Burn injuries are complex and involve injuries that require immediate and specialized intervention. Burn injuries often require a long rehabilitation process to regain functional independence, often requiring long-term adaptation or compensatory training. These patients will need Provide physical and psychological support throughout the recovery process. This is especially true when injured as a result of disaster or conflict. 
Acute rehabilitation will support the medical needs of the patient. However, rehabilitation plays an important role in the acute phase, allowing patients to prepare physically and mentally for the upcoming treatment. This article will focus on physical rehabilitation for patients with There are burns, but important wound care considerations regarding mobility and positioning will be included.
Burn rehabilitation begins from the first day of injury and continues through the scar maturation period, which often lasts for several years, especially in relation to preventing contractures and incomplete growth in children. 
Please read the linked article for background knowledge on skin anatomy and physiology. Understanding skin structure is an important part of burn classification. Please read the linked article for background on wound healing. Know the expected timeline Wound healing and the body’s response to injury are critical for patient education and for distinguishing normal wound healing from signs and symptoms of infection. This article also contains links to wound assessment and wound debridement for a better understanding of these procedures. wound care is Professional skills and should not be performed without proper training. Physiotherapists can specialize in wound management with advanced training.
Types of Burns
There are several common causes of burns, including but not limited to:
- Thermal burns: These occur when a heat source raises the temperature of the skin and surrounding tissues. This causes tissue cell death or charring. Heat sources can include hot metal, scalding liquids, steam, and flames. Thermal burns can also result from exposure to extreme cold, such as frostbite.
- Radiation burns: Radiation burns occur as a result of prolonged exposure to ultraviolet light or other sources of radiation. Radiation sources can include the sun and X-rays.
- Chemical burns: These are caused by strong acid-base detergents or solvents that come into contact with the skin.
- Electrical burns: Electrical burns occur when alternating current (AC) or direct current (DC) current comes into contact with the body. These burns increase the likelihood of internal damage.
Classification of Burns
Depth of burn classification
Table 1. Burn depth features adapted from Lathia et al. 2020.  Depth of burns, tissue destruction, burn appearance, pain sensitivity, healing time and prognosis, superficial. 1st degree burns Red blisters on the outer layer of the epidermis Uncommon Mild edema Capillary refill: blanching of affected areas Pressure and refill (see video example below) Pain Less than 14 days No long-term scarring expected wet red blisters Subcutaneous edema Capillary refill Very painful and irritating 7 – 20 days In rare cases may leave scar Pigmented changes Deep localized thickening (DPT) ie second degree burns: deep epidermis and several layers of dermis damage most of the nerve endings hair follicles and sweat glands are damaged and variable in color (mottled) damp or Waxy dry General vesicles No capillary refill or slow refill Eschar form Less sensitive to pain due to nerve endings being destroyed Healing time of at least 21 days but difficult to determine Scar contracture risk May require graft Full thickness burn (FTB) ie Third-degree burns with damage to all skin layers or Destroyed; visible fat or bone. White, burnt, dry, inelastic, no blisters, loss of skin nociceptors, no pain, but patients usually feel pain. Severe scars with risk of contractures No skin regrowth Requiring excision and grafting Long term hospitalization
Below is a video that explains burn classification and staging in more detail. It also includes examples of how burns look.
What follows is a video of a capillary refill test performed on a healthy finger. Note how pale the skin is after the pressure is removed, and how long it takes to recover the color. A capillary refill test (CRT) is a rapid test used to assess blood flow through peripheral tissues. it is a quick test of the nail bed to monitor blood flow to the tissue and dehydration.  The CRT measures the efficacy of the vasculature of the hands and feet as they are farther away from the heart. 
Total Burned Surface Area (TBSA): The area of the body affected by the burn. This is expressed as a percentage, for example, if the graph shows a 20% TBSA burn, it means that 20% of the patient’s total surface area was affected by the burn.
- Adults and children use different forms
- Severe burns involve 30% TBSA or more in adults and 20% TBSA or more in children.
- The location and type of burn also affects severity and has functional implications. Example: A deep burn on the hand registers as a small TBSA but has a huge impact on the patient’s function.
The two most common recording methods for TBSA are the Rule of Nine and Lund and Browder.  Examples of both methods are shown below for reference.
Example of the Rule of Nines and Lund-Browder Evaluation
Immediate Medical Care Needs
During the first aid phase of severe burns, medical management will include:
- Fluid resuscitation
- Airway management
- Wound debridement and/or surgical procedures such as escharotomy or fasciotomy 
- Pain management
Acute Rehabilitation for Burn Injury
Acute Burn Injury Mobility Precautions
- Burn injuries encountered in conflict or disaster areas are often combined with fractures internal injuries or trauma such as brain and/or head injuries. Appropriate mobility precautions, such as spinal and/or cervical immobilization or bed rest required for weight-bearing extremities Visceral injury or bleeding needs to be determined with the medical team.
- If shrapnel is present in the burn/wound and cannot be easily removed due to the risk of further tissue damage, it can be left in place.  In these cases, please hear the advice of the medical team on mobilizing the affected areas.
- Pain following surgical debridement  is planned accordingly with an analgesic schedule.
Once the patient’s condition is stable, rehabilitation should begin immediately. Studies have found that early initiation of limb positioning and splinting has a positive effect on subsequent contractures in burn patients. 
Acute burn rehabilitation focuses on: respiratory care edema management positioning splints and decompression early mobilization progressively graded exercises maintaining functional independence patient and caregiver education 
The goals of respiratory care physical therapy include: airway maintenance, clearance of secretions, improvement of gas exchange, prevention and/or treatment of atelectasis, and maintenance of chest expansion. 
For a more in-depth look at these topics, read more about inhalation injuries and chest physiotherapy.
Edema is a normal response to injury and an important step in wound healing. However, excessive edema can negatively affect wound healing.
Acute oedema management includes:
- Appropriate extremity positioning
- Using the Muscle Pump Action with Active AROM
- Facial edema requires the patient to sit at least 45 degrees 24 hours a day
- Dressings expected for edema management are firm but allow for AROM in all joints
Positioning, Splinting, Pressure Relief
Proper and correct positioning is essential for contracture prevention. Positioning to prevent contractures should be used prophylactically even when there are no signs of loss of ROM after initial assessment of the affected area. Splinting and positioning according to the severity of the burn Projects may need to last at least six months for optimal results. 
Burn victims often want to get into a comfortable position, which is usually the flexion mode. If the patient is allowed to hold these positions over time, the scar tissue that forms will cause the muscle to shorten in length. Scar tissue after a burn can form rapidly years later Hour.
- Shoulders: Horizontal abduction 90 degrees, adduction 20 degrees, external rotation encouraged
- Scapula: retracted, depressed, supinated
- Upper Extremity: Neutral Rotation Forearm Supination
- Elbows: extended
- Wrist: 30-40 degrees of extension MP 45-70 degrees of flexion IP extension thumb abduction and relative
- Neck: slightly extended, no pillow
- Hips: Slight Abduction Full Extension Block External Rotation 
Bone Landmarks and Underlying Stress Processes
Burn victims are at high risk of further skin breakdown in areas of increased pressure. Unload and provide proper pressure relief as needed. This is especially true after skin grafts or surgical flaps. Do not apply pressure to the area behind the skin graft or flap because Blockage of blood flow prevents new tissue from surviving.
Splinting is typically indicated:
- positioning of extremities to prevent contractures
- Protects the graft or surgical flap during the initial stages of healing
According to a 2020 systematic review, the use of orthoses should be considered a treatment option to improve ROM or reduce contracture in adults with burns. The study also found that patients who used splints or orthotics had fewer events due to the need for reconstruction Surgery is performed late in their healing process and provides positive skin graft results with proper orthotic use. 
A splint or orthosis can be used on any part of the body or joint. They are most commonly used to locate the mouth (42%), followed by the neck (12%) hands and armpits (10% each), ankles (8%) elbows (4%) and knees (2%). Unfortunately, there is no standardized wearing time or schedule for burn contractures manage. Studies in the non-burn specific literature evaluating the management of hand and finger contractures using dynamic splints recommend wearing the orthosis for at least 12 weeks over a range of extreme range of motion for more than 6 hours per day. 
Read this article for more in-depth information on burn splints.
Early Mobility Exercises Functional Independence
The goal of early mobilization and therapeutic intervention after burn injury is to maintain functional mobility and endurance while the body heals. The extent of the burn will determine the intensity of treatment. Areas affected by burns require mild ROM, which should decrease slowly and steadily Exercise-related pain and inflammation. 
There are few studies on early mobilization after acute burn injury. A 2019 meta-analysis and systematic review of ICU trauma patients found that early mobilization reduced duration of mechanical ventilation, but mortality and length of hospital stay were similar to those Patients who did not receive early mobilization.  However, a 2020 retrospective study of ICU trauma patients not only showed that early mobilization is a safe, feasible and effective strategy for improving functional outcomes, but patients who underwent early mobilization were less likely to die In ICU and hospital.  Please read this article for more in-depth information on early mobilization of ICU patients.
While further research is needed on the effectiveness and risks/benefits of early mobilization in post-burn patients, data from similar populations suggest that benefits may outweigh no mobilization intervention. Read this article for more in-depth information on recovery from burn injuries.
Because of the lengthy recovery and recovery times for burn patients and caregivers, education is critical to successful burn management and rehabilitation.
Such education and training should include:
- ROM and stretching exercises, especially if the patient is afraid of exercise due to pain
- Contracture aetiology and prevention
- Functional activity and mobility, including use of assistive devices
- Positioning and Decompression Techniques
- Splint use and wearing schedule
- Infection control
- Expected healing time of patients from the acute phase to the subacute phase and beyond 
Treatment Red Flags
Rehabilitation therapists, such as physical therapists, usually have the most direct contact with patients. Therefore, it is important to monitor these patients for treatment red flags and alert the medical team when appropriate.
- Hypovolemic shock
- Infection: This is the most common cause of death in burn victims who survive the initial injury.
- Compartment syndrome
- Inadequate pain management
Become familiar with the signs and symptoms of sepsis.
Rehabilitation in conflict and disaster scene support
- International Disaster Response: Dos and Don’ts
- Early recovery in conflict and disaster Humanity and inclusion
- Recovery from sudden-onset disasters Humanity and inclusion
- Rehabilitation treatment planning tool for common conflict and emergency-related injuries
Burns Specific Support
- International Society for Burn Injuries
- Burn Foundations and Partnerships
- American Burn Association
Technical Standards for Medical Teams
- Minimum Technical Standards and Recommendations for Emergency Medical Team Rehabilitation
- Minimum Technical Standards and Recommendations for TBI Recovery Teams in Sudden Disasters
- Lathia C, Skelton P, Clift Z. Early rehabilitation in conflicts and disasters. Handicap International: London, UK. 2020.
- Jeschke MG, van Baar ME, Choudhry MA, Chung KK, Gibran NS, Logsetty S. Burn injury. Nature Reviews Disease Primers. 2020 Feb 13;6(1):1-25.
- YouTube. Burns: Clinical Estimation – Emergency Medicine | Lecturio. Available from: https://www.youtube.com/watch?v=vCzPNl8EvHM [last accessed 03/03/2022]
- Capillary nail refill test. Available from: https://medlineplus.gov/ency/article/003394.htm (Accessed 24 October 2020)
- Capillary nail refill test. Available from: http://pennstatehershey.adam.com/content.aspx?productid=117&pid=1&gid=003394 (last Accessed 25 October 2020
- YouTube. Capillary Refill Test. Available from: https://www.youtube.com/watch?v=n–wFoZFklg [last accessed 02/03/2022]
- Legrand M, Barraud D, Constant I, Devauchelle P, Donat N, Fontaine M, Goffinet L, Hoffmann C, Jeanne M, Jonqueres J, Leclerc T. Management of severe thermal burns in the acute phase in adults and children. Anaesthesia Critical Care & Pain Medicine. 2020 Apr 1;39(2):253-67.
- Puri V, Shrotriya R, Bachhav M. The scourge of burn contractures: Who will bell the cat?. Burns. 2019 Jun 1;45(4):791-7.
- Parry IS, Schneider JC, Yelvington M, Sharp P, Serghiou M, Ryan CM, Richardson E, Pontius K, Niszczak J, McMahon M, MacDonald LE. Systematic review and expert consensus on the use of orthoses (splints and casts) with adults and children after burn injury to determine practice guidelines. Journal of Burn Care & Research. 2020 May 2;41(3):503-34.
- Higgins SD, Erdogan M, Coles SJ, Green RS. Early mobilization of trauma patients admitted to intensive care units: a systematic review and meta-analyses. Injury. 2019 Nov 1;50(11):1809-15.
- Coles SJ, Erdogan M, Higgins SD, Green RS. Impact of an early mobilization protocol on outcomes in trauma patients admitted to the intensive care unit: A retrospective pre-post study. Journal of Trauma and Acute Care Surgery. 2020 Apr 1;88(4):515-21.