Sub Acute Burn Physiotherapy Rehabilitation

Original Editor - Carin Hunter based on the course by ReLab
Top Contributors - Carin Hunter

Rationale for immobilisation in the Sub-acute Stage ∙ Maintenance of range of motion ∙ Regain range of motion (Kwan 2002; Boscheinen Morrin 2004)

Role of the Physiotherapist in the Rehabilitation of the Sub  Acute Burn Patient

Beyond the acute stage of immobilisation, inpatient and outpatient rehabilitation typically  consists of a variety of interventions including pressure garment therapy, silicone therapy,  scar massage, range of motion and mobilisation techniques, strengthening, functional and gait  retraining, and balance and fine motor retraining ( Schneider et al, 2012). Interventions  should be tailored according to a full patient assessment.  

As it would be unethical to withhold treatment, physiotherapy intervention as a whole is not  well investigated. Schneider et al (2012) found a significant improvement in contractures; balance and hand function with inpatient rehabilitation, through a longitudinal observational  study of eleven people. However, in the following section, we will attempt to display the  evidence for commonly used modalities.  

The patient

∙ Primary closure of wound

∙ Scar remodelling

∙ Scar contraction


∙ Optimise scar appearance

∙ Limit effects of scar contraction/prolonged positioning on range of motion and  function

∙ Address effects of prolonged bed rest  

Common modalities

∙ Mobilisation- both mobility and specific joint mobilisation

∙ Scar management adjuncts

o Pressure garments, silicone, massage

∙ Continuation of oedema/ positioning management where necessary


5.21 Mobilisation

The advantages of general mobilisation for a burns patient to counteract the effects of  prolonged bed rest are no different to that of a surgical or medical patient. Burns patients  should be mobilised as early as possible to avoid deconditioning and possible respiratory  complications associated with prolonged bed rest (Esselman 2007).

As outlined in the above introduction, due to the ethical issues surrounding withdrawal or  modification of treatment the evidence surround the optimal duration, frequency and methods  of physiotherapy interventions in the treatment of burn patients is unclear. Despite this lack  of clarify surrounding these issues it is clear that both active and passive mobilisation plays a  key role throughout the stages of burn recovery. Below is a summary of the  recommendations from the currently literature on passive and active mobilisation of burns.  

5.211 Active ROM

∙ Depending on the need for immobilisation gentle active ROM exercises is the  preferred treatment during the acute stage of injury as it is the most effective means of  reducing oedema by means of active muscle contraction (Glassey 2004). If this is not  possible due to sedation, surgical intervention etc. then positioning the patient is the  next best alternative (see immobilisation and position).

5.212 Passive ROM

∙ Passive ROM exercises in the acute stage are contraindicated as applying passive  stretching forces may result in future damage to the burned structures (Boscheinen Morrin 2004). Applying these passive manoeuvres in the acute stage will result in  increased oedema, haemorrhage and fibrosis of the burned tissues (Cooper 2007).

∙ The biomechanical principle of creep when passive stretching. A slow sustained  stretch is more tolerable for patient and more effective for producing lengthening  (Kwan 2002).

∙ Passive joint mobilisations can begin during the scar maturation phase once the scar  tissue has adequate tensile strength to tolerate friction caused by mobilisation  techniques (Boscheinen-Morrin and Connolly 2001).


Frequency, Duration Recommendations

∙ Physiotherapy intervention should be twice daily with patients prescribed frequent  active exercises in between sessions.  

∙ For the sedated patient gentle passive range of motion exercises should be done 3  times a day once indicated (Boscheinen-Morrin and Connolly 2001).

∙ Dependent on the severity of the burn active and very gentle passive range of motion  exercises for the hand and fingers are begun from day one of injury.  


∙ Active or Passive range of motion exercises should not be carried out if there is  suspected damage to extensor tendons (common occurrence with deep dermal and full  thickness burns). Flexion of the PIP joints should be avoided at all costs to prevent  extensor tendon rupture. The hand should be splinted in the position of safe  immobilisation or alternatively a volar PIP extension splint until surgical intervention  (Boscheinen-Morrin and Connolly 2001) is discussed.  

∙ Range of motion exercises are also contraindicated post skin grafting as a period of 3- 5 days immobilisation is required to enable graft healing (Boscheinen-Morrin and  Connolly 2001).

Evidence for hand mobilisation

There is currently limited evidence which examines the effectiveness of hand exercises for  the burned hand specifically. Studies in the area of burns generally include subjects who  have extensive % TBSA in which their hand/hands may be involved.  

Okhovation et al (2007) carried out an RCT in which they compared a routine rehabilitation  protocol with a burn rehabilitation protocol. This study is particularly relevant form a hand  burn rehabilitation perspective as 83% of subjects recruited had partial / full thickness hand  burns

Subjects: 30 burn admissions to Tehran Hospital in 2005. Matched in pairs based on clinical  details (sex, age, TBSA, depth of burn). Randomly assigned into two groups

Intervention: The routine rehabilitation protocol included chest physiotherapy and  active/passive movements 15-20 minutes daily commenced 2/52 post admission. The burn  rehabilitation protocol involved routine protocol plus targeted stretching program to


contracture risk areas for 30-45min 2-3times daily commenced on day1 of admission.  Outcome measures: Outcome measures used were Presence of burn contracture  (goniometry) Occurrence of thrombosis Length of Hospital Stay Skin grafting requirement.

Results: Development of post burn contractures on discharge from hospital was 6% in the  burn rehabilitation group versus 73% in the routine rehabilitation group. No significant  difference regarding thrombosis, duration of stay and number of skin grafts

Limitations: There were several limitations to the study. The recruitment process was not  clearly defined. Information on the group matching and randomised allocation process was  not provided. No inclusion/exclusion criterion was defined. Frequency, duration and  commencement of the two protocols unequal and appear very bias towards targeted stretching  program.

Functional Rehabilitation of the Hand

Salter and Chesire (2000) suggest that the burnt hand should be used for light self-care  activities as soon as tolerated by the patient. This is based on the principle that everyday  activities will promote regular movement patterns of the affected hand. Emphasis should be  placed on intrinsic flexion of the MCP joints and intrinsic IP joint extension, gross gripping  (i.e. composite flexion), maintenance of the web spaces and opposition of the thumb.

Practical factors to consider when mobilising

∙ Be aware of dressing clinic/daily dressing changes. Mobilisation should coincide with  this as it is important to monitor the wound during AROM frequently.

∙ Timing of pain relief. This should be timed appropriately to ensure maximal benefit  during treatment sessions.

∙ Observe the patient carrying out the AROM and PROM exercises prior to beginning  treatment. Also observe the patient taking on/off splints.

∙ Always monitor for post exercise pain and wound breakdown.

∙ Avoid blanching for long period as you may compromise vascularity. ∙ The patient may present with a reduced capacity for exercise secondary to increased  metabolic rate, altered thermoregulation and increased nutritional demands.  ∙ Postural hypotension may be present due to prolonged bed rest and low haemoglobin. (ANZBA 2007)


Five principles of scar massage:

1. Prevent adherence

2. Reduce redness

3. Reduce elevation of scar tissue

4. Relieve pruritus

5. Moisturise (Glassey 2004) Scar Massage Techniques

∙ Retrograde massage to aid venous return, increase lymphatic drainage, mobilise fluid  ∙ Effleurage to increase circulation

∙ Static pressure to reduce pockets of swelling

∙ Finger and thumb kneading to mobilise the scar and surrounding tissue ∙ Skin rolling to restore mobility to tissue interfaces

∙ Wringing the scar to stretch and promote collagenous remodelling

∙ Frictions to loosen adhesions

(Holey and Cook 2003)

Guidelines for Massage during 3 Stages of healing Inflammatory Phase gentle massage to decrease oedema and increase blood supply  (currently no high level evidence to support this) Proliferative Phase Massage that applies gentle stress to the healing scar is recommended  to ensure collagen is aligned correctly. Remodelling Phase Massage should be progressed to include prolonged stretching to  minimise adhesions. This is proposed to aid in scar tissue breakdown

Table 10 Guidelines for scar massage during healing stages (Glassey 2004)


Table 11. Evidence for the use of massage in scar management

Article Field et al 2000


Morien et al 2008

Pilot Study

Shin and Bordeaux,  2012 Lit review Subjects 20 subjects in remodelling phase of  wound healing.  Randomly assigned into  2 groups

Massage Vs Control

8 Children  

Mean age 13.5 years  (10-17years)

All thermal burns  including hand burns

Not burn specific,  though the majority  of scars were of this  origin

10 articles: n=144  adult and children

Intervention Massage Therapy Group:

30minutes massage with  cocoa butter twice  weekly for 5 weeks

Control Group:

Standard Treatment

20-25 minute  massage session  once daily for 5 days


petrissage, friction,  lengthening rolling)

Session followed by  discussion of  psychosocial issues

Time to Rx: mean  4.3 months. +  variation in  protocols. 20  mins/day- 30 mins 2x  weekly. 1 Rx-6  months Rx Outcome  


Itching: VAS

Pain: McGill Pain


Anxiety: State Trait  Anxiety Inventory

Mood: Profile of Mood  States

Likert pictorial scale  

Goniometry Range of  Motion

Patient and observer  scar assessment  scale, Vancouver  scar scale, thickness,  vascularity, colour,  pain, pruritus, mood,  anxiety, and  depression. Results Massage Therapy Group  Reported: decreased  itching, pain, anxiety and  increased mood  

Ratings improved from  the 1st-last day of the  study

Increased ROM in  massaged tissue.  Decreased ROM in  unmassaged tissue

No significant  difference in mood  across time

45.7% improved in at  least one of the above  parameters. 54.7%  had no improvement.  

Noted massage was  more economical  than silicone/PGT.


Limitations Small Sample Size

No follow up


population. Mood Instrument may have  been influenced by  other factors.  Recruitment and area  to be massaged not  random

Small sample size

No follow up

No discussion of  quality or statistical  tests.

Conclusion on Scar Massage

Evidence suggests that burn patients receive psychological benefits from massage in terms of  altered mood (decreased depression, anger), decreased pain, and anxiety (Field et al 1998).  Evidence also indicates that massage increases ROM in non-burned patients, but little  evidence exist examining the effect of massage on ROM in burn patients (Morien et al 2008).

Recommendations for practice and safety considerations.

Insufficient consistency in literature with regards to protocols on frequency or duration of  treatment. Suggestions for practice include (Shin and Bordeaux, 2012, Morien et al, 2008)  

∙ Clean hands essential

∙ Use non irritating lubricant, free of any known sensitisers.  

∙ Modify practice according to patient stage of healing, sensitivity and pain levels. Contraindications: Shin and Bordeaux 2012

∙ Compromised integrity of epidermis

∙ Acute infection

∙ Bleeding

∙ Wound dehiscence,  

∙ Graft failure

∙ Intolerable discomfort

∙ Hypersensitivity to emollient