Key points

Introduction

The rehabilitation of a patient with burns can be one of the most complex, time-consuming, and costly endeavors in rehabilitation medicine. Extensive burns and associated injuries often lead to long-term physical and psychological dysfunction. As the mortality from burn injuries has decreased over time because of the development of comprehensive burn centers, there is continued need for well-designed rehabilitation protocols and care pathways from the acute stabilization phase through the patient’s return to the community. Superficial partial-thickness burns that avoid critical body areas such as the face, hands, feet, genitalia, perineum, or major joints typically require acute treatment and short-term multidisciplinary management and follow-up. In contrast, deep partial-thickness or full-thickness burns, burn injuries requiring substantial grafting, and burns over critical areas are all indications for referral to a burn center to ensure that the patient has access to comprehensive burn-focused care. Complex burn injuries require an interdisciplinary effort in which the stabilization, reconstruction, and rehabilitation process is carefully planned among the burn physicians, nurses, therapists, social workers, and other support services. The group activity of this interdisciplinary team is synergistic, producing more than what the team members could produce separately. This article presents an overview of the rehabilitation medicine approach to the care of patients with extensive burns with additional focus on the neurologic or musculoskeletal complications.

Introduction

The rehabilitation of a patient with burns can be one of the most complex, time-consuming, and costly endeavors in rehabilitation medicine. Extensive burns and associated injuries often lead to long-term physical and psychological dysfunction. As the mortality from burn injuries has decreased over time because of the development of comprehensive burn centers, there is continued need for well-designed rehabilitation protocols and care pathways from the acute stabilization phase through the patient’s return to the community. Superficial partial-thickness burns that avoid critical body areas such as the face, hands, feet, genitalia, perineum, or major joints typically require acute treatment and short-term multidisciplinary management and follow-up. In contrast, deep partial-thickness or full-thickness burns, burn injuries requiring substantial grafting, and burns over critical areas are all indications for referral to a burn center to ensure that the patient has access to comprehensive burn-focused care. Complex burn injuries require an interdisciplinary effort in which the stabilization, reconstruction, and rehabilitation process is carefully planned among the burn physicians, nurses, therapists, social workers, and other support services. The group activity of this interdisciplinary team is synergistic, producing more than what the team members could produce separately. This article presents an overview of the rehabilitation medicine approach to the care of patients with extensive burns with additional focus on the neurologic or musculoskeletal complications.

Functional loss caused by a burn

The World Health Organization provides a contextual framework through the terms impairment , activity , and participation to understand how a burn injury affects a person’s ability to move, care for him or herself, and fulfill a role in society. The terms activity and participation have replaced the older terms of disability and handicap , respectively ( Table 1 ).

Burn care in terms of reconstruction, rehabilitation, and recovery can also be understood in this model. Reconstruction can be defined as the restoration of the skin and related structures that are causing the loss of function and impairment. Rehabilitation is then necessary to regain the ability to perform a functional activity with that body part. With ongoing comprehensive care, a person then can move toward recovery of meaningful participation in life in his or her home community and potentially place of employment.

Functional assessment of a burn patient

Burn rehabilitation starts with assessing the location of the burns, the total body surface area involved, and the depth of the burn. Burn and graft donor sites, areas of contracture, and scar development must be assessed with particular attention to how the burn affects range of motion (ROM) and function of the body part. In complex cases, the rehabilitation professional must account for other organ system injuries and complications, including inhalation injuries, central and peripheral nervous system injuries, musculoskeletal trauma, and heterotopic ossification.

The burn team must also learn about the person with the burn, taking into account a person’s premorbid functional status, current functional status, social and caregiver support, living environment, and goals of care. In general, burn patients who are younger, higher functioning at baseline, married, and employed have the best functional outcomes.