors were accounted for ^[13]. Two-year Australian registry data put no-problem prevalence at 24 months at roughly 70 percent for mobility and 78 percent for self-care but only about 48 to 52 percent for usual activities, pain, and anxiety or depression, confirming that major burns are often an ongoing disorder rather than a closed episode ^[29].

Social context shapes who returns. Residence in the highest community-distress ZIP codes roughly doubled the odds of unemployment at 6 months independent of race, with older age, larger burns, more operations, Black race, and preinjury unemployment also raising the odds ^[14]. Body image is a further lever: better body image was positively associated with both physical function and employment after burn, while burn size, age, and amputation were negatively associated with physical function ^[86]. These findings have motivated structured vocational evaluation; an integrated review developed an evidence-based framework outlining seven key processes for vocational evaluation following burn injury ^[15]. Qualitative scoping work emphasizes that resumption of work is a key recovery marker for working-aged adults yet that clinical practices, service gaps, and outcome understanding remain underdescribed, and that support at transition points and peer-led programs matter ^[72].

Quality of life as a long-term outcome¶

The recovery curve for health-related quality of life is well characterized and consistent. An individual-participant-data meta-analysis found large improvement in HRQoL up to six months after burns and relative stability thereafter through 24 months, but estimated EQ-5D utility scores remained below general-population norms, with females, long hospital stays, and major burns showing delayed and worse recovery; at 24 months, pain/discomfort and anxiety/depression remained below norms in all subgroups and usual activities remained impaired in major burns ^[18]. Systematic reviews of adult HRQoL show most domains affected shortly after injury and improving over time, with the lowest long-term scores clustering in the work, heat-sensitivity, emotional-functioning, physical-functioning, and pain domains ^[19]. Predictor reviews identify burn severity, postburn depression, post-traumatic stress symptoms, avoidance coping, less social or emotional support, higher neuroticism, and postburn unemployment as predictors of poorer HRQoL, with weaker contributions from female sex, pain, and substance-use disorder, so both physical and psychological problems demand attention for months to years ^[20].

Severity and length of stay scale the deficit. Total BSHS-B quality of life correlated strongly and negatively with both length of stay and TBSA, with length of stay most strongly tied to decreased work and social function and no difference by burn mechanism ^[25]. Utility-score reviews show wide variation between studies (0.06 to 0.972), negative correlation with burn severity, and a tendency for adult utility to rise with time since injury ^[23]. A long-term-sequelae meta-analysis across sepsis, trauma, and burns found overall SF-36 and EQ-5D quality of life comparable across the three etiologies and effects of critical illness persisting for years after hospitalization ^[84]. Recovery is not uniform, however. Growth-mixture modeling of satisfaction with life identified two trajectories: an unchanged majority (60 percent) with high, flat satisfaction and a dissatisfied minority (40 percent) starting at the low end of average and worsening over two years, with older age, worse mental health, and preinjury unemployment predicting the dissatisfied class ^[26]. Recovery trajectories for EQ-5D-5L likewise show most patients becoming "problem-free," but deep dermal or full-thickness burns and preexisting mental-health, alcohol, or drug conditions predict sub-optimal trajectories, and survivors of any severity can still struggle through the first 12 months ^[28].

The honest framing for patients is that quality of life recovers substantially and most survivors report generally good life satisfaction and moderate quality of life, while some severely burned patients continue to report impaired quality of life almost a decade after injury ^[24]. Function and quality of life, not survival, are now the rational compass for assessing burn outcome ^[3].

Special considerations¶

Older adults. Age changes both the level and the shape of recovery. A Burn Model System investigation found older adults (65+) had significantly worse physical-component scores than younger adults preinjury and at two years, with the gap closing by five years, and worse mental-component scores at every interval, supporting a distinct physical-function recovery trajectory in the elderly ^[74]. Older data on elderly burn survivors showed high in-hospital mortality (49 percent) and 47 percent reduced to a more dependent living status at discharge, though projected life expectancy for survivors approached that of uninjured peers ^[75]. Body mass index interacts with age: in elderly patients with less severe burns, higher BMI was associated with lower FIM locomotion scores and reduced likelihood of returning home, and among larger burns women showed lower FIM transfer and locomotion scores than men ^[93].

Electrical injury. Electrical injuries behave differently. Amputation and neurological deficits are common, patients are more often male and injured at work, and at 24 months survivors had significantly worse SF-12 physical scores and were nearly half as likely to be employed as fire/flame survivors, with no significant difference in life satisfaction or mental-component scores ^[16]. By contrast, an SF-36 comparison found no significant differences in self-reported quality of life or full-time employment between electrical and thermal injury, with both groups above population means on many dimensions, illustrating how conclusions depend on instrument and timing ^[17].

Amputation and disability. Postburn amputation predicts worse measured function: pediatric burn amputees reported significantly lower physical-function scores at 24 months than non-amputees, though without difference in self-appearance scores ^[76]. In a survivor survey, one-third self-identified as disabled due to their burn, and visible burns, facial scars, higher TBSA, and older age at injury increased disability odds, with 91 percent reporting work challenges and 40 percent requiring job modifications ^[77].

Children and adolescents. Pediatric HRQoL improves over time across all longitudinal studies, with long-term problems concentrating in the appearance and parental-concern domains and impaired HRQoL predicted by burn severity, facial and hand burns, comorbidity, and short time since burn ^[21]. A systematic review of physical, psychological, and social outcomes in survivors aged 5 to 18 found generally better physical and social outcomes but worse psychological functioning relative to non-burn peers, with physical disability linked to psychological and social functioning ^[22]. The psychological signal is consistent: pediatric burn survivors show elevated anxiety and traumatic-stress symptoms and higher long-term psychopathology, marking them a particularly vulnerable population ^[80]. Massive pediatric burns produce significant long-term physical and psychosocial impairment, and cross-country comparison found physical-function differences at six months driven by severity and amputation rather than country of residence ^[78].

Low-resource settings and contractures. Where care is delayed, contractures dominate the functional story. In a low- and middle-income-country cohort, functional range-of-motion limitation affected 48 percent of joints at discharge and fell to 22 percent at 12 months, but patients with a contracture at 12 months reported significantly more disability and lower quality of life, with patient delay and deep-burn TBSA predicting contracture development ^[70]. Contracture-release surgery in the same setting improved mean functional range of motion from 37 percent to 109 percent, lifted disability-free survival from 55 to 97 percent, and raised quality of life from 0.69 to 0.93 at 12 months, demonstrating that regaining a functional joint directly reduces disability and improves quality of life ^[71].

Facial burns and stigma. Visible facial scarring, functional impairment, and low socioeconomic status are associated with more severe stigma and greater psychological distress, with children, women, and the financially insecure particularly vulnerable, and multidisciplinary medical, psychological, and community interventions described as central to improving social reintegration ^[81].

Management¶

The management content here concerns how function and quality of life are supported, not a single protocol. Postoperative hand therapy is described as crucial and as requiring a multidisciplinary team of experienced burn surgeon, hand surgeon, and hand therapist, with treatment goals of preserving function and aesthetics and preventing the debilitating contractures that limit hand function and may require reconstruction ^[90]. Structured, ICF-based rehabilitation has been tested directly: a prospective multicenter non-inferiority trial of 103 work-injured patients found a newly established ICF-based program produced significant improvement in SF-36 physical-component scores and in grip strength and active range of motion, with no significant change in mental-component scores, and confirmed non-inferiority to a well-established program for nearly all outcomes ^[82]. The trial protocol notes that severe burns produce relevant restrictions of physical, psychological, and social integrity and require specialized rehabilitation, motivating these structured programs ^[83].

Psychological interventions improve mood and quality of life with limited transfer to physical function. Acceptance and Commitment Therapy added to routine rehabilitation improved anxiety, depression, and sleep quality but conferred no additional benefit on Fugl-Meyer motor function or activities of daily living ^[85]. Dignity therapy reduced loss of dignity, anxiety, and depression and improved burn-specific health ^[87]. The recurring management lesson is that the physical and psychosocial dimensions of recovery respond to partly different interventions and that a program targeting only one will leave the other lagging ^[82,85].

Controversies and Evidence Gaps¶

The central unsettled question is whether better wound and scar care has actually improved patients' lives. Most patients recover within the first years and report generally good life satisfaction, yet some severely burned patients still report impaired quality of life nearly a decade out, and the assumption that decades of progress in wound healing and scar quality would improve quality of life remains largely hypothetical; except for functional release of contractures, improved scar aesthetics does not necessarily translate into improved quality of life ^[24]. That single finding should discipline how scar-directed interventions are presented to patients.

A second gap is measurement itself. The field uses dozens of instruments with weak comparative psychometrics: no HRQoL instrument has enough evidence for a strong routine-use recommendation ^[41], 77 different patient-reported measures appeared across 117 adult studies with only a handful adequately validated ^[42], and the ICF, while conceptually adopted, has been applied minimally and inconsistently in actual burn-recovery studies ^[40]. Burn assessments systematically over-represent body function and under-represent the activity, participation, environmental, and body-structure domains ^[36,38,39]. Until measurement converges, pooling and comparison across studies will stay limited, a problem visible in the wide between-study variation in utility scores and in fatigue and sleep prevalence ^[23,35].

Third, the intervention evidence is thin at the participation level. Exercise improves impairment-level outcomes more reliably than participation-level quality of life, with meta-analyses showing significant heterogeneity, limited safety data, and inconsistent effects on relationships and some physiological measures ^[62,63,64]. Recovery of functional independence after major burn is described from a literature in which discharge-to-independent-living rates span 27 to 97 percent and return-to-work rates span 52 to 80 percent, reflecting both real heterogeneity and inconsistent reporting, while major-burn survivors remain consistently below baseline function ^[27]. Return-to-activities-and-participation conclusions, especially for children, are constrained by a paucity of comparable studies ^[40].

Finally, the field is still defining what "outcome" should mean. With mortality low and stable, quality of life and return to baseline activity belong in outcome assessment ^[3], and leaders have argued that the study of burn recovery should include resilience alongside disability and that better understanding of hypermetabolism, inflammation, scar modulation, skin replacement, and recalcitrant problems such as heterotopic ossification is essential to improving functional outcomes ^[1]. The throughline is that the interventions and constructs survivors care about most, participation and quality of life, are exactly the ones the current evidence base measures least well.

References¶

[1] Ryan CM, Parry I, Richard R. "Functional Outcomes Following Burn Injury." Journal of burn care & research : official publication of the American Burn Association 2017. PMID: 28328664. ↩

[3] Jaskille AD, Shupp JW, Pavlovich AR, et al. "Outcomes from burn injury-should decreasing mortality continue to be our compass?" Clinics in plastic surgery 2009. PMID: 19793563. ↩

[4] Huang M, Moralez G, Romero SA, et al. "The benefits of an unsupervised exercise program in persons with well-healed burn injuries within the International Classification of Functioning, Disability and Health (ICF)." Burns : journal of the International Society for Burn Injuries 2020. PMID: 32660830. ↩

[5] Grisbrook TL, Stearne SM, Reid SL, et al. "Demonstration of the use of the ICF framework in detailing complex functional deficits after major burn." Burns : journal of the International Society for Burn Injuries 2012. PMID: 22079536. ↩

[6] Hu Y, Zhi L, Wang Y, et al. "Global, Regional, and National Burden of Burns From 1990 to 2021." The Journal of craniofacial surgery 2025. PMID: 40965363. ↩

[90] Pan BS, Vu AT, Yakuboff KP. "Management of the Acutely Burned Hand." The Journal of hand surgery 2015. PMID: 26043803. ↩

[7] Deng H, Genovese TJ, Schneider JC. "A Narrative Review of Outcomes in Burn Rehabilitation Based on the International Classification of Functioning, Disability, and Health." Physical medicine and rehabilitation clinics of North America 2023. PMID: 37806703. ↩

[8] Spronk I, Edgar DW, van Baar ME, et al. "Improved and standardized method for assessing years lived with disability after burns and its application to estimate the non-fatal burden of disease of burn injuries in Australia, New Zealand and the Netherlands." BMC public health 2020. PMID: 31996206. ↩

[9] Mason ST, Esselman P, Fraser R, et al. "Return to work after burn injury: a systematic review." Journal of burn care & research : official publication of the American Burn Association 2012. PMID: 22138806. ↩

[10] Brych SB, Engrav LH, Rivara FP, et al. "Time off work and return to work rates after burns: systematic review of the literature and a large two-center series." The Journal of burn care & rehabilitation 2001. PMID: 11761392. ↩

[11] Quinn T, Wasiak J, Cleland H. "An examination of factors that affect return to work following burns: a systematic review of the literature." Burns : journal of the International Society for Burn Injuries 2010. PMID: 20395053. ↩

[12] Spronk I, Carling C, Ryan D, et al. "Return to work in adults after burn injury in Australia: Western Australian outcomes, 2006-2024." Burns : journal of the International Society for Burn Injuries 2025. PMID: 41066934. ↩

[13] Carrougher GJ, Bamer AM, Mandell SP, et al. "Factors Affecting Employment After Burn Injury in the United States: A Burn Model System National Database Investigation." Archives of physical medicine and rehabilitation 2020. PMID: 31626744. ↩

[14] Agoubi LL, Murphy S, McMullen K, et al. "Association between community distress and return to work after burn injury." Burns : journal of the International Society for Burn Injuries 2025. PMID: 39522135. ↩

[15] Stergiou-Kita M, Grigorovich A. "Guidelines for vocational evaluation following burns: integrated review of relevant process and factors." Journal of occupational rehabilitation 2013. PMID: 23423804. ↩

[16] Stockly OR, Wolfe AE, Espinoza LF, et al. "The impact of electrical injuries on long-term outcomes: A Burn Model System National Database study." Burns : journal of the International Society for Burn Injuries 2020. PMID: 31420267. ↩

[17] Cochran A, Edelman LS, Saffle JR, et al. "Self-reported quality of life after electrical and thermal injury." The Journal of burn care & rehabilitation 2004. PMID: 14726740. ↩

[18] Spronk I, Van Loey NEE, Sewalt C, et al. "Recovery of health-related quality of life after burn injuries: An individual participant data meta-analysis." PloS one 2020. PMID: 31923272. ↩

[19] Spronk I, Legemate C, Oen I, et al. "Health related quality of life in adults after burn injuries: A systematic review." PloS one 2018. PMID: 29795616. ↩

[20] Spronk I, Legemate CM, Dokter J, et al. "Predictors of health-related quality of life after burn injuries: a systematic review." Critical care (London, England) 2018. PMID: 29898757. ↩

[21] Spronk I, Legemate CM, Polinder S, et al. "Health-related quality of life in children after burn injuries: A systematic review." The journal of trauma and acute care surgery 2018. PMID: 30256329. ↩

[22] Patel KF, Rodríguez-Mercedes SL, Grant GG, et al. "Physical, Psychological, and Social Outcomes in Pediatric Burn Survivors Ages 5 to 18 Years: A Systematic Review." Journal of burn care & research : official publication of the American Burn Association 2022. PMID: 34922361. ↩

[23] Synodinou D, Savoie-White FH, Sangone A, et al. "Health utilities in burn injury survivors: A systematic review." Burns : journal of the International Society for Burn Injuries 2022. PMID: 34844813. ↩

[24] Atiyeh B, El Hachem TF, Chalhoub R, et al. "Have the recent advancements in wound repair and scar management technology improved the quality of life in burn patients?" Burns : journal of the International Society for Burn Injuries 2025. PMID: 40112656. ↩

[25] Kishawi D, Wozniak AW, Mosier MJ. "TBSA and length of stay impact quality of life following burn injury." Burns : journal of the International Society for Burn Injuries 2020. PMID: 31862278. ↩

[26] Amtmann D, Bocell FD, McMullen K, et al. "Satisfaction With Life Over Time in People With Burn Injury: A Burn Model System Study." Archives of physical medicine and rehabilitation 2020. PMID: 29050789. ↩

[27] Jawad AM, Kadhum M, Evans J, et al. "Recovery of functional independence following major burn: A systematic review." Burns : journal of the International Society for Burn Injuries 2024. PMID: 38492981. ↩

[28] Tracy LM, Capell E, Cleland HJ, et al. "Health-related quality of life outcomes and recovery trajectories following burn injury." Burns : journal of the International Society for Burn Injuries 2026. PMID: 41707543. ↩

[29] Tracy LM, Cameron PA, Cleland HJ, et al. "Quality of life and return to work rates in the first two years following major burn injury." Burns : journal of the International Society for Burn Injuries 2025. PMID: 39848117. ↩

[30] Ullrich PM, Askay SW, Patterson DR. "Pain, depression, and physical functioning following burn injury." Rehabilitation psychology 2009. PMID: 19469612. ↩

[31] Questad KA, Patterson DR, Boltwood MD, et al. "Relating mental health and physical function at discharge to rehabilitation status at three months postburn." The Journal of burn care & rehabilitation 1988. PMID: 3356747. ↩

[32] Budzyńska A, Talarska D, Bączyk G. "Wound Pain as a Determinant of Function in Patients Hospitalised for Burns." International journal of environmental research and public health 2023. PMID: 36767319. ↩

[33] Gunawardena DA, Stanley E, Issler-Fisher AC. "Understanding Neural Factors in Burn-related Pruritus and Neuropathic Pain." Journal of burn care & research : official publication of the American Burn Association 2023. PMID: 36794899. ↩

[34] Lerman SF, Owens MA, Liu T, et al. "Sleep after burn injuries: A systematic review and meta-analysis." Sleep medicine reviews 2022. PMID: 36087455. ↩

[35] Prent JM, Wildekamp M, Scholten-Jaegers S, et al. "The prevalence of perceived fatigue in burn survivors: A systematic review of cross-sectional and longitudinal studies." Burns : journal of the International Society for Burn Injuries 2025. PMID: 40359591. ↩

[36] Wasiak J, McMahon M, Danilla S, et al. "Measuring common outcome measures and their concepts using the International Classification of Functioning, Disability and Health (ICF) in adults with burn injury: a systematic review." Burns : journal of the International Society for Burn Injuries 2011. PMID: 21530087. ↩

[38] Osborne CL, Petersson C, Graham JE, et al. "The Burn Model Systems outcome measures: a content analysis using the International Classification of Functioning, Disability, and Health." Disability and rehabilitation 2017. PMID: 27758149. ↩

[39] Osborne CL, Petersson C, Graham JE, et al. "The multicenter benchmarking study of burn injury: A content analysis of the outcome measures using the international classification of functioning, disability and health." Burns : journal of the International Society for Burn Injuries 2016. PMID: 27524436. ↩

[40] Osborne CL, Meyer WJ, Ottenbacher KJ, et al. "Burn patients' return to daily activities and participation as defined by the International Classification of Functioning, Disability and Health: A systematic review." Burns : journal of the International Society for Burn Injuries 2017. PMID: 28041750. ↩

[91] Meirte J, van Loey NE, Maertens K, et al. "Classification of quality of life subscales within the ICF framework in burn research: identifying overlaps and gaps." Burns : journal of the International Society for Burn Injuries 2014. PMID: 24685352. ↩

[41] Legemate CM, Spronk I, Mokkink LB, et al. "Evaluation of measurement properties of health-related quality of life instruments for burns: A systematic review." The journal of trauma and acute care surgery 2020. PMID: 31972752. ↩

[42] Griffiths C, Guest E, White P, et al. "A Systematic Review of Patient-Reported Outcome Measures Used in Adult Burn Research." Journal of burn care & research : official publication of the American Burn Association 2017. PMID: 27893571. ↩

[43] Li C, Solish M, Rogers AD. "Evaluation of patient-reported outcome measures in burn-specific tools: A systematic review." Burns : journal of the International Society for Burn Injuries 2024. PMID: 38040617. ↩

[44] Oster C, Willebrand M, Dyster-Aas J, et al. "Validation of the EQ-5D questionnaire in burn injured adults." Burns : journal of the International Society for Burn Injuries 2009. PMID: 19297100. ↩

[45] Gerrard P, Goldstein R, Divita MA, et al. "Validity and reliability of the FIM instrument in the inpatient burn rehabilitation population." Archives of physical medicine and rehabilitation 2013. PMID: 23473701. ↩

[46] Yoder LH, Nayback AM, Gaylord K. "The evolution and utility of the burn specific health scale: A systematic review." Burns : journal of the International Society for Burn Injuries 2010. PMID: 20382480. ↩

[92] Smailes ST, Engelsman K, Dziewulski P. "Physical functional outcome assessment of patients with major burns admitted to a UK Burn Intensive Care Unit." Burns : journal of the International Society for Burn Injuries 2013. PMID: 22677162. ↩

[47] Lin SY, Chen CC, Mao HF, et al. "The development and preliminary validation of the Taiwanese Manual Ability Measure for Burns." Burns : journal of the International Society for Burn Injuries 2013. PMID: 23347889. ↩

[48] Mc Kittrick A, Jones A, Lam H, et al. "A feasibility study of the Canadian Occupational Performance Measure (COPM) in the burn cohort in an acute tertiary facility." Burns : journal of the International Society for Burn Injuries 2022. PMID: 34563421. ↩

[49] Johnson SP, Chung KC. "Outcomes Assessment After Hand Burns." Hand clinics 2017. PMID: 28363303. ↩

[50] Cancio JM, Stav WB, Colaianni D. "An Occupation-Based Review of Outcome Measures Used to Assess Hand Function After Burn Injury." Journal of burn care & research : official publication of the American Burn Association 2025. PMID: 38963863. ↩

[54] Schneider JC, Qu HD, Lowry J, et al. "Efficacy of inpatient burn rehabilitation: a prospective pilot study examining range of motion, hand function and balance." Burns : journal of the International Society for Burn Injuries 2012. PMID: 22119446. ↩

[56] Webb DC, Byrne M, Kolmus A, et al. "Outcomes of a shoulder treatment flowchart in patients with axillary burns." Journal of burn care & research : official publication of the American Burn Association 2011. PMID: 21336045. ↩

[57] Ghalayini G, O'Brien L, Bourke-Taylor HM. "Recovery in the first six months after hand and upper limb burns: A prospective cohort study." Australian occupational therapy journal 2019. PMID: 30276820. ↩

[58] Holavanahalli RK, Helm PA, Gorman AR, et al. "Outcomes after deep full-thickness hand burns." Archives of physical medicine and rehabilitation 2007. PMID: 18036979. ↩

[59] Dunpath T, Chetty V, Van Der Reyden D. "The experience of acute burns of the hand - patients perspectives." Disability and rehabilitation 2015. PMID: 25109499. ↩

[60] Mc Kittrick A, Gustafsson L, Hodson T, et al. "Exploration of individuals perspectives of recovery following severe hand burn injuries." Burns : journal of the International Society for Burn Injuries 2023. PMID: 35570111. ↩

[61] Paratz JD, Stockton K, Plaza A, et al. "Intensive exercise after thermal injury improves physical, functional, and psychological outcomes." The journal of trauma and acute care surgery 2012. PMID: 22710771. ↩

[62] Flores O, Tyack Z, Stockton K, et al. "Exercise training for improving outcomes post-burns: a systematic review and meta-analysis." Clinical rehabilitation 2018. PMID: 29320878. ↩

[63] Abonie US, Ackah M, Mudawarima T, et al. "Effectiveness of physiotherapist-led exercise interventions for burn rehabilitation: A systematic review and meta-analysis." PloS one 2024. PMID: 39739910. ↩

[64] Vigneron L, Martín Núñez J, Zamora Tortosa J, et al. "Effects on health-related quality of life of therapeutic exercise in burn survivors: A systematic review and meta-analyses." Burns : journal of the International Society for Burn Injuries 2026. PMID: 41447903. ↩

[65] Allam NM, Abdel-Aal NM, Ali KM, et al. "Effect of sensorimotor training on stability, mobility, and quality of life after lower extremity thermal burns: A prospective randomised controlled trial." Clinical rehabilitation 2025. PMID: 39930868. ↩

[66] Shi JJ, Sun Y, Pan SS, et al. "Manufacture and clinical application of the forearm pronation's assistant tableware in the severely burned." Burns : journal of the International Society for Burn Injuries 2021. PMID: 32917474. ↩

[67] Weinstock-Zlotnick G, Torres-Gray D, Segal R. "Effect of pressure garment work gloves on hand function in patients with hand burns: a pilot study." Journal of hand therapy : official journal of the American Society of Hand Therapists 2004. PMID: 15273678. ↩

[68] Yoshida A, Yamamoto M, Li-Tsang CWP, et al. "A systematic review assessing the effectiveness of hand therapy programmes in adults with burns using the ICF framework." Nagoya journal of medical science 2022. PMID: 36544605. ↩

[69] Khanipour M, Lajevardi L, Taghizadeh G, et al. "Effects of an Occupation-Based Intervention on Hand and Upper Extremity Function, Daily Activities, and Quality of Life in People With Burn Injuries: A Randomized Controlled Trial." The American journal of occupational therapy : official publication of the American Occupational Therapy Association 2023. PMID: 37851587. ↩

[70] Hendriks TCC, Botman M, Binnerts JJ, et al. "The development of burn scar contractures and impact on joint function, disability and quality of life in low- and middle-income countries: A prospective cohort study with one-year follow-up." Burns : journal of the International Society for Burn Injuries 2022. PMID: 34716045. ↩

[71] Hendriks TCC, Botman M, de Haas LEM, et al. "Burn scar contracture release surgery effectively improves functional range of motion, disability and quality of life: A pre/post cohort study with long-term follow-up in a Low- and Middle-Income Country." Burns : journal of the International Society for Burn Injuries 2021. PMID: 33485727. ↩

[72] Katsu A, Mackenzie L, Tyack Z, et al. "Understanding return-to-employment experiences after burns: Qualitative scoping review findings." Australian occupational therapy journal 2024. PMID: 37990624. ↩

[93] Farrell RT, Gamelli RL, Aleem RF, et al. "The relationship of body mass index and functional outcomes in patients with acute burns." Journal of burn care & research : official publication of the American Burn Association 2008. PMID: 18182905. ↩

[74] Hong A, Stewart BT, Orton C, et al. "Long-term Physical and Mental Health Outcomes of Older Adults Following a Major Burn Injury: A Burn Model System Investigation." Journal of burn care & research : official publication of the American Burn Association 2025. PMID: 39400121. ↩

[75] Manktelow A, Meyer AA, Herzog SR, et al. "Analysis of life expectancy and living status of elderly patients surviving a burn injury." The Journal of trauma 1989. PMID: 2918559. ↩

[76] Choe D, Humbert A, Wolfe E, et al. "Pediatric Patients with Postburn Amputations Report Worse Long-term Physical Function but Not Self-Appearance: A Burn Model System Study." Journal of burn care & research : official publication of the American Burn Association 2024. PMID: 39196760. ↩

[77] Stanton EW, Celie KB, Chacon D, et al. "The Burn Survivor's Perspective on Disability: A Survey-Based Analysis." Journal of burn care & research : official publication of the American Burn Association 2025. PMID: 40814285. ↩

[78] Kowalske A, Stubbs A, Roaten K, et al. "Physical and Psychosocial Outcome Comparisons in Similar Groups of Pediatric Burn Patients in the United States and Mexico: A Burn Model System Study." Journal of burn care & research : official publication of the American Burn Association 2025. PMID: 40253578. ↩

[80] Woolard A, Hill NTM, McQueen M, et al. "The psychological impact of paediatric burn injuries: a systematic review." BMC public health 2021. PMID: 34906121. ↩

[81] Niederegger T, Schaschinger T, Karakas E, et al. "Psychological impact and stigma after facial burns: A systematic review." Journal of plastic, reconstructive & aesthetic surgery : JPRAS 2026. PMID: 41152058. ↩

[82] Harhaus L, Ziegenthaler H, Neubauer H, et al. "A prospective multicenter non-inferiority trial to evaluate a new burn rehabilitation program based on the International Classification of Functioning, Disability and Health (ICF)." Burns : journal of the International Society for Burn Injuries 2025. PMID: 40117998. ↩

[83] Neubauer H, Stolle A, Ripper S, et al. "Evaluation of an International Classification of Functioning, Disability and Health-based rehabilitation for thermal burn injuries: a prospective non-randomized design." Trials 2019. PMID: 31856888. ↩

[84] Haug VF, Tapking C, Panayi AC, et al. "Long-term sequelae of critical illness in sepsis, trauma and burns: A systematic review and meta-analysis." The journal of trauma and acute care surgery 2021. PMID: 34252062. ↩

[85] Ruan J, Huo T, Zhang Y, et al. "Effect of Acceptance and Commitment Therapy on psychological wellbeing and physical function in rehabilitation patients after burns: A randomized controlled trial." Burns : journal of the International Society for Burn Injuries 2025. PMID: 40834484. ↩

[86] Ali M, McMullen K, Solis-Beach K, et al. "The Impact of Body Image on Physical Function and Return to Work After Burn: A Burn Model System Study." Journal of burn care & research : official publication of the American Burn Association 2025. PMID: 39301888. ↩

[87] Deng Y, Yao Y, Wang C, et al. "Effects of Dignity Therapy on Dignity, Anxiety, Depression and Quality of Life for People With Burns: A Randomised Controlled Trial." Journal of advanced nursing 2025. PMID: 39304304. ↩

[94] Holavanahalli RK, Badger K, Acton A. "Community Reintegration." Journal of burn care & research : official publication of the American Burn Association 2017. PMID: 28368917. ↩

[95] Li L, Wu XL, Xu L. "Factors affecting self-perceived participation and autonomy among patients with burns: A follow-up study." Burns : journal of the International Society for Burn Injuries 2018. PMID: 30107943. ↩