Burn Injury Management Considerations for Rehabilitation Professionals

Introduction[edit | edit source]

Burn injuries are a major cause of pain and disability.[1] Optimal rehabilitation care for individuals with burn injuries requires a multifaceted, multidisciplinary approach. This page explores some of the key elements that must be considered in a rehabilitation plan when working with individuals with burns, including pain management, oedema management, scar management and surgical considerations.

It is essential to remember that every intervention discussed on this page must be coordinated with the medical / surgical team to ensure tailored management protocols for each patient.

Pain Management for Individuals with Burn Injuries[edit | edit source]

There are many factors to consider when treating pain associated with burn injuries.[2] Pain assessments should be performed during each phase of care,[3] and both pharmacological and alternative management strategies can be used to manage pain in patients with burn injuries.

General Points on Pharmacology for Individuals with Burn Injuries[edit | edit source]

"Pain distress is common during the acute phase [of a burn injury] despite the use of opioids and/or ketamine."[4]

The general consensus is that "opioid therapy is an essential tool for pain management in thermal injuries",[4] and patients with burn injuries are often given opioids in higher doses and for longer durations than typical dosing guidelines. However, many patients with burns continue to experience pain and are at risk for opioid tolerance.[3][4][5]

Romanowski et al.[3] include the following recommendations in their guidelines on pain management in adult patients with burn injuries:

  • opioid therapy needs to be individualised to each patient and continuously adjusted during their care (considering individual responses, adverse effects, and narrow therapeutic windows)[3]
  • while the reasonable use of opioids is supported to manage severe pain, attempts should be made to use "as few opiate equivalents as needed"[3]
  • opioid pain medications should be used in conjunction with other treatments, including non-opioid medications and non-pharmacological treatments[3]

For more information, please see: American Burn Association Guidelines on the Management of Acute Pain in the Adult Burn Patient: A Review of the Literature, a Compilation of Expert Opinion, and Next Steps[3]

Pain Management in Individuals with Burn Injuries Admitted to Hospital[edit | edit source]

"Burn injury is widely considered one of the most painful injuries that a person can sustain. In addition to the intrinsic pain caused by the burn itself, the proper treatment of a burn injury requires painful procedures including debridement of the wound, daily wound care, and surgery, followed by aggressive physical and occupational therapy."[3]

In the initial phases, pain associated with burn injuries tends to be described as background pain, breakthrough pain and procedural pain. Patients may go on to experience persistent or chronic pain, as well as specific types of pain such as post-burn pruritus (itching).[4][1]

The management for each type of pain can differ.[5] Pain management, especially in the hospital setting will be affected by the depth of burn injury and what structures are still intact and functioning. To learn more about burn wound classification by depth and size please see: Burn Wound Classification.

Background Pain[edit | edit source]

This type of pain is defined as "pain at rest that is almost always present and not caused by specific medical procedures".[5] Thus, it is persistent but usually low-grade.[1] It can be present at the injury site and in other areas (i.e. primary and secondary pain). Background pain tends to be managed with moderate-potency opioids (preferably given orally).[5]

Breakthrough Pain[edit | edit source]

Breakthrough pain is a transient increase in pain in individuals who are experiencing background pain.[5] It can indicate worsening background pain or can be from another source.[6]

Pain Associated with Procedures[edit | edit source]

Individuals with burn injuries often require a number of procedures (e.g. mobilisation, skin grafts, debridement, dressing changes, etc). These procedures can add to a patient's pain experience, often causing high-intensity pain that is short to medium in duration.[1]

Important considerations:[1]

  • each procedure causes a new, painful stimulus, which adds to the stress response
  • analgesia should be given at an appropriate time to ensure maximum benefit[6]
  • analgesia should be used in a preventive way, especially as some procedures can be predicted
  • general anaesthetic may be used for prolonged procedures
Pain Associated with Surgery[edit | edit source]

Early post-operative pain tends to be managed with opioids and other non-opioid medications:[1]

  • patient-controlled analgesia (PCA) can be used (particularly for breakthrough pain after a procedure[5]), but the patient must be conscious and alert[6] and be able to understand how to use the device
  • non-steroidal anti-inflammatory drugs (NSAIDs) have been used to help manage pain after surgery:
    • however, they are used infrequently in individuals who are critically ill[6]
    • they "should be used with extreme caution especially in patients with bigger burns and those on intensive care"[7]
  • local anaesthetic gels may be applied after surgery to large, raw areas, such as donor sites, before the dressing is applied
Pain Associated with Dressing Changes and Wound Cleaning[edit | edit source]

Pain management during dressing changes and wound care is a significant consideration:[1]

  • a general anaesthetic or deep intravenous sedation may be required while dressing large, deep burns
  • smaller dressings can be managed by administering analgesia (e.g. opioids, local anaesthetics) before starting the procedure
  • nitrous oxide (e.g. Entonox) and opioids can be used for short procedures to help reduce breakthrough pain and avoid long periods of sedation
  • using appropriate dressings can help reduce the requirement for procedures - please see Burn Wound Injury Dressing Selection and Advanced Dressing Selection for Burn Wound Injuries for more information on burn wound dressings
Pain Associated with Rehabilitation[edit | edit source]

Physiotherapists and occupational therapists commonly work with patients with burn injuries in primary healthcare settings. However, moving the affected area/s can exacerbate pain and trigger the stress response. Rehabilitation interventions are, therefore, often scheduled after pain relief has been administered:[1]

  • during the acute phase, physiotherapists and occupational therapists may perform passive range of motion exercises or create splints while a patient is in theatre or having their dressings changed
  • during the subacute and chronic phases, oral analgesics are commonly used to ensure patients can actively participate in treatment

Post-burn Pruritus[edit | edit source]

Post-burn pruritus (itching sensations on or around the burn, graft, or donor site) is a common issue after burn injury, affecting up to 93% of individuals by the day of their discharge.[8] It can have a significant impact on recovery, causing distress and affecting quality of life. Patients can also potentially cause trauma to their wounds by scratching, which can delay healing.[9]

Please note that the use of restraints to prevent a patient from itching are considered an absolute last resort. Depending on your location, the use of restraints may require specific medical orders that need to be regularly reviewed. Other options to try first include:

  • extra layers of fluffy bandages to protect the primary dressings (but it is essential to ensure that proper air exchange can occur)
  • gloves (with fingers) or mitts (without figures)

Current treatments for post-burn pruritus have not been found to have clinically significant benefits, so further research on post-burn pruritus management is required.[8] Treatments include:[10]

  • topical treatments
  • systemic treatments, such as antihistamines, opioid receptor agonists or antagonists, gabapentin or pregabalin, antidepressants, etc
  • extracorporeal shockwave therapy (ESWT)
  • pressure therapy
  • massage therapy
  • education
  • cold compresses in the subacute phase[1]
  • moisturisers[7]

For more information on post-burn pruritus, please see: Burn Wound Injury Special Concern: Post-burn Pruritus

Persistent / Chronic Pain[edit | edit source]

Some individuals after a burn injury will develop chronic or persistent pain, affecting quality of life, sleep, increasing morbidity and decreasing functional recovery. Chronic neuropathic pain after burn injury has a reported prevalence of 7.3% to 18%.[11] It develops as a result of partial or complete peripheral nerve injuries.[11] Individuals with burn injuries may develop hyperalgesia or allodynia. There is a strong correlation between the severity of chronic pain symptoms and the total burn surface area and number of skin grafts performed.[12]

Treatments for persistent pain following a burn injury might include:[1]

  • analgesics
  • antidepressants
  • anticonvulsants
  • regional nerve block
  • cognitive behavioural therapy
Alternative Pain Management Techniques for Burn Injuries[edit | edit source]

Romanowski et al. recommend "that every patient be offered a nonpharmacological pain control technique, at least as an adjunctive measure to their pain control regimen".[3]

There are four broad categories of nonpharmacological techniques:[3]

  1. cognitive-behavioral therapy (CBT)
    • "most effective when decatastrophizing and reinterpreting pain signals were targeted"[3]
  2. hypnosis
    • can be used to help manage procedural pain and anxiety
    • "most effective when the affective component of pain was targeted in posthypnotic suggestions and for patients who had high pain"
  3. distraction
    • i.e. redirecting the patient's attention from the pain sensation
    • virtual reality has the most robust evidence
      • the patient is immersed in a virtual world
      • patients who "feel more “present” in the virtual world have lower pain scores during wound care and physiotherapy"[3]
      • patients using virtual reality can have lower pain scores during dressing changes[13][14]
  4. relaxation (breathing, music,[15] stress inoculation, aromatherapy, massage)

Rehabilitation strategies to help with pain, post-burn pruritus and altered sensation include:[7]

  • education, reassurance, distraction
  • splinting
  • exercise
  • massage
  • sensory re-education / desensitisation

Sleep normalisation also plays a role in pain management:

  • a night of poor sleep predicts increased pain and greater analgesia use the next day
  • increased pain during the day predicts poor sleep quality that night[16]

Oedema Management for Individuals with Burn Injuries[edit | edit source]

Burn injuries induce oedema.[17] Two interventions for oedema management in burn injuries include elevation and compression.

Whenever implementing interventions for burn injuries, remember that all post-operative, consultant and multidisciplinary team advice must be followed.[17] Care must be taken to reduce the risk of skin breakdown and contracture development, and all indications and contraindications must be considered.

Elevation[edit | edit source]

In order to decrease oedema, a limb should ideally be elevated above the level of the heart.[18] Sometimes, this may not be possible due to pain and discomfort or lack of range of motion. In these cases, it is important to raise the limb as high as possible through positioning and other adjuncts, such as pillows, towels, splints and slings.[17][2][19]

Patients with severe burns that cover a large Total Body Surface Area (TBSA) are at risk of systematic inflammation. In these cases, the following precautions should be considered:[20]

  • elevate the head: in the case of anterior neck burns, do not place a pillow under the head, as this can cause a contracture to develop
  • elevate all affected limbs
  • maintain the feet at 90 degrees
  • maintain the hips in a neutral position
  • monitor for pressure sores
Compression[edit | edit source]

Compression is commonly used to help manage oedema in burn injuries:[21]

  • pressure garment therapy (discussed below) has been shown to be beneficial in burn injures[20] - it can be used for both oedema and scar management, depending on the age of the burn and the initial depth of injury
  • coban wrap is often used for burn injuries of the hand and is useful in the acute stage of a burn injury because it does not stick to the underlying tissue[22]

For more information on Coban wraps, please see: Burns and Plastic Surgery Occupational Therapy.

Scar Management for Individuals with Burn Injuries[edit | edit source]

Hypertrophic scarring is a common complication in burn injuries, affecting up to 70% of patients.[23] Hypertrophic scars are visible, elevated scars. Unlike keloid scars, they do not spread into surrounding tissues, and they often regress spontaneously.[24] Hypertrophic scars can have a significant impact on an individual with burn injuries, potentially causing:[25][26][27]

  • pain
  • pruritus
  • reduced range of motion (particularly when they occur on or near a joint)
  • psychosocial / psychological effects
  • cosmetic effects
  • altered self-image

Scar Outcome Measures[edit | edit source]

Vancouver Burn Scar Scale (VBSS/VSS):

  • assesses vascularity, height, pliability, and pigmentation of the scar
  • does not measure a patient's subjective assessment of the scar, such as pain, itching, functional or psychological impact[28]
  • for more information, please see: Burns Scar Index (Vancouver Scar Scale)

Patient and Observer Scar Assessment Scale (POSAS):

  • measures pigmentation, vascularity, thickness, relief, pliability and surface area, as well as pain, itching, colour, stiffness, thickness and relief
  • for more information, please see: About POSAS

Management Options for Hypertrophic Scars[edit | edit source]

The following sections discuss approaches used to help manage hypertrophic scars, such as silicone, compression / pressure garment therapy (PGT) and massage. Other treatments include:

Silicone[edit | edit source]

Silicone can be applied in the form of a gel or sheeting. While some randomised controlled trials have found that topical silicone gel can be effective in preventing post-operative scarring,[32] a 2020 Cochrane review notes "there is currently limited rigorous RCT [randomised controlled trial] evidence available about the clinical effectiveness of SGS [silicone gel sheeting] in the treatment of hypertrophic scars"[33] and further research is required.[33] Nischwitz et al.[25] note that silicone gel appears to be mainly beneficial for post-burn pruritus and pain.[25] Some important clinical points:

  • silicone gels tend to be easier to apply than sheets and can also be used on more areas of the body[2]
  • silicone gel sheets can be washed and reused, which reduces the financial burden on the patient[34]

For more information on silicone products, including procedures for sheet silicone, precautions and considerations, please see page 18 of Burn Physiotherapy and Occupational Therapy Guidelines.

Pressure Garment Therapy (PGT)[edit | edit source]

Compression therapy aims to "keep developing scars flat and prevent raised scarring [...]. The type of compression used depends on wound healing, area of body affected, time since healing and individual patient needs."[17]

Compression can be achieved in different ways, such as pressure garments (off-the-shelf or customised), cohesive flexible bandages, tubular elasticised stockings and bandaging.[17]

Pressure garment therapy (PGT) is widely used in the management of hypertrophic scars.[20] There have been a number of studies on pressure garment therapy, but they often have different outcomes and may contradict each other.[35] Some recent research suggests:

  • there is "sufficient evidence to support the prophylactic and curative use of pressure therapy for scar management"[36]
  • PGT can help improve a scar's colour, thickness and quality and reduce pain[36]
  • De Decker et al.[36] recommend that PGT should be started sooner than two months post-burn, but ideally as early as possible
  • the wound must have closed and be stable enough to tolerate pressure before starting PGT (always check with the surgeon)[2]
  • PGT should be worn while the scar remains active[17]
  • De Decker et al.[36] PGT should continue for at least 12 months, preferably for up to 18-24 months[36]
  • recommended pressures for PGT vary
    • De Decker et al.[36] recommend minimal pressures of around 20-25 mmHg
    • Shirakami et al.[37] recommend that pressure should be between 20-30 mmHg (above capillary pressure)
    • please note that pressures exceeding 30-40 mmHg can have adverse effects (again figures given in the literature vary)[37][2]
  • it is typically recommended that pressure garments be worn at all times apart from showering or bathing, massage and moisturising (i.e. around 23 hours every day)[17]
  • adherence can be an issue for pressure garment therapy - it can be uncomfortable to wear the garment, especially in warm weather, and it can cause overheating, wound breakdown and itching[38]

How does pressure garment therapy work?[20]

Applying pressure to a burn injury is believed to reduce scarring by "hastening scar maturation and encouraging reorientation of collagen fibres into uniform, parallel patterns as opposed to the whorled pattern seen in untreated scars."[20] It potentially creates localised hypoxia to the scar, thus reducing blood flow to hyper-vascular scars. This reduces the influx of collagen and decreases scar formation.

Pressure garment therapy is believed to help:[20]

  • reduce scar thickness
  • reduce redness
  • decrease swelling
  • reduce post-burn pruritus
  • improve the protection of healed skin grafts
  • maintain contours and prevent contractures


Pressure Garment Care

It is important to educate patients on how to look after their pressure garments.

Two sets of garments are recommended for hygiene purposes (one in the wash and one being worn).[17]

  • Washing instructions:[40][41]
    • hand wash:
      • soak pressure garment in cool water and mild soap
      • rinse well with clean, cool water
      • roll the garment in a towel to soak up excess water
    • machine wash:
      • use a mild soap or detergent
      • wash with cool water on a gentle / delicate cycle
  • Drying instructions:[40][41]
    • air-dry only: pressure garments cannot be placed in a heated dryer as this will destroy their elasticity and compression ability
    • do not put the garment in sunlight or in front of a heater

Pressure garments need to be re-tensioned or remeasured and replaced every three to six months, depending on the level of wear and tear.[17]

For more information on compression and pressure garment therapy, including procedures, precautions and contraindications, please see pages 14-17 of Burn Physiotherapy and Occupational Therapy Guidelines.

Scar Massage[edit | edit source]

Scar massage is routinely used in many burn rehabilitation units around the world. Reported clinical benefits include:[42]

  • improved pliability and range of motion of the scar
  • reduced pain and skin sensitivity
  • reduced post-burn pruritus
  • decreased anxiety
  • changes in scar characteristics and reduction in scar thickness

Recent research suggests:

  • there is low-to-moderate quality evidence that massage can reduce pain and the intensity of post-burn scar pruritus[43]
  • there is low-to-moderate quality evidence that massage has "negligible or unclear effects for improving scar elasticity and vascularisation"[43]
  • another review by Barnes et al.[44] found that scar massage can help with symptoms associated with hypertrophic burn scars, even when different massage techniques are used
    • when used together, friction and oscillation can improve scar function
    • longer sessions of effleurage and petrissage can help with scar visibility and pain
    • each massage technique helped with scar pruritus
    • "massage techniques should be tailored to the patients’ symptoms"
  • further research is required[45][44]

Massage treatment considerations:

  • there is insufficient evidence to determine protocols on the frequency or duration of treatment
  • clean hands are essential
  • use a lubricant or lotion that is free of irritants  
  • clinicians must adapt treatment based on the patient's stage of healing, sensitivity and pain levels

Massage contraindications:[2][46]

  • open wound
  • acute infection
  • bleeding
  • graft failure
  • intolerable discomfort
  • hypersensitivity to emollient


For more information on massage, including procedures, precautions and considerations, please see page 20 of Burn Physiotherapy and Occupational Therapy Guidelines.

Surgical Management for Individuals with Burn Injuries[edit | edit source]

“In deep partial thickness and full thickness burns, the entire epidermis and much of the dermis is lost, dramatically limiting the ability to heal spontaneously.”[48] These burns require surgical intervention to remove devitalised tissue and to promote regeneration by providing the injured skin with a new source of epidermis.[48]

Since the 1970s, the acute management of burn injuries has included early excision and grafting, it is the current standard of care for burn wound injuries. This approach has led to improved survival rates and decreased length of hospital stay.[49]

Early Excision[edit | edit source]

Early excision is considered the gold-standard treatment:[49]

  • there is debate over the optimal timing for early excision
  • surgery aims to ensure there is no full-thickness necrotic tissue with debridement down to viable tissue

Skin Grafts[edit | edit source]

A skin graft is an area of skin that is moved from one area of the body to another area.

Early autografting (i.e. transplanting skin from a healthy donor site to the burned area) rapidly closes excised wounds, which reduces infection risk and pain and facilitates earlier mobilisation. Allografting (i.e. using skin from another person) is used to temporarily cover debrided tissue when:[49]

  • there are issues with the viability or bacterial load of the wound bed
  • the patient is not sufficiently medically stable

Autologous split-thickness skin grafts are the gold standard management approach for deep partial and full-thickness acute burns.[48][49] Autologous skin grafts can be split-thickness skin grafts (STSGs) or full-thickness skin grafts (FTSGs).[50]

Split-thickness skin grafts (STSG):[50]

  • most commonly used for wound coverage
  • include the epidermis and the upper layer of the dermis
  • are beneficial when patients have extensive TBSA burns, as the same donor sites can be re-harvested after one to two weeks (this can, however, lead to hypopigmentation)
  • mesh grafts can increase the total surface area of the mesh, but can result in significant scarring[49]
    • mesh grafts are processed to "punch" holes or apertures into the graft; this increases its size, allows topical agents through the graft and serous fluid or blood out
    • STSGs are often meshed and expanded for burns of more than 30-40%TBSA
    • meshed grafts are more commonly used for the back, trunk, legs and arms
  • sheet grafts (i.e. “donor sites that are excised and used as-is”) are used for more cosmetic areas, such as the face, hands and neck[49]

For more information on STSGs, please see: Burn injury.[49]

Full-thickness skin grafts (FTSG):[50]

  • the epidermis and the dermis to the underlying fat layer are harvested using a scalpel
  • associated with decreased scar and contracture formation, so they are useful in areas of cosmetic importance and across joints
  • however, they lead to full-thickness wounds at the donor site; these must be closed primarily or have reconstructive flap closure
  • have a higher failure rate

The following short, optional video shows the skin graft procedure.


Graft Failure[edit | edit source]

A graft should be stable within five days. It should be placed over bleeding, healthy tissue to ensure adequate vascularity.[2]

Post-operatively, the graft site will be dressed with sufficient pressure to limit haematoma formation but without causing damage to the delicate tissue. It is essential to consider the dressing pressure needed for successful graft stability and healing. Too much pressure can cause damage to the fragile tissue and a newly placed skin graft to fail.

The area should be immobilised in an “anti-deformity” position to prevent shearing forces that might disrupt the graft. Areas that are highly mobile, such as the hand, might require splinting to ensure immobility.[2]

Skin grafts are more likely to fail if:[49]

  • excision of the recipient site is insufficient
  • there is shear stress
  • there is wound infection

Other causes of graft failure include:[2]

  • inadequate blood supply to the wound bed
  • collection of fluid beneath the graft (e.g. haematoma)
  • the properties of the donor site (e.g. level of vascularity)
Skin Substitutes[edit | edit source]

If the excised area requires more skin than is available, temporary skin cover is required. There are many types of skin substitutes (biomaterial and engineered tissue grafts).[48][49]

If you would like more information on skin substitutes, please see:

There are differences in how a newly placed graft is managed versus a healed graft. You will need to consult with the surgeon and medical team for specific management protocols.

Skin Flaps[edit | edit source]

Skin flaps are also used in patients with burn injuries. Unlike skin grafts which are vascularised by the recipient site, a skin flap has its own vasculature (i.e. it brings its own blood supply from the donor site).[2]

Skin flaps might be used on areas such as:[2]

  • bone without periosteum
  • tendon without paratenon
  • cartilage without perichondrium

The following optional video explains more about skin flaps and shows different types of flap surgery. You can only view this video on YouTube.


Reconstruction Surgery[edit | edit source]

“Overall survival of the skin graft is important, but cosmetic outcomes and body image cannot be ignored when treating burn patients.”[50]

Burn scars that develop after skin grafting and can lead to:[50]

  • anxiety
  • depression
  • pain
  • itching
  • altered pigmentation
  • temperature intolerance
  • decreased range of motion (from contractures)

Surgical scar revision is “the standard of care” for individuals with burn injuries who develop contractures or who have poor cosmetic outcomes. Around 5-20% of individuals with burn injuries go on to have reconstructive surgery.[53] Surgical scar revision can involve skin substitutes, laser therapy, flaps, biomaterials, etc.[50]

References[edit | edit source]

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