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A burn is defined as a traumatic injury to the skin or other organic tissue primarily caused by thermal trauma. It results when some or all of the cells in the skin or other tissues are destroyed by heat, cold, electricity, radiation, or caustic chemicals.1


Burn injuries can occur by various mechanisms, including fire/flames (43%), scald (34%), contact (9%), electrical (4%), chemical (3%) and other (i.e., radiation, friction, thermal) (12%). Place of occurrence is mainly at home (73%), occupational (8%), street/highway (8%), recreational/sport (5%) and other (9%). Males (68%) tend to have higher burn rates than females (32%). Caucasian (59%) is the ethnicity with most burn cases followed by African-Americans (20%).2 According to the World Health Organization’s Global Burn Registry of 8,640 burn patients, children comprised of 42% of the burn patient registry, and the most common type of burn among children was scald burn (80%).3

Epidemiology including risk factors and primary prevention

Each year in the United States, 1.1 million burn injuries require medical attention. Approximately 50,000 of these require hospitalization; 20,000 have major burns involving at least 25 percent of their total body surface, and approximately 4,500 of these people die.1

Vulnerable populations include children, women and older adults. Among risk factors, lack of supervision of children, comorbid illness of older adults, clothing made out of flammable material and low socioeconomic status are more common. Other risk factors are occupations that increase exposure to fire, overcrowding, lack of proper safety measures, underlying medical conditions (epilepsy, peripheral neuropathy, and physical and cognitive disabilities), alcohol abuse and smoking.4

Flame related injuries are the most common reason for admission to U.S. Burn Centers, while scalding is the most common pediatric burn injury. Risk of death is greatest in adults over 60 years of age and children under 2. Prevention strategies should address the hazards for specific burn injuries, education for vulnerable populations and first aid training.2


The skin provides a barrier to the environment, regulates body temperature and serves as an important component of immune system. It is composed of three layers: epidermis, dermis and subcutaneous layers. Figure 1 classifies burn injuries by burn depth. Partial thickness burns occur when there is a burn injury to the epidermis or dermis. Full thickness burns extend past the epidermis and dermis and into the subcutaneous tissue, muscle, and or bone.5

Figure 2 illustrates burn injury severity based on total body surface area (TBSA) of the burn injury.5

Burn injuries cause the most destructive stress response on the body when compared to sepsis and other forms of trauma, including brain injury, spinal cord injury, and polytrauma.6 Burn injuries ignite local and systemic responses throughout the body. In local responses, there are three zones of a burn: coagulation (irreversible tissue loss due to coagulation of proteins), stasis (decreased tissue perfusion that if managed appropriately prevents irreversible damage), and hyperemia (outermost zone, good recovery except with prolonged hypoperfusion or severe sepsis).7

Systemically, burn injuries induce a prolonged hypermetabolic state and massive inflammatory response that can cause multiorgan system dysfunction. The hypermetabolic state can last for years after the initial burn. 8 A surge in proinflammatory cytokines (IL-6, IL-1b, TNF alpha), catecholamines (dopamine, epinephrine, norepinephrine), and hormones (cortisol, glucagon) after a burn injury perpetuate the hypermetabolic state9 and lead to organ dysfunction. Cardiovascular changes after burn injury include elevated heart rate, increased cardiac output, and increased capillary permeability leading to loss of intravascular proteins and extravasation of fluids into the interstitial compartment.8 Myocardial contractility is decreased, possibly due to release of Tumor Necrosis Factor- α (TNF- α). These changes result in systemic hypotension and end organ hypoperfusion. Burns can cause pulmonary dysfunction including bronchoconstriction and respiratory failure. Skeletal muscle breakdown and proteolysis after burn injury occurs as a response to ameliorate the hypermetabolic state and due to prolonged immobilization. Adipose tissue is altered after burn injury and lipolysis is activated to help meet the energy demands of the body. Patients with burn injury are at risk for cachexia due to the hypermetabolic state.7 Additionally, non-specific down regulation of the immune response can occur after burn injury, which in turn affects both cell mediated and humoral pathways.7

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

Initial phase (resuscitation): 1-3 days. Interdisciplinary team at a dedicated burn center, with focus on the burn’s pathophysiology, inhalation injury, and edema formation.10 Fluid resuscitation serves as the mainstay of systemic treatment in moderate and severe burns to maintain organ and tissue perfusion. The Parkland formula [Total crystalloid fluid resuscitation in first 24 hrs = 4ml x %TBSA x weight (kg)] is used to calculate the initial fluid requirements of a patient within 24 hours after acute burn injury. 11 Acutely, goals are promotion of wound healing, scar suppression, pain reduction and prevention of complications.12

Second phase (wound care): The objective here is excision of nonviable tissue and biological closure, infection prevention, facilitation of wound healing while ensuring adequate pain control. Local wound management includes topical antibiotics and various biologic and non-biologic dressing as means of protection from the environment, drainage absorption, and providing a moist environment for wound healing.12

Third phase (definitive wound closure): This involves replacing temporary wound covers with a definitive cover. Skin grafts are used in treating partial thickness and full thickness burns. Early surgical removal of burned skin followed by skin grafting reduces the number of days in the hospital and usually improves the function and appearance of the burned area.12

Final stage (rehabilitation, reconstruction, and reintegration): Rehabilitation for patients with burn injuries starts from the day of injury, lasting for several years and requires multidisciplinary efforts. It also emphasizes preparing the patient for the psychological and social challenges the patient may face once integration to society occurs.1,2

Specific secondary or associated conditions and complications

Skin and joint contractures, neuropathies, heterotopic ossification, septic arthritis, joint subluxations/dislocations, hypertrophic scarring, pruritus and dry skin, abnormal gait or postures (e.g., scoliosis), critical care myopathy/neuropathy and heat intolerance are all possible complications that may arise after a burn injury.14

Essentials of Assessment


After initial assessment, it is important to obtain a history of the event either from the patient or a bystander. An adequate history will help determine the potential of an inhalation injury, concomitant trauma and any preexisting medical conditions that may influence the patient’s outcomes or physical exam. It is crucial to obtain the patients chief complaint, circumstances of the injury (enclosed space, related trauma, non-accidental injuries, etc.) the source of the burning agent (thermal, chemical, electrical, etc.) medications patient is taking, status of tetanus immunization and if there was loss of consciousness at any time during the event.1

If meeting the patient for the first time during the final rehabilitation phase, it is important to inquire about potential sequelae that may result from burn injuries; for example, pruritus, sleep disturbance, change in mood, pain, and impairments in mobility, self-care, activities of daily living, and instrumental activities of daily living. 

Physical examination

Post critical-care examination includes:

General: Evaluate mental status, cognition, appearance, vital signs and pain level.1

Cardiovascular: Auscultate heart and evaluate heart rate and rhythm.

Respiratory: Auscultate lungs. Evaluate oxygen requirement. If patient has tracheostomy, assess trach and evaluate secretions.

Skin: Describe burn location, size, depth and burn pattern. Body surface area may be calculated using the Rule-of-Nines and the Lund and Browder chart (takes into account changes in body surface area with age and growth). Evaluate for cyanosis, circulation, edema, redness, warmth, scarring, ulcerations, document skin graft location and status, and assess donor sites.1,2

Musculoskeletal: Range of motion (ROM), atrophy, muscle wasting, strength, joint deformity (contractures), bony abnormality (heterotopic ossification (HO).1,2

Extremities: if burn injury resulted in amputation, evaluate residual limb shape, length, ROM, strength, skin, and incision.

Neurological: Evaluate cranial nerves, changes in sensation, reflexes, tone, proprioception and coordination).1,2

Psychiatric: evaluate affect and mood for anxiety, depression, post-traumatic stress disorder, and adjustment disorder.

Functional assessment

A multidisciplinary team composed of a physiatrist, speech therapist, occupational therapist, physical therapist, nurse, rehabilitation psychologist, social worker, and case manager can be helpful to comprehensively evaluate the function of a patient who has sustained a severe burn injury.

Various functional assessment tools exist that can aide the multidisciplinary team. The Borg Exertion Scale and vital signs (heart rate, respiratory rate, and blood pressure) assess tolerance to daily activities and exercise. The Functional Independence Measure and the Care Item Set are tools that are used to measure self-care and mobility.

Psychological distress occurs in many burn patients for whom adequate evaluation needs to be performed in order to identify depression (PHQ-9, Beck Depression Scale), anxiety (Depression Anxiety Stress Scale, Beck Anxiety Scale), PTSD and/or body image issues (Rosenberg Self-Esteem Scale).15

Laboratory studies

Pre-albumin and albumin are useful for assessing protein/nutritional status. White blood cell (WBC) count, neutrophil percentage, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) may help detect the presence of infection, although early on they may have a low yield because of the inflammatory response associated with the burn itself.


Heterotopic ossification (HO) can be a sequela of a burn injury. Triple phase bone scintigraphy is sensitive for detecting HO, and the gold standard for diagnosing HO. Xray

If concern for limb ischemia, assessment of peripheral pulses in burn patients can be performed with a Doppler ultrasound.1

Supplemental assessment tools

The Burn Specific Health Scale (BSHS) is as a specific outcome measure for burn injuries including physical, psychological, and social aspects. Jebsen Hand Function Test helps assess a broad range of uni-manual hand functions required for activities of daily living (ADLs). The West-Haven-Yale Multidimensional Pain Inventory may be used in conjunction with behavioral and psycho-physiological strategies to help assesses chronic pain in individuals. Craig Handicap Assessment and Reporting Technique is a simple objective measure of the degree to which impairments and disabilities result in handicaps.15 Electrodiagnostic test may be performed to evaluate for neuropathy or myopathy. Sequential photography can be taken to help assess burn and scar progression.

Early predictions of outcomes

The progress that has been made in burn care over the past few decades has dramatically increased survival rates for burn victims such as; antibiotic therapy, techniques to excise burn eschar and new technology/clinical skills in the management of burn wounds, resuscitation and nutrition.16 Outcomes are poorer as burn depth and TBSA increase (>40%).2 Associated injuries, such as head injury, inhalation injury, and comorbidities, such as diabetes have been shown to worsen outcomes. Increase mortality after burn injury is associated with age less than 2 years or older than 60.13


Healed burn skin is fragile and sensitive to the sun and chemicals. With a deep partial thickness or full thickness burn, sweat glands are destroyed and are not replaced when the skin heals. This type of damage can lead to problems with thermoregulation in hot and humid conditions because sweating is crucial in controlling body temperature. Precaution with certain forms of exercise, recreation, or working conditions should be followed to avoid complications such as heat stroke.13 Healed burns, donor sites, and skin grafts are more sensitive to UV light and are risk for sunburn; therefore, patients who experience burn injuries should protect themselves from sun exposure by wearing specialized SPF clothing and utilizing sunscreen with SPF of 30 or higher.

Occupational environments should be considered prior to return to work. Patients with inhalation injuries should refrain from working in environments with dust, fumes or respiratory irritants.

Social role and social support system

Burn patients face social, emotional, vocational and physical challenges. Peer counseling groups for support and mutual problem solving are often helpful.17 See “Patient and Family Education.”

Professional issues

Employment after burn injury is possible. Mason et al published a systematic review that analyzed return to work outcomes after burn injury and found that 72% of burn patients employed at the time of injury were able to return to work. Risk factors for unemployment include unemployment prior to injury, greater TBSA, longer hospital stay, greater number of surgical procedures, and pre-existing psychiatric conditions.18

Employment outcomes after burn injury vary if the burn injury occurred at or outside of work. For those burned at work, pain (72%), neurologic problems (62%), and psychiatric problems (53%) are the most limiting factors. Those burned outside of work demonstrate limitations secondary to pain (63%), neurologic problems (59%), and impaired mobility (54%) Barriers to return to work early after burn injuries are physical and wound issues, while long term disabilities are secondary to working conditions (temperature, humidity, safety) and psychosocial factors.19

Rehabilitation Management and Treatments

Available or current treatment guidelines

Surgical treatment guideline is provided by the American Burn Association. Currently, no consensus guideline exists for burn rehabilitation.

At different disease stages

Initial phase (resuscitation): Critical care services to monitor and correct fluid and electrolyte, metabolic, cardio-pulmonary, hemostatic derangements and infections.17

Second phase (hypermetabolic state, wound care, surgical care, pain management, positioning & splinting): Debridement can be performed to remove eschar and necrotic tissue to prepare a viable base for wound healing, grafting and prevent infections. Escharotomy is indicated in circumferential and partial thickness burns that present with pressure of at least 40mmHgG to prevent necrosis of underlying tissues.20

Topical wound care topical agents (silver sulfadiazine, gauze with bacitracin or mupirocin, mafenide acetate and acetic acid soak). Synthetic dressings with Duoderm, Tegaderm, Xeroform, silver coated gauze (Aquacel, Mepilex, Acticoat) reduce dressing change frequency and patient discomfort.17

Burn injuries induce a systemic response resulting in a hypermetabolic state that can cause multi organ system damage. Propranolol has been shown to modulate the hypermetabolic state, lower heart rate, decrease blood loss during skin grafting procedures, and accelerate wound healing in severely burned adults.21 Oxandrolone is an anabolic steroid shown to decrease protein catabolism, muscle wasting, and hospital stay while improving wound healing, morbidity, and mortality of severely burned patients.22 Maximizing nutrition is critical and early enteral feeding is often necessary. Patients who are severely burned (TBSA >20%) are recommended to have a diet high in protein (1.5-2g/kg/day), low in fat, and supplemented with vitamin C, D, E and zinc.23 Stress induced diabetes after burn injury is associated with worse outcomes, and research has shown that blood glucose level between 130 mg/dL to 150 mg/dL is associated with decreased infection, sepsis associated organ failure, and mortality.24

Adequate pain control is imperative throughout the recovery process. Pain after burn is complex, can be difficult to treat, and often requires multiple modalities. Treatment options include but are not limited to short and long-acting opioids, NSAID, Tylenol, gabapentin, Lyrica, and antidepressants. Non pharmacological pain management modalities include cognitive behavior therapy, meditation, yoga, deep breathing, distraction, virtual reality, imagery, hypnosis, progressive muscle relaxation, positive reinforcement and cognitive restructuring.20

Over 1/3 of patients with burn injuries develop contracture, which is a barrier to recovery. Patients with extensive burn injuries, large graft size, amputation, inhalation injury, and long hospitalization are at higher risk for developing contractures. Positioning and splinting are important to maintain joint range of motion when a patient is unable especially during the acute hospitalization.25 Patients will favor resting in a shortened, flexed position therefore correct alignment is crucial to prevent contractures. Anti-contracture positioning is determined by location and direction of contracture of the affected burn area.26 Contractures are most common at the shoulder, elbow, and knee. Recommended shoulder positioning is 90 degrees of abduction and external rotation, knee positioning is full extension. Splinting assist in maintains anti-contracture positioning in patients experiencing pain, poor compliance or when positioning alone is not sufficient. Along with positioning and splinting, passive and active range of motion exercises prevent contractures.  Figure 3 outlines recommend positioning to prevent contractures.

Figure 3. Positioning to prevent contracture after burn26,27

Body PartContracture Prevention Positioning
NeckNeck midline and 15 degrees of extension
ShoulderArms in 90 degrees of abduction
ElbowElbow in extension (approximately 5-10 degrees from full extension)
ForearmForearm in neutral position with 10 degrees of supination
WristWrist in 10-15 degrees of extension
HandMetacarpophalangeal joints 70 degrees of flexion, Interphalangeal joints in full extension, Thumb carpometacarpal joint in abduction and thumb MCP and IP in full extension
HipHip in neutral position with 10-15 degrees of abduction
KneeKnee in extension (approximately 5 degrees from full extension)
Ankle/footAnkle and foot in neutral position

Third phase (definitive wound closure):

Temporary skin grafts include cadaveric allograft, Xenograft, Biobrane, or Transcyte. Autografts are permanent skin grafts and are the gold standard in skin substitutes.39 They provide wound closure, help modulate metabolic needs, reduce evaporation and serves as a mechanical barrier to infection.20

Final stage (rehabilitation, reconstruction, reintegration):

Acute inpatient rehabilitation can be appropriate for patients with burn injury who are below functional baseline and are medically complex. The acute inpatient rehabilitation team is composed of a physiatrist, nurse, physical therapist, occupational therapist, speech therapist, rehabilitation psychologist, case manager, and social worker. Goals during inpatient rehabilitation include but are not limited to improving function, activities of daily living, self-care, and mobility.  

Medically, physiatrists manage various sequelae after burn—pain, changes in mood, sleep disturbances, and pruritus.  Multiple modalities are used to managed pain so that pain is not a barrier to a patient’s progress during the rehab. Short and long-acting opioids, NSAID, acetaminophen, gabapentin, pregabalin, and antidepressants can be used to manage burn pain.  Anxiety and depression can exacerbate the perception of pain.28 Patterson et al. conducted a randomized double blind controlled trial to evaluate the effect of lorazepam as an adjust to opioid analgesia in the treatment of burn pain and found that 1mg PO lorazepam improved analgesic effect of opioid during burn wound care procedures without reported adverse events.29 Approximately 45% of patients with burn injury experience some type of psychological distress within the first 2 years post burn. Severe Post Traumatic Stress Disorder (PTSD) 1 month after discharge is associated with poorer functional, psychological, and social outcomes.30 Sleep disturbances are common after burn injury and poor sleep is associated with increased pain.31 Pruritus is prevalent in over 90% of burn patients at 3 months and over 40% of burn survivors after 4 years. Risk factors that increase pruritus include greater % TBSA burned or grafter, female gender, PTSD, prolonged wound healing, and hypertrophic scars.32 Routine wound care and moisturization with ointments like Aquaphor can decrease pruritus along with pharmacological agents such as gabapentin and cetirizine.33

After completion of inpatient rehabilitation and discharge home, patients who have burn injuries can continue to benefit from physical, occupational, and speech therapy in the outpatient setting. Intensive exercise defined as 1 hour of aerobic and resistance training 3 times a week is associated with improved aerobic capacity, muscle strength, physical mobility, quality of life, body image, and affect.34 Scar management with massage therapy desensitizes skin, prevents adhesions, stretches skin, and decreases pruritus. Custom compression garments are the mainstay for treatment of hypertrophic scars after burn injury. Compression garments are worn 23 hours/day for 1-1.5 years.

Coordination of care

An interdisciplinary team approach by health care providers specialized in burn care is ideal. It should include physician specialized in burn and reconstructive surgery, intensivist, physiatrist, physical therapist, occupational therapist, speech therapist, nurse, psychologist, social worker, case manager, the patient and their family (as appropriate). Communication is critical to ensure treatment coordination and establishment of goals are met during and between the rehabilitation process.35

Patient & family education

Recovery and rehabilitation after major burns may require multiple surgeries and may take years until the patient is able to achieve optimal outcome. It is essential that the patient is educated at every stage of his rehabilitation process so that the goals of their rehabilitation treatment are clear and how their participation is essential to ensure the best possible outcome. Education to the patient and the caregiver about possible long term physical, physiological and vocational challenges is of outmost importance, as well as a consistent approach from all members of the multidisciplinary team.26

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

  • Patients should receive optimal treatment and care during the different stages of his injury, as this will assure that the patient has a favorable recuperation, decreasing the likelihood of developing long term complications.
  • It is crucial to take adequate measures to avoid long term complications such as contractures and psychological problems which may interfere with the patient’s ability to have a successful re-integration into the community.
  • In order to offer patients a successful treatment and an optimal recovery, a coordinated multidisciplinary approach is needed at all stages.

Cutting Edge/Emerging and Unique Concepts and Practice

Photobiomodulation involves inducing wound healing by illuminating wounds with light emitting diodes or lasers.36 Oxandrolone is an anabolic steroid that has been extensively studied in the burn population and has been shown to significantly increase lean body mass retention and decrease length of hospital stay.37 Glutamine is a nutritional supplement which has been shown to decrease infection rates, improve wound healing, and decrease hospital length of stay for burn patients.38

Gaps in the Evidence-Based Knowledge

  • Controversies exist over the efficacy of pressure garments, massage therapy, specific topical agents and splinting techniques.
  • There is need in developing validated measurement and data collection tools to assist in the care and development of evidence base guidelines in order to benefit the burn population.
  • Lack of targeted, strategic manner to guide best practice, reduce variability and ultimately improve patient outcomes.
  • The translation of evidence into practice is an area in need of research and audit.


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Original Version of the Topic

Barbara de Lateur, MD, Asare Christian, MD, Jing Wang, MD.  Burn Rehabilitation. 12/27/2012.

Previous Revision(s) of the Topic

Isabel Borras-Fernandez, MD, Brenda Castillo, MD, Jean Carlos Gallardo, MD, David Atkins, MD.  Burn Rehabilitation. 4/3/2017.

Author Disclosure

Juliet Zakel, MD
Nothing to Disclose