Burns Rehabilitation: Physiotherapy Management

Goals of Physiotherapy

• Prevention of contractures and deformity
• Maintenance and restoration of ROM
• Reduction of oedema
• Scar management
• Restoration of strength, aerobic capacity, and functional independence
• Pain and itch management
• Psychological support and return to activities of daily living (ADL) and work

"Rehabilitation is an integral part of the clinical care plan for the burn patient and should be initiated on admission." - Schwartz's Principles of Surgery, 11th Ed.

Phases of Burn Care and Physiotherapy Roles

Phase 1: Emergent / Resuscitative Phase

• Positioning to reduce oedema and prevent early contracture (e.g., elevation of burned limbs)
• Anti-deformity positioning (see Positioning section below)
• Passive ROM if the patient cannot participate actively
• Respiratory physiotherapy if inhalation injury is present (airway clearance, ventilator weaning support)

Phase 2: Acute Phase (wound closure)

• Active and active-assisted ROM exercises, progressing to resisted exercises
• Splinting introduced alongside exercise
• Ambulation encouraged early - patients with foot/leg burns should walk independently (without assistive devices where possible) to prevent swelling and disuse atrophy; when not ambulating, elevate the limb
• Wound-adjacent exercises are resumed as early as safely possible after skin grafting
• Oedema management

Phase 3: Rehabilitative / Outpatient Phase

• Progressive exercise to restore full functional capacity
• Scar management (compression garments, silicone, massage)
• Return to work and recreational activities
• ADL retraining
• Psychological rehabilitation

Core Physiotherapy Interventions

1. Exercise

• Aerobic capacity (Hedge's g = 1.13, 95% CI: 0.44-1.83, p = 0.00)
• Muscle strength (Hedge's g = 2.27, 95% CI: 0.42-4.13, p = 0.02)
• Lean body mass and pulmonary function

• Range of motion (ROM) exercises - passive, active-assisted, active; started day 1
• Stretching - sustained stretching to lengthen maturing scar tissue
• Strengthening - progressive resistance exercises for muscles affected by burns, immobility, and catabolism
• Aerobic/cardiovascular conditioning - cycling, treadmill, hydrotherapy walking; addresses the severe deconditioning and muscle catabolism characteristic of major burns
• Functional task training - reaching, gripping, ADL-specific movements

• "Patients who are unable to actively participate should have passive range-of-motion exercises done at least twice a day." - Schwartz's Principles of Surgery
• Post-grafting: the graft should be evaluated early and exercise resumed at the earliest possible time
• For hands: passive ROM exercises are essential to prevent the notoriously rapid stiffening that occurs in hand burns
• Burned skin and active scars contract over hours, not days - hence frequent, daily exercise is non-negotiable

2. Positioning and Splinting

• Used throughout recovery alongside exercise - not as a substitute for it
• Purpose varies by healing stage: during acute phase, splints protect healing tissues; later, they prevent and treat scar contractures
• Where possible, splint joints at end of range to maximise stretch on the scar
• If active contracture is present and end-range splinting is not yet achievable, serial splinting or casting is used - progressively increasing ROM
• Strict monitoring is required to prevent pressure injury or wound breakdown under splints
• Materials: thermoplastics, plaster of Paris; topical negative pressure dressings can also act as immobilising splints

3. Oedema Management

• Elevation of burned limbs - most effective in the first 24-72 hours
• Active movement (muscle pump)
• Compression (early, if wounds allow)
• Reduction of oedema directly improves ROM and reduces the risk of joint stiffness

4. Scar Management

Compression Garments (Pressure Therapy)

• Custom-made pressure garments (e.g., Tubigrip, custom Lycra suits) applied once wounds are adequately healed (usually >80% closure)
• Recommended pressure: approximately 25 mmHg to exceed capillary perfusion pressure
• Duration: worn 23 hours/day for 6-18 months until scar maturation (pale, soft, flat)
• Provide vascular support and are often found more comfortable by patients
• Whether they definitively prevent hypertrophic scar formation is debated, but they remain standard of care - Schwartz's

Silicone Products

• Silicone gel sheets or topical silicone applied to healed scars to speed maturation
• Used where pressure garments are difficult to apply, or as adjuncts
• Worn for several hours per day

Massage

• Softens scar tissue, reduces pruritus (itch), and improves pliability
• A 2024 systematic review (Santuzzi et al., J Physiother, PMID 38072714) found massage, laser, and shockwave therapy improve pain and scar pruritus after burns
• Use moisturising cream/oil (unscented); avoid fragile or incompletely healed skin
• Techniques: effleurage, circular friction, cross-fibre friction

5. Respiratory Physiotherapy

• Inhalation injury (chemical/thermal airway damage)
• Patients on mechanical ventilation
• Chest burns with restrictive eschar
• Prolonged immobility

6. Hydrotherapy

• Warm water immersion (shower or bath) assists with wound debridement, ROM, and pain management during exercises
• Exercises in water are easier due to buoyancy and warmth promoting tissue extensibility
• Care with infection control (clean water, no cross-contamination)

7. Ambulation and Mobility

• "Patients with foot and extremity burns should be instructed to walk independently without crutches or other assistive devices to prevent extremity swelling, desensitize the burned areas, and prevent disuse atrophy" - Schwartz's Principles of Surgery
• Early mobilisation reduces pulmonary complications, DVT risk, and deconditioning
• Graduated from bed mobility - sitting - standing - walking - stairs - community

8. ADL Training and Return to Function

• Therapy is structured around regaining independence in self-care, meal preparation, work, and recreation
• Upper limb burns: adaptive equipment, technique modification
• Progressive introduction of occupationally relevant tasks

Scar Maturation Timeline

• Acute stage (weeks): red, raised, firm - most active period
• ~3 months: still hypertrophic
• ~7-9 months: progressive softening, flattening, fading
• Mature scar (12-24 months): pale, soft, flat - physiotherapy input decreases

Multidisciplinary Team

• Burns nurses (daily wound care, dressings, reinforcement of positioning)
• Occupational therapists (hand function, ADL retraining, splinting for fine motor)
• Dietitians (high-calorie, high-protein intake to combat catabolism and support exercise)
• Psychologists (coping, PTSD, body image)
• Surgeons (grafting decisions, contracture release timing, laser therapy)
• Social workers, prosthetics/orthotics (as needed)

Special Considerations

• Physiotherapy started day 1 is mandatory
• Elevation, Volar resting splints in the "safe position" (anti-claw: wrist extended, MCPs flexed 70-90°, IPs extended, thumb abducted and opposed)
• Frequent active ROM exercises; buddy strapping

• Play-based therapy where possible
• Close family involvement
• Monitor for growth-related contracture recurrence even after apparent resolution

• Post-graft immobilisation typically 3-7 days, then early mobilisation
• Re-evaluate frequently and resume exercise as soon as graft take is confirmed

• Respiratory physiotherapy from ICU admission
• Incentive spirometry, postural drainage, bronchial hygiene

Key Evidence Summary

• Bailey & Love's Short Practice of Surgery, 28th Edition (p. 700)
• Schwartz's Principles of Surgery, 11th Edition
• NSW ACI Burn Physiotherapy and Occupational Therapy Clinical Practice Guide, 2nd Edition (2025)
• Abonie et al., PLoS One 2024 [PMID 39739910] - Systematic review and meta-analysis of physiotherapist-led exercise in burn rehabilitation
• Santuzzi et al., J Physiother 2024 [PMID 38072714] - Systematic review on massage, laser, and shockwave therapy for burn scar pain