PHYSICAL THERAPY
MANAGEMENT FOR BURN
INJURY
INTRODUCTION
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Rehabilitation of patients with Burns is an ever-changing process that
may need to be modified daily.
Physical therapist should work in coordination with other specialists
of Rehabilitation team enabling the patient to attain their Goals
The difficult phase of Rehabilitation occurs after wound has healed
and scar tissue begin to contract
Physical Therapist should establish a treatment program in
conjunction with Wound Healing process, to achieve the maximum
Rehabilitation.
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PHYSICAL THERAPY ASSESSMENT
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Initial assessment of Burns done by Medical Team
gives valuable information to the Therapist
Physical Therapy Assessment is of more value to
plan the Rehabilitation .
The healing of Burn wound is dynamic process and
changes may occur daily.
Frequent assessment will keep the Physical Therapist
informed about the problems .
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SUBJECTIVE ASSESSMENT
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NAME
AGE
SEX
OCCUPATION
DATE OF ASSESSMENT
REGISTRATION NUMBER
CHIEF COMPLAINT
PHT 331 – 1435-1436H – 1st SEMESTER
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PRESENT MEDICAL HISTORY:
 HISTORY OF INJURY (how?, when?, why? )
 Whether patient get thrown or fall due to explosion
 Any Inhalation injuries.
 DEPTH OF BURNS, CALCULATE TBSA (RULE OF NINE)
 ASSOCIATED MEDICAL PROBLEMS CAUSED DUE TO BURNS
 VITAL SIGNS: PULSE, BLOOD RESSURE,RESPIRATORY RATE
PAST MEDICAL HISTORY:
 HISTORY FROM PATIENT / FAMILY MEMBERS REGARDING ANY PRE EXISTING
LIMITATIONS OR PREVIOUS INJURIES WHICH MAY AFFECT REHABILITATION.
 GENERALIZED ILLNESS
 HISTORY OF ALLERGY
 PAST MEDICAL , SURGICAL, PHYSICAL THERAPY TREATMENT
 Whether suicide? Were family or friends also injured.
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PAIN HISTORY:
 INTENSITY OF PAIN – VAS SCALE
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(no pain)
(unbearable pain)
Side of pain
Site of pain
Type of pain
Aggravating factors
Relieving factors
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OBJECTIVE ASSESSMENT
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ON OBSERVATION:
LEVEL OF CONSCIOUSNESS
MONITORS CONNECTED
CHECK FOR CATHETHERS
ANY EXTERNAL AIDS SUCH AS SPLINT,ORTHOSIS
AREA OF DAMAGED SKIN
OEDEMA
SCAR TISSUE ( HEALING SCAR, SURGICAL SCAR)
RESTRICTIVE ESCHAR
ANY DISCHARGE FROM WOUND
CHEST MOVEMENTS
IF PATIENT MOBILE , GAIT & POSTURE
ANY CONTRACTURES ,DEFORMITY
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ON PALPATION:
VITAL SIGNS
TENDERNESS
MOBLITY OF SCAR
Location of OEDEMA
ON EXAMINATION:
MOTOR EXAMINATION:
JOINT RANGE OF MOTION: ( AROM, PROM):
Goniometry is used, good view of extremity during assessment.
MUSCLE POWER: ( MRC GRADING)
MMT, Functional test, done on involved and uninvolved side.
MUSCLE GIRTH: CIRCUMFERENCE MEASUREMENT
Edema assessment : CIRCUMFERENCE MEASUREMENT
SENSORY EXAMIANTION
SUPERFICIAL SENSATION & DTR
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FUNCTIONAL ASSESSMENT:
FUNCTIONAL POSITIONS - LYING TO SITTING,
SITTING TO STANDING ETC…
ADL ASSESSMENT :
ACTIVITIES OF DAILY LIVING ( INDEPENDENT OR
DEPENDENT)
AMBULATION ASSESSMENT
{ The assessment determine which areas need to be
addressed first.}
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BURN INJURY GOALS AND
OUTCOME
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It is difficult to list specific outcome because of varied
nature of each Burn injury.
Goals suggested by AMERICAN PHYSICAL THERAPY
ASSOCIATION,ALEXANDRIA. (APTA)
1.Wound and soft Tissue healing is enhanced
2. Risk of Infection and complication is reduced
3. Risk of secondary impairments are reduced
4. Attainment of full Joint Range of movement
5. Restoration of pre injury level of Cardiac endurance
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6. Good to Normal Muscle strength
7. Independent Ambulation
8. Independent function in ADL
9. Minimal scar formation
10. Patient, family, caregivers understanding of
expectations and goals and outcomes is increased.
11. Aerobic capacity is increased
12. Self Management of symptoms is improved
THE OPTIMAL OUTCOME OF REHABILITATION IS THE
RETURN OF A PATIENT TO NORMAL , PREINJURY
FUNCTION AND LIFE STYLE.
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PHYSICAL THERAPY INTERVENTION
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FIRST PRIORITIES:
1.CONTROL AND RESOLUTION OF OEDEMA
Elevating extremities and encouraging active
movements especially hand , ankle .
2. PRESERVING RANGE OF MOTION
Encouraging active movement
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Edema control
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Edema develop within 8-12 hours after burn injury and
peaks at approximately 36 hours.
Failure to reduce edema in the first 48-72 hours can result in
organized edema component creating a fixed deformity.
A positioning program focuses on reducing edema through
elevation of the extremities.
Improper elevation during the initial period of edema may
leads to calcification and increased bone density especially
in the elbow.
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Elevation of an extremity above heart level can be
accomplished using common items such as pillows, bath,
blankets, towels, foam wedge, beside bed table.
If the head of bed position is changed, the position of the
extremities will need to be changed accordingly to maintain
proper elevation.
Elevation of the upper extremities must be maintained
while patient is lying, sitting or ambulating.
Lower extremities should be elevated when the patient is
sitting by placing them on foot stool.
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POSITIONING & SPLINTING
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Positioning begin on the day of admission
GOALS of positioning:
1. Minimize edema
2. prevent tissue destruction
3. Maintain soft tissue in an elongated state
SPLINTING
Extension of positioning programme
Patients positioned in anti-deformity positions
Indications:
1.Prevention of contractures
2. Maintenance of ROM ( Achieved During exercise or surgical release)
3. Correction of contractures
4. Protection of joint/tendon
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TECHNIQUES OF SPLINTING
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SIMPLE DESIGN, EASY TO APPLY, REMOVE ,CLEAN
USUALLY WORN DURING NIGHTS
SKIN GRAFTING – CONTINOUSLY
NO PRESSURE POINTS ON SKIN
STATIC OR DYNAMIC SPLINT
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POSITION STRATEGIES FOR
COMMON DEFORMITIES
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S.No
REGION
COMMON
DEFORMITY
MOTIONS TO
BE STRESSED
SUGGESTED
APPROACHES
1.
ANTERIOR NECK
FLEXION
HYPER EXTENSION
USE DOUBLE
MATTRESS/ USE RIGID
CERVICAL COLLAR
2.
SHOULDER-AXILLA
ADDUCTION &
INT.ROTATION
ABDUCTION,
FLEXION,
EXT.ROTATION
AIRPLANE SPLINT
3.
ELBOW
FLEXION &
PRONATION
EXTENSION&
SUPINATION
SPLINT IN EXTENSION
4.
HIP& GROIN
FLEXION-ADDUCTION
HIP EXTENSION
ABDUCTION
NEUTRAL,EXTENSION
WITH SLIGHT
ABDUCTION
5.
KNEE
FLEXION
EXTENSION
POSTERIOR KNEE
SPLINT
6.
ANKLE
PLANTAR FLEXION
DORSI
FLEXION
AFO – FOOT IN
NEUTRAL,CUT OUT AT
TA TENDON
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POSITIONING
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NECK POSITIONING
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AIR PLANE SPLINT
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INTRINSIC PLUS DEFORMITY
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Splinting may be initiated at any time in the acute burn period
depending on individual patient needs and functional range of
motion.
Some areas, especially the hands, require splinting immediately
after burn injury to aid in edema resolution and to maintain function
joint position.
Continuous splinting is indicated in treatment of:
(1) burn wound edema in the hands.
(2) exposed tendons.
(3) peripheral neuropathies.
(4) uncooperative or unresponsive patients.
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These splints must be removed several times daily
and with the exception of exposed tendons, the
involved areas should be undergo exercise.
Splints may be used with nearly every type of burn
wound treatment including grafts and other biologic
dressing. Frequent assessment, at least on a daily
basis, is the key to effective splinting, thus insuring
proper fit and function.
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According to period of immobilization
1) Primary splints:
During the acute phase and pre grafting
period, static splints (without movable parts) are
used to position the involved joints during sleep,
inactivity, or periods of unresponsiveness. Whenever
possible, these splints should be applied to adjacent
intact skin.
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2) Postural splints or post graft splint:
During the immediate post graft phase, splints are used to
immobilize joints in proper functional position, but must allow access
for continued wound care. These splints are worn continuously for 5
to 14 days until the graft is secure.
3) Follow up splints or night splint:
The chronic phase of burn care begins with wound closure and
continues until full maturation of the wound (one to two years).
Dynamic splints (movable parts) are used to increase function.
They can provide support to the joint without restricting antagonistic
movements, provide slow steady force to stretch a skin contracture,
or provide resistive force for exercise.
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Characteristics of ideal splint
 Non toxic or free from leads
 Light in weight
 Made from non absorber material
 Well padded, especially over bony prominence
 Easy to be shaped, to be controlled
 Firm enough
 Fabricated from no expensive material
 Need minimal time to be fabricated
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ACTIVE EXERCISES
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IF PATIENT ABLE TO FOLLOW COMMANDS, ACTIVE
EXERCISES ENCOURAGED FROM THE FIRST DAY OF
ADMISSION
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ACTIVE EXRCISES TO LIMBS AND TRUNK
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UNAFFECTED LIMB SHOULD ALSO BE CONCENTRATED
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IF SKIN GRAFT IS DONE THEN EXERCISE AFTER 3 -5 DAYS
WITH THE CONCERN OF THE PLASTIC SURGEON
AREA SHOULD BE LUBRICATED BEFORE EXERCISE WITH
OLIVE OIL .
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PASSIVE EXERCISE
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If Patient cannot perform Active exercise then ACTIVE ASSISTED and PASSIVE EXERCISE should be encouraged.
Stress should be applied gradually to the area of Skin
graft
In HEALED burn wounds-----Ultrasound Therapy can be
given to increase the pliability of tissue before exercise
therapy
STRETCHING EXERCISES will help to prevent
contractures.
Medication to minimize pain before exercise session
Assistance from Family members.
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STRETCHING EXERCISES
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Goals of stretching
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The overall goal of stretching is to regain or reestablish
normal range of motion of joints and mobility of soft tissues that
surround a joint.
specific goals are
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Prevent irreversible contractures
Increase general flexibility of a part of body prior to vigorous
strengthening exercises.
Prevent or minimize the risk of musculotendinous injuries related to
specific physical activities and sports,
Correct deformities
Increase circulation
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Indications of stretching
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In burn injury
Where contractures and scar tissue leads to limitation of motion
When the contractures interfere with activity of daily living and
personal hygiene.
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When the contractures leads to vascular and circulatory deficiency.
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When the limitation leads to skeletal and structure deformities.
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Inco-ordination and imbalance
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When there is muscle weakness that opposite to tight muscle so
stretch tight muscle prior to strength weak muscle
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Precautions of stretching:
Don't passively force a joint beyond its normal range of motion
Newly united fractures should be protected by stabilization between
fracture site and joint where the motion take place.
Patients with suspected osteoporosis due to disease, prolonged bed rest,
age, prolonged use of steroid.
After immobilization for long periods avoids vigorous stretching because the
tissue looses it s tensile strength.
Avoid stretching of edematous tissue, as it is more susceptible to injury than
normal tissue.
Avoid stretching of weak muscle particularly those support body
structures in relation to gravity.
Avoid stretching exposed tendon because it is more susceptible to rupture.
Take care of IV lines during stretching.
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Contraindications of stretching:
1. Bony block.
2. Recent skin graft.
3. Evidence of acute inflammatory or infectious process.
4. Sharp pain (acute stage of bum).
5. Evidence of tissue trauma.
6. When contracture is needed to develop stability.
7. Exposed joints.
8. Exposed tendon.
9. Thrombophlebitis.
10. D.V.T
11. Compartment syndrome
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STRENGTHENING EXERCISES
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Isokinetic exercise
Resisted exercises with pulleys and free weights
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AEROBIC EXERCISE
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INCREASE CARDIO VASCULAR ENDURANCE
STATIONARY BICYCLE
ROWING ERGOMETRY
TREADMILL WALKING
STAIR CLIMBING
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AMBULATION
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Should be initiated at the earliest.
Tilt table treatment for patient with orthostatic
hypertension or severe pain in legs
Suggest a suitable Walking aid such as FRAMES,
CRUTCHES, WHEEL CHAIR
Positive changes in attitude of Patient
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Factors affect exercise prescription in burned patient
The degree of burn
1st & 2nd degree pain
contracture
limitation of ROM
Apply
Mobilization
stretching
Extend of burn ( location )
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Intensity
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Face ( functional movement )
Neck ( mobilization – stretching )
In acute stage ( decrease intensity )
As in acute stage, there is depletion of glucose so glycogen in muscle and liver will
convert into glucose and this make wasting or atrophy of muscle so we not increase
intensity .
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In chronic stage ( increase intensity )
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Type of burn
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Stage of burn
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Acute ( mobilization + stretching )
Chronic ( strength - massage )
Graft
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Internal ( no exercise )
External ( exercise )
Immediately after application of graft ( for 14 days ) immobilization
After healing graft ( joint play technique)
Age of patient
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Duration ( decrease in young and old )
Intensity ( increase in adult only)
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Laser & wound healing
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Definition: 
It’s acronym of light amplification by stimulated 
emission of radiation.
 It is a device that amplifies the light to produce a
strong highly directional and parallel beam of light
of specific wave length. And so it’s a new kind of
anti-inflammatory treatment, it doesn’t induce any
damage as non-steroidal modality because it’s noninvasive, and painless.
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Laser biostimulation and wound healing:
Enwemeka ( 1988) reported that biostimulation of laser
would accelerate the recovery from the inflammatory phase
of healing by:
Altering the level of prostaglandin
Increase adenosine triphosphate(ATP) synthesis by enhancing
electron transfer in the inner membrane of mitochondria.
Quicken protein ( collagen ) synthesis by quickening DNA
and RNA synthesis.
Enhance the ability of immune cells to combat invading
pathogens.
Augment fibroplasias
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High voltage galvanic stimulation and wound healing
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Definition 
 HV is a term applied to electrical stimulation
devices capable of delivering amplitudes greater
than 100 V.
 HV generators produce a high voltage current with
high peak intensity but a low average current and
very short pulse duration.
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ultrasonic Therapy on wound
healing
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Acute stage:
The effects of stable cavitation acoustic streaming appear to increase ca+
ions diffusion across the cell membranes which is of great importance since
Ca+ is cellular messenger can have marked effect in increasing the
production and release of wound healing factors. Thus the US has a proinflammatory effect not anti-inflammatory effect.
Proliferative stage
This begin approximately 3 days after injury and is the stage at which the
connective tissue is laid down by fibroblast for the new blood vessels.
During repair, it has been shown that US can promote collagen synthesis
due to increased cell membrane permeability allowing the entry of Ca+
ions, which control cellular activity.
Ultrasound is also believed to encourage the growth of new capillaries
during repair of soft tissue after injury.
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Remodeling stage:
This stage can last months or years until the new tissue is
as near in structure as possible to the original tissue.
Ultrasound is concerned to improve the extensibility of
mature collagen such as that is found in scar tissue by
promoting the reorientation of the fibers which leads to
greater elasticity without loss of strength.
The treatment goals of US in wound repair are
stimulation of fibroblast and macrophages,
degranulation of mast cells, promotion of angeogenesis,
reduction of the inflammatory phase of repair and
acceleration of healing.
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SCAR MANAGEMENT
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Scar Management is important incase of wound
closure, skin graft, healed burn wound.
The newly healed areas may become raised and
firm.
METHODS OF SCAR MANAGEMENT
 1.PRESSURE DRESSINGS
 2.MASSAGE
 3. CAMOUFLAGE MAKE UP
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PRESSURE DRESSINGS
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Pressure may exert control over hypertrophic scarring by
1. Thinning of Dermis
2.altering the biochemical structure of scar tissue
3. decreasing blood flow to the area
4. reorganizing collagen bundles
5.Decreasing tissue water content.
Scar less than 6 months old respond to pressure therapy
METHODS:
A. ELASTIC WRAPS
B. SELF- ADHERENT ELASTIC BANDAGE
C. PRESSURE GARMENTS
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MASSAGE
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DEEP FRICTION MASSAGE:
It loosens the scar tissue by mobilizing cutaneous
tissue from underlying tissue and break the
adhesions.
It is used as an adjunct to ROM exercises
Massage is done in slow , firm manner for 5-10
minutes, 3-6 times daily
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The grafting and post-grafting stage
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The Goals of physical therapy treatment
1. To prevent structural damage of dry grafted
skin/ donor site / third burns that lack sensation.
2. To reduce edema.
3. To prevent infection.
4. To prevent scar formation of grafted skin.
5. To avoid contracture and deformity.
6. To increase ROM and strength of the muscles.
7. To improve functional activities and walking
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Physical therapy treatment post
operative skin graft
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1. For 4 or 5 days post operative the graft are
usually left undisturbed.
2. The fifth post operative day when the graft is noted
to be surviving, dressing changes with non adherent
gauze are instituted.
3. The seventh to tenth post operative day the healing
graft is well vascular, gentle range of motion exercises
(passively)
N.B.: It may be advisable to exercise without dressings
during this phase of healing. Because a dressing that
slips or rubs may harm rather than protect the healing
wound.
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4. Elevation is used to control edema.
5. Usually by about 2 weeks postoperative the graft will be pink
and adherent over its area and the graft appears to have taken
well (compression wraps are applied).
6. The early use of pressure garments.
a. By 2 weeks post operative with consulting the treating physician.
b. Care must be taken in application to prevent shearing forces.
c. If commercial pressure garments are used, Zippers are helpful.
d. Pressure garments should not be prescribed until edema is
decreased, because a decrease in edema will decrease the
garment's ability to apply firm Pressure over the grated area
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7. Splint may be applied over the pressure
garment to maintain the grafted part in its
maximally lengthened position.
8. In the later stages of healing (3 to 4 weeks post
operative) after the wound is closed, gentle
massage is used with a topical lubricant To keep the
skin pliable, to mobilize the skin and underlying
scar.
9. Positioning: according to the site
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10. Five weeks after grafting, some recovery of sensation
may be noted and continues to improve.
11. When there is complete recovery of sensation start.
A) Ultrasound:
To improve circulation and to re-arrange collagen fibers
B) Followed by cold application or hydrotherapy to gain
relaxation.
C) Then we apply active stretch followed by prolonged
passive stretch and should be graduated until 20 minutes.
12. Functional exercises then gait training.
13. Group exercises.
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N.B. Splint at night and at rest.
Advices the patient should be caution against
exposure of either graft donor or recipient sites to
the sun for at least 6 months. Pressure garments and
sun screens are helpful in protecting the graft from
exposure.
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Management of donor sites
Split thickness skin graft donor sites:
Application of pressure garments to prevent
hypertrophic scar.
Massage with a topical lubricant after (5-10 days
of epithelialization has occurred).
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Full thickness skin graft donor sites
1) Sutures are removed at (7 to 10 days).
2) Massage may be initiated 2 to 3 days after,
suture removal to help soften scar.
3) Application of pressure garments.
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CAMOUFLAGE MAKE-UP
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Used for FACE,HAND ,NECK
Applied for hypo or hyper pigmentation of skin due to
Burn injury
AVAILABLE IN MULTIPLE
SKIN SHADES
WATER PROOF Models
are available
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HOME EXERCISE PROGRAMME
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Patient encouraged To continue ROM exercises,
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Splinting & positioning
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Massage
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Video tape recording of Exercise and instructions will
be beneficial
Teach splint care and handling
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DO’S & DONT’S
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DO’S:
1.EXERCISE REGULARLY
2. PROPER SKIN CARE
3. Apply moisturizing cream
4. WASH and pat the surface with soft towel
DONT’S
1.Avoid strong perfumes or strong soap.
2.AVOID GOING OUT IN SUN
3. Never scratch the area
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COMMUNITY PROGRAMMES
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BURN PREVENTION PROGRAMME
SCHOOL REENTRY PROGRAMME
BURN CAMP
ADULT SUPPORT GROUP
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