Burn rehabilitation and functional outcomes

Overview

Burn rehabilitation is the longest phase of burn care. Acute wound closure occupies days to weeks; rehabilitation occupies months to years. The clinical question shifts from "will this patient survive" to "will this patient regain the range of motion, strength, sensation, and psychosocial footing required to resume their life." The rehabilitation literature covers acute-phase positioning, pressure garment therapy, exercise programming, pain and pruritus management, scar care, contracture surgery indications, outcome assessment instruments, and return to work or school.

Two findings anchor the clinical reality of the field. First, contractures remain common despite modern rehabilitation: a Burn Model System analysis of 1,031 pediatric patients found that 237 (23%) developed at least one contracture at hospital discharge, and a 300-patient adult cohort found that 86.3% had limited range of motion at discharge [1, 2]. Second, the functional and psychosocial impact is broad at discharge: Burn Model System data document significant deficits in Short Form-36, Functional Independence Measure, and Brief Symptom Inventory scores at discharge across all age groups ^[3]. Rehabilitation is the discipline that intervenes between these two facts.

The evidence base is uneven across the rehabilitation continuum. Pediatric exercise programs in burn care demonstrate recovery of lean body mass, muscle strength, and cardiorespiratory fitness over 6 to 12 weeks [62, 67, 68]. Pressure garment therapy, by contrast, has been studied over multiple decades and remains supported by only modest meta-analytic effect sizes [31, 32, 33]. Orthotic use rests largely on expert consensus, with only one practice guideline supported by direct evidence in a systematic review ^[16]. The literature on telerehabilitation, mirror therapy, and several promising adjuncts is too thin to support strong direction.

Epidemiology

The frequency and distribution of post-burn functional impairment determine rehabilitation resource demand. Contracture data come from two complementary sources: the Burn Model System national database and large single-center cohorts. In 1,031 pediatric Burn Model System patients, 237 (23%) developed at least one contracture by hospital discharge, with a mean of 3.3 contractures per affected child ^[1]. The shoulder was the most frequently contracted joint (27.9%), followed by the elbow (17.6%), wrist (14.2%), knee (13.3%), and ankle (11.9%) ^[1]. Most contractures were mild (38.5%) or moderate (36.3%) ^[1].

Adult contracture epidemiology shows higher rates of any limited range of motion: in a 300-patient cohort, 259 (86.3%) had at least some limited range of motion at discharge, with the percentage of cutaneous functional unit burned, length of stay, weight gain, poor rehabilitation compliance, and lower-extremity joint burns independently associated with moderate-to-severe involvement ^[2]. Risk-factor profiles differ by dataset: in pediatric patients, total age, length of stay, ICU length of stay, presence of amputation, TBSA burned, and TBSA grafted predict the number of contractures, while age, ICU length of stay, presence of amputation, and Black race predict contracture severity ^[1]; in adults, percentage of cutaneous functional unit burned, length of stay, weight gain, poor compliance, and lower-extremity joint burns are independently associated with moderate-to-severe limited motion ^[2].

Pressure garment use is widespread despite uneven evidence. National Health Service burns services in the United Kingdom treat approximately 2,845 patients per year and prescribe pressure garments for 6 to 18 months at an annual program cost of £2,171,184 ^[36]. Outpatient therapy use declines steeply over the first 2 years post-injury: among 1,520 Burn Model System participants, physical and occupational therapy use fell from 48.5% at 6 months to 28.6% at 12 months and 18.1% at 24 months ^[9].

Heterotopic ossification is uncommon but consequential. In 2,979 Burn Model System patients with HO risk-factor data, 98 (3.5%) developed clinical HO ^[86]. A separate 21-year single-center series identified 42 patients, with the elbow involved in over 90% of cases and 44% of presentations bilateral ^[87]. Microstomia at hospital discharge occurs in 4.7% of adult and 11% of pediatric burn survivors with significantly larger TBSA, higher rates of inhalation injury, more ventilator days, and more adjacent contractures than survivors without microstomia ^[29].

Return to work data inform the duration of vocational impact. A systematic review reported time to return to work ranging from 4.7 weeks to 24 months ^[7]. The most common employment barriers were pain (72% of patients burned at work; 63% of those burned outside work), neurologic problems (62% and 59%), psychiatric problems (53%), and impaired mobility (54%) ^[8]. The severity of the burn was the most significant predictor of failure to return to work across reviewed studies [5, 7].

Pathophysiology

Burn rehabilitation addresses the somatic, metabolic, and psychosocial sequelae of thermal injury that persist after wound closure. Three mechanisms drive most post-burn impairment.

First, dermal and subdermal scar contracts as it matures. In children, continuous body growth interacts with scar rigidity to produce progressive burn-scar contracture ^[20]. Lower-extremity joint burns and percentage of cutaneous functional unit burned are independently associated with moderate-to-severe limited motion ^[2].

Second, the post-burn hypermetabolic state produces sustained loss of lean body mass and muscle strength. Severely burned children at discharge have lean body mass at 77% of age-sex-matched nonburn values, peak torque at 53%, power at 62%, and cardiorespiratory fitness at 56% ^[68]. Multi-month hormonal trials (12-month oxandrolone, growth hormone over 12 to 18 months) document the prolonged hypermetabolic and recovery time-course in major pediatric burns and motivate the functional rationale for resistance and aerobic exercise programs [64, 71]. Resting energy expenditure is elevated after severe burn injury and is improved by recombinant human growth hormone administration, most markedly at the 0.1 mg/kg/d dose ^[64].

Third, peripheral and central nervous system changes generate chronic pain, pruritus, and altered sensation. Pruritus is a common postburn symptom; the 2024 Cochrane review identifies six intervention categories targeting different mechanisms (neuromodulatory agents, topical therapies, physical modalities, laser scar revision, electrical stimulation, and other) ^[60]. The Burn Specific Pain Anxiety Scale predicts procedural pain levels rated later the same day but does not predict later-day background pain, supporting pain-anxiety as a measurable construct in rehabilitation ^[85].

Classification

Outcome measurement in burn rehabilitation uses overlapping generic and burn-specific instruments mapped to the International Classification of Functioning, Disability and Health (ICF). Across 94 studies of post-burn health-related quality of life, twenty different instruments were applied; the Burn Specific Health Scale-Brief (BSHS-B; 46%), the Short Form-36 (SF-36; 42%), and the EuroQol questionnaire (EQ-5D; 9%) accounted for the majority of use ^[77]. The BSHS-B is the most frequently used burn-specific instrument, and its domains are associated with burn severity at follow-up [75, 76].

The generic SF-36 and burn-specific BSHS-B converge on physical and pain domains but diverge on activity limitations; the EQ-5D shows lower convergence with the BSHS-B than SF-36 does, particularly in the activity domain ^[78]. ICF mapping shows that no single instrument captures all relevant domains; generic instruments under-represent burn-specific issues, while burn-specific instruments under-represent contextual factors [82, 83].

Hand function instruments used in burn rehabilitation include the Disabilities of the Arm, Shoulder, and Hand (DASH) and Michigan Hand Questionnaire applied in surgical and enzymatic debridement studies ^[28] and the short-form QuickDASH, which has been used as a concurrent-validity reference (r = -0.79) for the Taiwanese Manual Ability Measure adapted for burns ^[84]. The Vancouver Scar Scale (VSS) and Patient and Observer Scar Assessment Scale (POSAS) anchor scar evaluation. Pain anxiety measurement uses the Burn Specific Pain Anxiety Scale (BSPAS), which predicts procedural pain ratings later the same day and demonstrates incremental validity over global anxiety instruments ^[85].

Assessment

Pre-treatment assessment in burn rehabilitation centers on joint range of motion, hand and upper-extremity function, scar characteristics, and health-related quality of life. Standardized goniometric range-of-motion measurement is the foundation; the cutaneous functional unit framework structures measurement around the soft-tissue territories crossed by each scar ^[2]. Standardized range-of-motion measurement at admission and across treatment supports tracking of intensive stretching. In a single-center inpatient rehabilitation protocol of at least 1 hour of daily stretching by experienced therapists, 88 joint contractures across nine patients showed an average weekly range-of-motion improvement of 8.2 degrees (95% CI, 6.5 to 9.9), with the largest gains in the first week (11.2 degrees; 95% CI, 8.7 to 13.6) ^[14].

Hand function assessment combines objective and patient-reported measures. The QuickDASH decreased significantly between sessions in a randomized hand-edema compression trial (P < 0.001) ^[22] and improved alongside BSHS-B and instrumental activities of daily living in a leap-motion-control hand-rehabilitation pilot relative to standard therapy ^[25]. The Taiwanese Manual Ability Measure for Burns shows high test-retest reliability (intraclass correlation coefficient 0.99) and adequate concurrent validity with the QuickDASH (r = -0.79) ^[84].

Scar assessment standardizes around the Vancouver Scar Scale. The PEGASUS feasibility study identified six outcome domains important to patients and clinicians: perceptions of appearance, specific scar characteristics, function, pain and itch, broader psychosocial outcomes, and treatment burden ^[36].

Recognition of heterotopic ossification depends on alertness during early rehabilitation. HO is first suspected by decreased range of motion, painful or swollen joint, or a nerve deficit; mean day of diagnosis is 71 days post-burn (range, 21 to 134) ^[87]. Surgical release is reserved for established lesions affecting activities of daily living ^[87].

Quality of life assessment benefits from longitudinal repeat measurement because most domains improve over time. Across the systematic review of HRQOL after burn, most mentally and physically oriented domains were affected shortly after burns but improved subsequently; the domains that remain depressed longest are work, heat sensitivity, emotional functioning, physical functioning, and pain/discomfort ^[77].

Management

Management spans the acute hospitalization, the early post-discharge months, and the long maturation phase that follows. The overall structure is: prevent loss, then recover function. Each phase has its own evidence base.

Acute-phase rehabilitation

Acute-phase rehabilitation begins on the day of admission and continues through wound closure. Core components are positioning, stretching, splinting, graded mobilization, and edema management, alongside scar management and psychosocial care as described in burn-rehabilitation principles literature ^[10]. A 12-year comparison of common therapeutic interventions across United States burn centers documented increases in the proportion of centers employing positioning (41% increase), active range of motion (48% increase), passive range of motion (52% increase), and ambulation (29% increase) ^[11]. The directional consensus is clear; the comparative evidence on dose and timing is thinner.

Early mobilization in the burn ICU is safe in selected populations. A retrospective cohort of 2,176 patients admitted to a trauma and burns ICU between May 2008 and April 2010 found no adverse events related to an early mobility program, with a decrease in airway, pulmonary, and vascular complications including pneumonia and deep vein thrombosis after the program's introduction ^[13]. Ventilator days and total length of stay did not change significantly ^[13]. The authors concluded that early mobilization was safe and effective in this setting ^[13].

Early ambulation after lower-extremity grafting is supported by formal practice guidelines developed through consensus and literature review ^[12]. Co-location of the inpatient rehabilitation service with the burn center shortened burn-center length of stay (28.5 ± 20.9 days versus 38.8 ± 34.2 days; P = 0.043) and reduced waiting time for rehabilitation (0.7 ± 1.1 days versus 1.5 ± 2.3 days; P = 0.010) ^[15].

Inpatient stretching protocols produce measurable contracture improvement during the acute hospitalization. A quality-improvement protocol of at least 1 hour of daily stretching by experienced therapists yielded an average weekly range-of-motion improvement of 8.2 degrees across 88 joint contractures in nine patients, with the largest gains in the first week (11.2 degrees) ^[14]. Digit contractures improved by 7.2 mm per week in flexion, with first-week gains of 12.8 mm ^[14]. Intensive stretching by experienced therapists yielded significant improvements in joint range of motion in patients with established burn-associated contracture ^[14].

Splinting and orthoses are widely used despite a thin evidence base. A 2020 systematic review and expert consensus reported that the low level of evidence in the available literature supported only one practice guideline: orthotic use should be considered as a treatment choice for improving range of motion or reducing contracture in adults ^[16]. Dynamic versus static splint case data demonstrate that dynamic splints can achieve tissue creep and progressive joint extension where static splints fail ^[17]. A randomized controlled pilot trial of a multi-axis shoulder abduction splint in acute burn rehabilitation reported significantly better shoulder abduction (P = 0.020) and flexion (P = 0.036) at 4 weeks in the splint group than the unsplinted group ^[18]. A separate randomized trial of shoulder splinting in adult burns found no significant difference at 12 weeks for shoulder abduction, flexion, BSHS-B quality of life, or Upper Extremity Functional Index ^[19]. The discrepancy reflects differences in splint design, patient population, and follow-up duration; the literature does not yet specify which splint for which patient at which dose.

Hand burn care during the acute phase combines compression for edema, positioning for joint preservation, and targeted range of motion. Coban self-adherent wraps reduced edema and improved active range of motion, grip strength, and dexterity compared to a control hand in a case study ^[21], and both standard and modified Coban application reduced edema more than a generic compression glove in a randomized hand-edema trial ^[22]. Gore-tex bag dressings outperformed traditional hand bandaging for digit range of motion, first carpometacarpal joint motion, and sensation in a healthy-subject comparison ^[23]. Skin grafting strategy in deep dermal hand burns does not differ between thick and standard split-thickness grafts at 1 year for range of motion, appearance, or patient satisfaction ^[26]. A separate comparison of allogeneic keratinocytes versus split skin graft for deep dermal hand burns found no statistically significant long-term differences in Vancouver Scar Scale or DASH score, with a trend toward higher VSS scores and impaired aesthetic results in the keratinocyte group ^[27].

Outpatient and community rehabilitation

Outpatient rehabilitation extends acute therapy through the first months after discharge. Among 1,520 Burn Model System participants followed at 6, 12, and 24 months, physical therapy and occupational therapy use declined steeply over time (48.5%, 28.6%, and 18.1% at the three time points), with decreasing use of burn-center-based therapy specifically (37.5%, 31.3%, and 25.9%) ^[9]. Burn-center rehabilitation was associated with higher physical function (+2.3) and social role scores (+2.5) in unadjusted models, but these differences were not statistically significant after adjustment for demographic factors ^[9]. Burn-center care was significantly associated with better community integration (P = 0.05); the authors concluded that structured physical and occupational therapy benefits burn survivors' functional outcomes regardless of setting ^[9].

Hospital-to-home transition programs improve scar and quality-of-life outcomes. A semi-experimental study randomized 80 patients with deep partial-thickness burns to a structured transition program versus standard care and found that time and group each contributed to scar reduction (5.71 and 8.81 units respectively, with an interactive effect of 5.22; P < 0.001) and to improved health-related quality of life (21.68 and 26.74 units; interactive improvement 24.71; P < 0.001) ^[101]. The transition program prevented excessive scar complications and supported a more favorable scar maturation process ^[101].

Scar and contracture management

Pressure garment therapy is the most-studied non-surgical scar intervention and the one with the most disappointing meta-analytic result. A meta-analysis of six unique trials involving 316 patients was unable to demonstrate a difference between global assessments of PGT-treated scars and control scars (weighted mean difference -0.46; 95% CI, -1.07 to 0.16) ^[31]. The meta-analysis found a small, statistically significant decrease in scar height for the PGT group (standardized mean difference -0.31; 95% CI, -0.63 to 0.00) but no effect on scar vascularity, pliability, or color ^[31]. PGT does not appear to alter global scar scores, and the small effect on height is of questionable clinical importance ^[31].

Pressure garment therapy is effective, but the clinical benefit is restricted to patients with moderate or severe scarring ^[32]. Combining pressure garment therapy with silicone did not prevent hypertrophic scars beyond pressure garment therapy alone ^[33]. The PEGASUS feasibility study found that a definitive randomized trial of pressure garment therapy was feasible but that staff attitudes and lack of equipoise complicated trial design ^[36].

Adherence to pressure garments is an under-recognized determinant of effect. A multimedia learning education program significantly improved patients' burn knowledge, reduced individual anxiety, and enhanced pressure garment compliance behavior at two weeks ^[34]. Patients describe pressure garments as identity-shaping objects with psychosocial functions beyond scar management ^[35].

Silicone gel and silicone sheeting improve scar appearance and symptoms, including vascularity, roughness, and itch, across randomized trials [37, 39, 40]. Silicone products in gel or sheet form are superior to topical onion extract preparations in treatment of hypertrophic scars ^[39]. Combined pressure plus silicone therapy produces VSS score reductions over 24 weeks but does not show a statistically significant difference from pressure therapy alone in the pace of change ^[38]. Enhanced patient education on silicone gel sheeting yields better subjective scar ratings for itch, color, hardness, and elevation ^[61].

Massage therapy reduces itching, pain, and anxiety acutely in burned adolescents and adults [41, 42], but its effect on long-term scar characteristics is uncertain. A randomized controlled trial of burn rehabilitation massage therapy in patients with hypertrophic scar found significant decreases in scar thickness, melanin, erythema, and transepidermal water loss in the massage group and significant improvements in skin distensibility, immediate distension, immediate retraction, and delayed distension; the authors concluded that massage therapy improves pain, pruritus, and scar characteristics in hypertrophic scars after burn ^[110]. A separate randomized controlled trial of massage on adult postburn scar found changes for all scar characteristics immediately after sessions but predominantly during the early weeks of treatment; the authors concluded that massage applied with the objective of increasing long-term scar elasticity or reducing erythema or thickness over the long-term should be reconsidered ^[43].

Extracorporeal shock wave therapy and laser therapies represent newer scar adjuncts. ESWT reduces scar pain in burn patients after wound recovery in randomized trials ^[44] and may improve pain, pruritus, and health-related quality of life when added to standard physical therapy ^[45]; a randomized trial against control found within-group improvement but no significant between-group difference at 2 weeks or 5 months ^[46]. A systematic review and meta-analysis of fractional CO2 laser treatment for burn scars found that laser therapy alone yielded statistically significant improvements in scar profiles ^[47]. Patient experience of early pulsed dye laser treatment supports its role in reducing the QoL burden of scar maturation ^[48].

Surgical contracture release is reserved for established deformity that does not respond to conservative measures. Postburn axillary contracture, postburn mentosternal contracture, and ankle equinus each have characteristic patterns and reconstruction strategies [90, 91, 92, 93]. The scapular flap is a reliable choice for axillary reconstruction ^[90]; mentosternal contractures classify into 4 groups based on the location and extent of the contracting band ^[91]. Equinus contracture recurrence after Ilizarov fixator treatment in children is 74%, reflecting the influence of ongoing growth on burn-scar contracture ^[93]. Operative release of elbow ankylosis from heterotopic bone improves the mean elbow arc of motion from 52 degrees to 119 degrees, although patients and surgeons should be aware of the moderate risk of recurrent pain or contracture after operative release [87, 88]. A pre-post cohort of 44 patients undergoing burn scar contracture release surgery on 115 affected joints found that mean range of motion improved from 37.3% of functional ROM preoperatively to 108.7% at 12 months postoperatively (p < 0.001), with disability-free survival improving from 55% to 97% and EQ-5D quality of life from 0.69 to 0.93 ^[111].

Pain and pruritus management

Procedural and background pain management is a constant throughout rehabilitation. The American Burn Association acute-pain guidelines, developed through systematic literature review and expert consensus, established 20 guidelines spanning pain assessment, opioids, nonopioid medications, regional anesthesia, and nonpharmacologic treatments and concluded that current evidence is inadequate to define a true standard of care, with a call for additional burn-specific and multimodal pain research ^[104]. Immersive virtual reality reduces patient-reported pain during physical therapy and dressing changes across adult and pediatric studies [49, 50, 51, 52, 53, 54, 56]. The analgesic effect does not diminish with repeated use of virtual reality over multiple treatments ^[49]. In children with acute burn injuries, average pain scores during procedural care fell from 4.1 to 1.3 on the Faces Scale when virtual reality was added to pharmacological analgesia ^[51]. A water-friendly virtual reality helmet extends the modality to patients with severe burns during wound care ^[50]. A 2009 systematic review concluded that VR in conjunction with pharmacological analgesia significantly reduced pain during wound dressing changes and physiotherapy ^[54]. A 2018 systematic review of 34 virtual-reality studies, including 23 randomized trials, found consistent reductions in pain, anxiety, and stress during dressing changes and physical rehabilitation with few side effects ^[106]. In school-aged children undergoing burn wound dressing changes, Wong-Baker pain scores during the procedure were 3.78 with VR compared with 5.58 without ^[107]. A feasibility study of a low-cost VR system added to pharmacological analgesia during physiotherapy in adult burn patients found a marginal trend toward pain reduction (p = 0.06) and no significant effect on anxiety, supporting potential utility in resource-limited settings ^[108]. In a randomized trial of interactive versus passive VR in pediatric thermal burns, both arms showed significant post-intervention improvements in pain, DASH scores, and range of motion ^[56]. A 2018 meta-analysis of 21 randomized trials in 660 adults undergoing burn wound care found that non-pharmacological interventions produced a moderate pooled effect on procedural pain (Hedges' g = 0.58; 95% CI, 0.33 to 0.84), with distraction interventions, particularly virtual reality, and hypnosis showing the largest effects ^[105]. In a study controlling for coping strategies during painful burn procedures, music distraction was associated with significantly fewer post-procedural intrusions and attention focus was associated with more intrusions ^[55].

Pruritus management has evolved with the Cochrane review of 25 randomized controlled trials assessing 21 interventions in 1,166 participants ^[60]. The review groups interventions into six categories: neuromodulatory agents (doxepin, gabapentin, pregabalin, ondansetron), topical therapies, physical modalities, laser scar revision, electrical stimulation, and other ^[60]. Low-certainty evidence supports doxepin cream over oral antihistamine (mean difference -2.60 on a 0 to 10 visual analogue scale; 95% CI, -3.79 to -1.42) ^[60]; gabapentin over cetirizine (-2.40 VAS; 95% CI, -4.14 to -0.66) ^[60]; pregabalin over cetirizine plus pheniramine (-0.80 VAS; 95% CI, -1.24 to -0.36) ^[60]; and moderate-certainty evidence supports ondansetron over diphenhydramine (-0.76 NAS; 95% CI, -1.50 to -0.02) ^[60] and enalapril ointment over placebo (-0.70 on a 0 to 4 itch scale; 95% CI, -1.04 to -0.36) ^[60]. Massage versus standard care reduces pruritus (standardized mean difference -0.86; 95% CI, -1.45 to -0.27) and pain (-1.32; 95% CI, -1.66 to -0.98) ^[60]. ESWT versus sham reduces pruritus (-1.20; 95% CI, -1.65 to -0.75) ^[60]. Pulsed high-intensity laser versus placebo laser reduces pruritus intensity (-0.51 on a 0 to 1 itch severity scale; 95% CI, -0.64 to -0.38) ^[60]. Across the Cochrane review, most studies were small and at high risk of bias related to blinding and incomplete outcome data; certainty of evidence is therefore moderate to low ^[60]. A separate 2009 evidence-based review classified ten trials and one case report and concluded that the best-quality pharmacological intervention was selective histamine receptor antagonists and the best-quality non-pharmacological intervention was pulsed dye laser ^[59]. The same review concluded that quality evidence for post-burn pruritus remained limited at that time and called for additional randomized trials ^[59]. Pulsed dye laser improves pruritus significantly relative to control treatment areas (P < 0.001) ^[58]. Itch scores significantly differed across observation times in a study of histamine receptor antagonists ^[57].

Exercise and functional reconditioning

Structured exercise programs are among the best-supported interventions in burn rehabilitation, particularly in pediatric severe burns. A 12-week resistance exercise program in children with burn injuries produced significant improvement in muscle strength, power, and lean body mass relative to a standard rehabilitation program without exercise ^[62]. The Shriners Hospitals 6-week resistance and aerobic exercise program in 33 children with mean 49% TBSA produced 5% increase in lean body mass, 18% increase in peak torque, 20% increase in power, and 18% increase in cardiorespiratory fitness (P < 0.0001 for all) ^[68]. A separate analysis of different exercise program durations in children with severe burns demonstrated significant improvements in muscle strength, peak VO2, and lean body mass after 6 weeks of training, with continued improvement in peak VO2 over an additional 6 weeks ^[67].

Exercise interacts with anabolic and beta-adrenergic pharmacology in the severely burned child. Recombinant human growth hormone administration improved growth and lean body mass while attenuating hypermetabolism ^[64]; in a comparison of growth hormone alone, exercise alone, and combined therapy, muscle strength increased only with exercise ^[63]. Oxandrolone at 0.1 mg/kg twice daily for 12 months produced 5-year improvements in height, bone mineral content, cardiac work, and muscle strength compared with placebo ^[71], with the maximal effect found in children aged 7 to 18 years ^[71]. Long-term oxandrolone treatment increased net deposition of leg muscle protein during amino acid infusion by attenuating protein breakdown ^[72]. Propranolol added to exercise training in children with severe burns produced a significantly greater percent change in peak VO2 than control without impairing strength or lean body mass gains ^[66]. Resting beta-adrenergic blockade did not affect internal body temperature of burned children exercising in the heat ^[74]. In a study of propranolol for pain after major burn, 77% of eligible patients were consented and genotyped at the study site; patients receiving propranolol had worse pain scores on study days 5 to 19, and the authors concluded that propranolol is unlikely to be a useful analgesic during the first few weeks after burn injury ^[73]. The exercise-augmentation finding and the pain-relief failure together illustrate that propranolol effects are pathway-specific.

Exercise training in adults shows similar functional gains. An intensive exercise program after thermal injury improved physical, functional, and psychological outcomes across mean change scores from baseline to 12 weeks in strength and aerobic capacity ^[70]. A randomized controlled trial of community-based exercise in adults with severe burns produced significant within-group increases in peak torque in both the exercise and standard-of-care arms, with the community-based exercise program comparing favorably to standard care ^[69].

Vocational and educational reintegration

Return to work is a primary participation outcome and a measurable endpoint. Time to return ranges from 4.7 weeks to 24 months across reviewed studies ^[7]. Common barriers include extent and severity of the burn, longer length of stay, and number of operative procedures ^[7]; severity of the burn is the most significant predictor of failure to return to work ^[7]. Among patients burned at work versus burned outside work, employment barriers cluster around pain, neurologic problems, psychiatric problems, and impaired mobility, with comparable rates reported in both groups ^[8]. In a military population of combat burns, TBSA burn, length of hospitalization, length of ICU stay, and inhalation injury were the most significant factors in determining return to duty status; thirty-four different parameters influencing return to work have been reported inconsistently across the literature, and a consensus dataset and statistical approach are needed ^[6]. Return to full-time employment does not differ significantly between groups ^[79].

Complications

Three rehabilitation-relevant complications deserve dedicated attention: heterotopic ossification, contracture recurrence, and persistent pain or pruritus.

Heterotopic ossification develops in 3.5% of severely burned adults in the Burn Model System database ^[86]. Patients with greater than 30% TBSA burn have 11.5 times higher odds of developing HO, and those with arm burns requiring skin grafting have 96.4 times higher odds; each additional trip to the operating room increases the odds by 30%, and each additional ventilator day increases the odds by 3.5% ^[86]. Joint contracture, inhalation injury, and bone exposure do not significantly increase the odds of HO in the adjusted multivariable model ^[86]. In a 21-year single-center series of 42 patients, the elbow was the site in over 90% of cases and 44% of cases were bilateral; greater than 90% of patients required ventilator support ^[87]. The mean day of HO diagnosis was 71 days post-burn ^[87]. Surgical release improves elbow arc of motion from a mean of 52 degrees to 119 degrees but is followed by repeat release in a subset of patients [87, 88]. A systematic review of kinesiotherapy for HO prevention infers that controlled passive range of motion exercises initiated early at a painless range can support prevention of neurogenic HO, while active range of motion within painless limits is beneficial for elbow and burn-joint HO prevention ^[89]. A high-quality clinical trial is still missing from this literature ^[89]. A foundational HO management series of 1,478 admissions identified 18 affected patients (1.2% incidence) with 17 of 18 elbow-involved; ten responded to conservative active range of motion therapy and regained functional motion, while eight required surgical management with all surgically treated patients achieving functional range of motion at a mean follow-up of 35 months ^[109].

Contracture recurrence after surgical release is high in children because of ongoing growth. Equinus contracture recurrence after Ilizarov fixator treatment is 74% ^[93]. Continuous body growth and the rigidity of scars in children are significant contributors to burn scar contractures ^[20]. Pediatric Burn Model System data confirm that age, length of stay, ICU length of stay, presence of amputation, TBSA burned, and TBSA grafted all predict the number of contractures, and that age, ICU length of stay, amputation, and Black race predict severity ^[1]. Limited range of motion at discharge correlates with larger burns, surgery, greater percentage of affected cutaneous functional unit, and lower-extremity joint burns ^[2].

Persistent post-burn pain and pruritus represent a heterogeneous symptom complex with substantial impact on rehabilitation participation. The Cochrane review's six-category framework structures targeted management ^[60]. Pulsed dye laser is the highest-quality non-pharmacological intervention for pruritus in the earlier systematic review ^[59]. Low-certainty evidence supports massage versus standard care for reducing burn-related pruritus (SMD -0.86; 95% CI, -1.45 to -0.27) and ESWT versus sham for reducing burn-related pruritus (SMD -1.20; 95% CI, -1.65 to -0.75) ^[60]. The Burn Specific Pain Anxiety Scale predicts later procedural pain ratings ^[85].

Special Considerations

Pediatric burn rehabilitation

Pediatric burn rehabilitation differs from adult care in three load-bearing dimensions: ongoing growth, school reintegration, and the central role of the family. Continuous body growth and scar rigidity drive progressive contracture in children ^[20], and pediatric exercise programs target the resultant lean-mass deficits and cardiorespiratory deconditioning that persist after discharge [62, 67, 68].

The Burn Model System pediatric contracture data, presented above, document a 23% contracture incidence at discharge in 1,031 patients ^[1]. Hand burns in pediatric cohorts preserve quality-of-life trajectory: despite severe injury, children with hand burns show continued improvement in quality of life for at least 2 years after injury ^[24]; this pattern holds for both small (<20% TBSA) and large (≥20% TBSA) burns ^[4].

Conservative versus early surgical management in pediatric burns showed no statistical difference in mortality, amputations, incidence of open wounds, contracture development, or number of reconstructive procedures except for children treated with skeletal suspension ^[96]. The pediatric evidence base on exercise, anabolic adjuncts, and propranolol is consolidated above under exercise and functional reconditioning [62, 63, 64, 65, 66, 67, 68, 71, 72, 74].

Older adults

Severe burn injury significantly impacts both functional outcome and psychosocial quality of life in older adults ^[3]. Older adults are under-represented in the pediatric-heavy exercise rehabilitation literature.

Peer support and burn camps

Peer support group programs are associated with psychosocial improvements across inpatient, outpatient, integrative, and camp formats ^[99]. In a systematic review of 25 articles, all inpatient peer support group articles (n = 4) reported associations with psychosocial improvements, integrative groups (n = 2) reported improvements in social integration and reduction in post-traumatic stress and anxiety, and outpatient groups (n = 8) demonstrated associations with psychosocial outcomes including life satisfaction and reduced isolation ^[99]. Findings for burn camps were less consistent: eight articles suggested improvements while three reported no significant psychosocial effects ^[99]. A separate systematic review of burn camps concluded that qualitative data suggest burn camps are beneficial for children with burn injuries ^[98]. A 2007 study of pediatric residential burn camp documented significant improvement in self-esteem from camp beginning to end ^[97].

Facial burns and microstomia

Microstomia at discharge occurs in 4.7% of adult and 11% of pediatric burn survivors and is associated with significantly larger TBSA burns, higher rates of inhalation injury, more ventilator days, and more adjacent contractures ^[29]. Burn size and length of time requiring ventilation predict microstomia; the authors of the Burn Model System microstomia study note that areas beyond the perioral region should be considered when developing a treatment and prevention program because of cutaneokinematic skin recruitment ^[29]. Psychological impact and stigma after facial burns are concerns addressed in the literature; psychological counselling, resilience training, and reconstructive surgery improve social reintegration and reduce stigma ^[30].

Hand burns

Hand burns receive dedicated rehabilitation attention because of the disproportionate functional consequences of even small affected surface areas. Compression strategies for hand-burn edema include Coban self-adherent wraps ^[21] and modified Coban application ^[22]. Leap motion control hand rehabilitation improved BSHS-B, QuickDASH, and instrumental activities of daily living relative to standard therapy in a controlled comparison ^[25]. A comparison of surgical and enzymatic debridement found that DASH and modified hand questionnaire scores favored enzymatic approaches, especially when conservative management followed debridement ^[28]. Early versus delayed excision and grafting did not significantly differ between EEG and DEG groups on hand function, although the EEG group had shorter hospital stays and lower treatment costs ^[102].

Amputation

Burn-related amputation produces specific rehabilitation demands. A 28-year review of 5,018 burn patients identified six patients with bilateral above-knee amputations, of whom four survived ^[94]. Maintenance of maximal viable limb length and any residual limb function offers significant functional benefit to multiple-limb amputees ^[95]. In pediatric Burn Model System data, presence of amputation predicts both the number of contractures (alongside total age, length of stay, length of ICU stay, TBSA burned, and TBSA grafted) and the severity of contractures (alongside age, ICU length of stay, and Black race) ^[1].

Outcomes

Quality of life outcomes after burn injury improve over time across most measured domains, with persistent deficits at long-term follow-up in work, heat sensitivity, emotional functioning, physical functioning, and pain or discomfort ^[77]. Burns negatively impact most quality-of-life dimensions in adult patients across longitudinal observation ^[81]. The simplified model of the BSHS-B is a reliable, valid, and useful tool for describing postburn health over time; in prospective validation, function and skin involvement scores increased over time while affect and relations did not change, and all three domains were associated with burn severity at 6 and 12 months postburn ^[76]. Higher convergence between SF-36 and BSHS-B than between SF-36 and EQ-5D supports using a generic plus burn-specific pair for comprehensive measurement ^[78]. The EQ-5D has acceptable psychometric properties for burn-injured adults and is short and easy to administer ^[80].

Children with burn injuries show continued improvement in quality of life for at least 2 years after injury, even with severe hand burns ^[24]. Children with hand burns have significantly worse outcomes than children with burns in other areas, with the most pronounced differences in fine motor function, gross motor function, and appearance; these findings apply to both small (<20% TBSA) and large (≥20% TBSA) burns ^[4]. Patients across all age groups show significant deficits at discharge, with recovery of physical and psychosocial functioning greatest from discharge to 6 months in patients aged 55 to 74 years and greatest at 1 year for patients aged 75 years or older ^[3].

Functional outcome measurement typically reports both the magnitude of improvement and the rate of change. The PEGASUS feasibility study identified function, perceptions of appearance, specific scar characteristics, pain and itch, broader psychosocial outcomes, and treatment burden as the six outcome domains most important to patients and clinicians ^[36]. ICF mapping of common quality-of-life instruments shows that no single instrument captures all relevant domains; the SF-36 captures only one domain in the activity limitations and includes no contextual factors ^[83]. The BSHS-B is the most-used burn-specific instrument in a systematic review of post-burn health-related quality of life ^[77].

Physical function measurement uses the 6-minute walk test, isokinetic dynamometry, and hand grip across adult studies. Burned children at discharge show lean body mass at 77%, peak torque at 53%, power at 62%, and cardiorespiratory fitness at 56% of age-sex-matched nonburn values ^[68].

Controversies and Evidence Gaps

The rehabilitation literature contains several unresolved questions where credible sources disagree or where the evidence remains too thin to support directional conclusions.

Pressure garment therapy is the canonical example. The 2009 meta-analysis concluded that PGT does not appear to alter global scar scores ^[31]. The 12-year within-wound study concluded that PGT is effective with benefits restricted to moderate or severe scarring ^[32]. The PEGASUS feasibility study found that staff perception of PGT effect varies considerably and that lack of equipoise complicates trial design ^[36]. Combined silicone-plus-pressure therapy did not improve outcomes beyond pressure therapy alone in randomized comparison ^[33]. The literature does not yet specify the optimal dose, duration, garment design, or patient selection criteria for PGT, and a definitive multicenter trial remains needed.

Orthoses rest on a similarly thin base. The 2020 systematic review and expert consensus reported that only one practice guideline could be recommended at the evidence level available: orthotic use should be considered for improving range of motion or reducing contracture in adults ^[16]. The remaining guidance came from expert consensus rather than direct evidence. A randomized shoulder abduction splint trial showed benefit in acute burn rehabilitation ^[18]; a separate randomized trial of shoulder splinting in adult burns showed no difference at 12 weeks ^[19]. The discrepancy reflects unresolved questions about splint design, patient population, and follow-up duration.

Long-term scar massage is contested. The 2019 randomized trial concluded that massage applied with the objective of increasing scar elasticity or reducing erythema or thickness over the long-term should be reconsidered ^[43]. The same modality reduces acute itch, pain, and anxiety in burned adolescents ^[41] and pruritus and pain at standardized-mean-difference effect sizes that the Cochrane review classifies as low-certainty evidence ^[60]. The literature supports short-term symptomatic use; the case for long-term scar remodeling is weak.

Extracorporeal shock wave therapy shows positive but inconsistent signals. A 2016 trial demonstrated significant reduction in scar pain after wound recovery ^[44]; a 2019 trial showed improvements in pain, pruritus, and HRQOL ^[45]; a 2022 trial showed within-group improvement but no significant between-group difference at 2 weeks or 5 months ^[46]. The Cochrane review classifies ESWT for pruritus as low-certainty evidence ^[60].

Propranolol presents a clear pathway-specific dissociation. Adding propranolol to exercise training augments the aerobic response in severely burned children ^[66] and does not impair strength gains ^[66]. A separate genotype-based randomized trial for pain found that propranolol-treated patients had worse pain scores on study days 5 to 19 and concluded that propranolol is unlikely to be a useful analgesic during the first few weeks after burn injury ^[73]. The two findings can both be true: propranolol's beta-blockade benefits the metabolic and cardiovascular axes of recovery without functioning as an analgesic.

Spa therapy for burn scar care lacks supporting evidence. A systematic review identified no strong study on the effectiveness of spa therapy and underscored the need for clinical studies to evaluate effects and benefits on quality of life ^[103]. The 2024 Cochrane pruritus review notes that most randomized trials were small and at high risk of performance, attrition, and detection bias ^[60].

Therapist confidence is a workforce gap. Initial survey results from one burn rehabilitation workshop indicated that more than 75% of therapists felt unconfident or strongly unconfident in providing burn rehabilitation ^[100]. The educational and supervisory infrastructure that supports rehabilitation effectiveness is not uniformly distributed across burn-care systems.

Across the rehabilitation literature, several themes recur. Sample sizes are small. Outcome measures are heterogeneous. Follow-up durations are short relative to the clinical course of scar maturation and functional recovery. Direct comparative trials between scar therapies are sparse. Pediatric and adult populations are studied separately, and findings do not always translate between them. The 2018 systematic review of HRQOL after burn injury recommended developing a guideline on the measurement of HRQOL in burns ^[77]; that recommendation remains a fair characterization of the state of measurement in the field.

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